Sugammadex in rocuronium anaphylaxis: dose matters

Barthel, Franziska; Stojeba, N.; Lyons, G.; Biermann, C.; Diemunsch, Pierre

doi:10.1093/bja/aes332

Cited by 37 publications

(32 citation statements)

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“…Sugammadex has been proposed as a useful treatment for anaphylaxis symptoms caused by rocuronium [59,60]. However, in a recently published series of cases, sugammadex did not modify the course of the reaction [61].…”

Section: Vasoactive Drugsmentioning

confidence: 98%

Practical Guidelines for Perioperative Hypersensitivity Reactions

Laguna¹,

Archilla²,

Doña³

et al. 2018

J Investig Allergol Clin Immunol

105

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Perioperative hypersensitivity reactions constitute a first-line problem for anesthesiologists and allergists, so it is advisable that hospitals have a consensus protocol for the diagnosis and management of these reactions. However, this kind of protocols is not present in many hospitals, leading to problems in treatment, the communication of incidents and subsequent etiological diagnosis. In this document we present a systematic review of the available scientific evidence and provide general guidelines for the management of acute episodes and Resumen:Las reacciones de hipersensibilidad perioperatorias constituyen un problema de primera línea para los anestesiólogos y alergólogos, por lo que es recomendable que los hospitales tengan un protocolo de consenso para el diagnóstico y el tratamiento de estas reacciones. Sin embargo, este tipo de protocolos no está presente en muchos hospitales, lo que conlleva problemas en el tratamiento, la comunicación de incidentes y el posterior diagnóstico etiológico. Este documento ha sido creado por miembros del Comité de Alergia a Medicamentos de la Sociedad Española de Alergia e Inmunología Clínica (SEAIC) en colaboración con miembros de la Sociedad Española de Anestesia (SEDAR). Se ha realizado una revisión sistemática de la evidencia científica disponible y se proporcionan pautas generales para el manejo de episodios agudos y para la derivación de pacientes con reacciones de hipersensibilidad perioperatoria a los Servicios de Alergología. Se propone un algoritmo práctico para el diagnóstico etiológico y se brindan recomendaciones para el manejo de pacientes con reacciones alérgicas perioperatorias.

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Section: Vasoactive Drugsmentioning

confidence: 98%

Practical Guidelines for Perioperative Hypersensitivity Reactions

Laguna¹,

Archilla²,

Doña³

et al. 2018

J Investig Allergol Clin Immunol

105

View full text Add to dashboard Cite

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“…This more or less corresponds to the periods of time reported in clinical cases of rocuronium allergy in which an injection of sugammadex resulted in improved hemodynamic and/or respiratory status within a few minutes (Table). The case reported by Barthel et al 12 was a typical example of the need to inject a sufficient dose when firstly, a high dose of rocuronium has been used (0.8 mgÁkg -1 in this case), and also, the time to onset of allergic symptoms following the injection of rocuronium was immediate. This is also consistent with the case of Conte et al, 11 where the authors administered sugammadex 14 mgÁkg -1 six minutes after a dose of rocuronium 0.6 mgÁkg -1 , resulting in correction of the hypotension within approximately one minute.…”

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confidence: 75%

“…Similarly, what dose of sugammadex is suitable in this context? 12 Barthel et al 12 (Table) reported the case of a patient who suffered serious anaphylactic shock (grade III) following administration of rocuronium. The first dose of sugammadex (12 mgÁkg -1 ) allowed transient improvement of the hemodynamic status.…”

mentioning

confidence: 99%

“…De même, quelle dose de sugammadex serait adaptée dans ce contexte? 12 En effet Barthel et al 12 (Tableau) rapportaient le cas d'une patiente ayant présenté un choc anaphylactique sévère (grade III) après l'administration de rocuronium et pour lequel une première dose de sugammadex (12 mgÁkg -1 ) permettait une amélioration transitoire de la situation hémodynamique suivie d'une nouvelle aggravation finalement corrigée par une dose supplémentaire de sugammadex de 4 mgÁkg -1 , soit 16 mgÁkg -1 au total. Si l'hypothèse de la possibilité de masquer l'antigène responsable de la réaction allergique devait être retenue pour expliquer ces résultats et puisque l'interaction sugammadex-rocuronium se fait sur la base d'un rapport de un pour un (une molécule de l'un se lie à une molécule de l'autre), 7 il serait ainsi logique de retenir les schémas posologiques proposés pour une décurarisation dite de secours, comme cela a pu être testé dans différentes études.…”

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A new option for the treatment of anaphylaxis linked to steroidal neuromuscular blockers: How much value should we grant to case reports?

