Abstract
Skin tests are the gold standard for detecting the culprit drug of anaphylaxis, and should ideally be performed after an interval of 4–6 weeks after the reaction to avoid false-negative results. However, when re-operation cannot be delayed and early allergy tests are necessary, special attention is required during subsequent anesthesia, because early skin tests tend to produce false-negative results. This report presents a case of rocuronium-induced anaphylaxis in which early skin tests showed negative results for all the drugs tested. The second anesthesia was safely performed by avoiding all the drugs used for the first anesthesia. Ultimately, skin tests and basophil activation tests (BATs) performed after re-operation demonstrated rocuronium as the drug responsible for anaphylaxis. We recommend performing BATs in addition to skin tests to improve the accuracy of diagnosis of anaphylaxis. In this report, we also discuss interpretation of the results of early skin tests and subsequent selection of drugs for anesthesia. After postponement of surgery due to anaphylaxis, we are often required to perform allergy tests at an early stage if re-operation cannot be delayed. In such cases, skin test results alone should not be used to guide subsequent anesthesia management to avoid recurrent anaphylaxis.
Highlights
Anaphylaxis is defined as a life-threatening systemic hypersensitivity reaction of sudden onset [1]
Since we considered the possibility of falsenegative results in skin tests, our second general anesthesia plan did not include any of the suspected offending drugs
We report here a case of rocuronium-induced anaphylaxis in which the second anesthesia was safely performed by avoiding all the drugs used for the first anesthesia
Summary
Anaphylaxis is defined as a life-threatening systemic hypersensitivity reaction of sudden onset [1]. Even if early skin test results are negative for all the drugs tested, special attention is required during the subsequent anesthesia. We describe a case of anaphylaxis in which early skin tests showed negative results for all the drugs tested, Journal of Anesthesia (2020) 34:624–629 despite which all of these drugs were avoided during subsequent anesthesia and surgery. Since early surgery was necessary to prevent occlusal deficiency and trismus, surgery was rescheduled for 10 days after the event Both skin prick tests (SPTs) and intradermal tests (IDTs) using all the drugs suspected to be the possible cause of anaphylaxis were performed eight days after the event, all of which showed negative reactions. The patient’s ratio of activated basophils was calculated and compared with that of a healthy male volunteer with no allergic skin test reaction to rocuronium. Drug concentrations for IDTs: histamine 10 μg/ml, propofol 0.01, 0.1, 1 mg/ml, rocuronium 0.5, 5, 50 μg/ ml, remifentanil 0.05, 0.5, 5 μg/ml
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