Sugammadex and anaphylaxis: An analysis of 33 published cases

Abstract

In this study, the published sugammadex-induced anaphylaxis reports were reviewed to determine similarities in their presentation during anesthesia. PubMed was searched for sugammadex-induced anaphylaxis without time limitation. Reports were evaluated if they were in English and met the criteria of anaphylaxis determined by the World Allergy Organization. Two independent reviewers extracted and assessed the data using predesigned data collection forms. In total, 23 suitable articles were found and 33 sugammadex-induced anaphylaxis cases were included in the study. The mean age was 43.09 years (from 3–89 years) and 17 (51.5%) of the patients were female. Considering all reported cases, the average onset time of anaphylaxis was 3.08 min, with a median of 3 min (range 1–8 min). The most common signs and symptoms were hypotension, tachycardia, erythema, and desaturation. Of the 20 patients who underwent confirmatory skin testing, 15 had a positive skin reaction for sugammadex. Epinephrine was not given when indicated in about 25% of cases. Sugammadex-induced anaphylaxis onset time was less than 5 min in 92.3% of all the reported cases. Rapid diagnosis and early recognition of signs and symptoms of anaphylaxis are essential for a favorable prognosis. Treatment needs to be started as soon as possible to ensure the best outcome for the patient.

Successful management of rocuronium-induced anaphylaxis with sugammadex: A case report

“…Moreover, sugammadex alone has been reported to be associated with allergic reactions. 8 In conclusion, we report here a rare case of severe rocuronium-induced anaphylaxis that was successfully treated with sugammadex in a patient with possible crossreactivity to cisatracurium. This case highlights the potential beneficial effect of sugammadex as an adjunct to conventional measures during rocuronium-induced anaphylaxis.…”

“…11 The clinical manifestation of perioperative anaphylaxis is diverse and ranges from mild to severe symptoms which can include cutaneous, respiratory, circulatory and central nervous changes, including cardiac arrest. 8,14 A fourgrade severity scale has been used to categorise the degree of the anaphylactic reaction: grade 1, anaphylaxis with cutaneous signs; grade 2, anaphylaxis with measurable but not life-threatening symptoms, including cardiovascular reaction (tachycardia, hypotension), gastrointestinal disturbance (nausea) and respiratory disturbance (cough or mechanical ventilation difficulty); grade 3, anaphylaxis with life-threatening reactions, including severe bronchospasm or cardiovascular collapse; grade 4, anaphylaxis with cardiac and/or respiratory arrest. [15][16][17][18][19][20][21] In this present case, the patient developed grade 4 anaphylaxis following rocuronium administration.…”

“… 4 – 6 Sugammadex is a modified gamma-cyclodextrin that has a high affinity for the steroidal NMBDs rocuronium and vecuronium. 7 , 8 It can form a tight inclusion complex with rocuronium or vecuronium, thereby inactivating the effects of these steroidal NMBDs and causing rapid reversal of neuromuscular blockade. 9 We report here, a case of severe rocuronium-induced anaphylaxis that was successfully treated with sugammadex in a patient with possible cross-reactivity to cisatracurium.…”

Role of sugammadex in the treatment of anaphylaxis due to rocuronium in children: Extrapolation from adult and animal reports

“…Despite the potential utility of sugammadex in this clinical scenario, its use should be considered carefully, and the risk–benefit ratio determined. Sugammadex itself can cause allergic reactions, the incidence of which is only now being recognized and investigated 34,35 . Sugammadex binds aminosteroid molecules, and there is the potential for sugammadex to bind other steroid molecules including hydrocortisone which may have undesirable physiologic effects, especially in the setting of an allergic reaction.…”

“…Sugammadex itself can cause allergic reactions, the incidence of which is only now being recognized and investigated. 34,35 Sugammadex binds aminosteroid molecules, and there intravenous fluids, bronchodilators, corticosteroids, and antihistamines. 5,6,36,37 A systematic approach is necessary for the diagnosis of an intraoperative allergic reaction, confirmation of the offending agent, its management under anesthesia, and the process for appropriate postoperative laboratory and skin testing to guide future anesthetic care.…”