Plaud

2014

Can J Anesth/J Can Anesth

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Neuromuscular blockers (NMBs) are commonly used in anesthesia to facilitate tracheal intubation and optimize surgical conditions. However, these compounds share a common side effect -the risk of an allergic reaction. Anaphylactic shock is a rare (approximately one case in 10,000-20,000 procedures) but life-threatening complication of anesthesia. 1 In France, various epidemiological studies over the last three decades have shown that the most common causal agents of anaphylaxis are NMBs. 2 In the event of anaphylactic shock, epinephrine is the first-line therapy. The dose is usually titrated -except in case of cardiac arrest -depending on the clinical presentation and based on heart rate and blood pressure, to avoid the occurrence of arrhythmia with large doses of epinephrine. 3 This symptomatic treatment, coupled with crystalloid fluid resuscitation, allows to counteract hemodynamic (decreased blood pressure and cardiac output) and respiratory (bronchoconstriction) effects of the numerous mediators that are released during the course of an anaphylactic reaction. Despite these measures, the outcome remains potentially lethal in approximately 10% of cases. 4 However, there is no specific therapy of NMBassociated anaphylaxis. Proposed therapies could involve a substance able to rapidly inhibit the anaphylactic reaction by masking or binding the causal allergen. A specific therapy for the anaphylactic reaction to dextran, used in some countries as a fluid therapy, was attempted during the 1980s with the arrival on the market of a dextran-inhibitor hapten. 5 This hapten was purported to reduce the allergystimulating effects of dextrans through specific inhibition. The effectiveness of this preventive strategy proved unreliable, notwithstanding the other adverse effects of dextrans, renal in particular. 6 Thus, there remains no specific strategy at this time regarding the prevention or treatment of allergic reactions to NMBs. Could this situation change with the recent availability of sugammadex? Sugammadex is a gammacyclodextrine that was modified by the addition of side chains that specifically encapsulate the steroidal core of the NMB, mainly through interactions between the negative charges of the cyclodextrine molecule and the positive charges of the quaternary ammonium ions. 7 Their binding at the centre of the cyclodextrine molecule, more specifically the sterol moiety, is strong and prolonged, implying the presence of various high-energy chemical bonds. Binding is rapid, and steroidal NMBs show a high affinity for sugammadex, especially rocuronium and to a lesser degree vecuronium. 8 Beyond the rapid reversal of NMBs allowed by sugammadex, 7 neutralizing the NMB molecules by masking the causal allergen (i.e., the quaternary ammonium ion) should also be considered when an NMB-related allergic event is suspected. This hypothesis was reported for the first time through a case report. 9 The authors of that report described a serious anaphylactic reaction that occurred immediately after an induction sequence that i...

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“…There have been a number of case reports of rocuronium-induced anaphylaxis, where sugammadex administration, along with resuscitative efforts, has significantly improved clinical parameters and/or outcome. [128][129][130][131][132] Sugammadex may be a useful adjunct to managing rocuronium-induced anaphylaxis. 133,134 However, one cutaneous model disputes sugammadex use in this situation, warranting the need for further studies.…”

mentioning

confidence: 99%

Safety and Efficacy of Sugammadex for Neuromuscular Blockade Reversal

Lobaz

Clymer

Sammut

2014

Clinical Medicine Insights: Therapeutics

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AbstrAct:Since its first human use in 2005, the γ-cyclodextrin sugammadex (Org 25969) has had the potential to become the reversal agent of choice, for rocuronium-or vecuronium-induced neuromuscular blockade. Sugammadex binds to the aminosteroid neuromuscular blocker, encapsulating it and extracting it from the neuromuscular junction, effectively ceasing activity and allowing neuromuscular transmission to recover rapidly. Phases I-III and subsequent trials have found sugammadex to be safe and effective in a wide range of doses and for the reversal of a range of depth of muscle relaxation in healthy volunteers and a variety of disease states. Sugammadex use may allow refinement of anesthetic practice and improvement in surgical conditions, through the maintenance of deep neuromuscular blockade right to the end of surgery, with subsequent rapid reversal. Debate remains about the use of sugammadex in the treatment of rocuronium anaphylaxis and airway emergencies. The high price of sugammadex currently prohibits its routine use, but if the price falls, after expiry of its patent, it may become cost-effective as a readily available agent in certain specific clinical situations. Serious adverse reactions have occurred in less than 1% of patients and are most commonly because of hypersensitivity. No deaths have been reported, but caution is advised in neonates, pediatrics, and pregnancy where data are lacking.

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Sugammadex in rocuronium anaphylaxis: dose matters

Cited by 37 publications

References 3 publications

Practical Guidelines for Perioperative Hypersensitivity Reactions

Practical Guidelines for Perioperative Hypersensitivity Reactions

A new option for the treatment of anaphylaxis linked to steroidal neuromuscular blockers: How much value should we grant to case reports?

Safety and Efficacy of Sugammadex for Neuromuscular Blockade Reversal

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