SUGAMMADEX ANAPHYLAXIS

Abstract

<h3>Introduction</h3> Sugammadex is a neuromuscular reversal agent used at the conclusion of surgeries to reverse the effects of rocuronium and vecuronium. It was first used in 2008 and the incidence of anaphylaxis has been estimated to be around 0.02%. We report a case of anaphylaxis to sugammadex which manifested abruptly with hypotension, diaphoresis, and dyspnea but with absence of rash. <h3>Case Description</h3> A 71YOF underwent an uncomplicated laparoscopic cholecystectomy. At the end of the procedure, patient received 200mg sugammadex IV and within 3 minutes she became hypotensive, diaphoretic, and dyspneic. She did not have a rash. She never received this medication before. She received IV fluids and she was started on phenylephrine drip. Patient was initially phenylephrine refractory but after 10 minutes her hypotension resolved. The diagnosis was unclear, therefore a repeat laparoscopy to rule out bleeding was performed and intraoperatively transesophageal echocardiogram showed normal left ventricle function, but minimal filling. The blood loss was estimated to be 30 ml. Due to high suspicion, Sugammadex was preemptively listed as an allergy. One hour after her symptoms began, tryptase level was 48.7 mcg/L, followed by 61.5 mcg/L 2.5 hours later. Baseline tryptase was 4.5 mcg/L. At a follow up visit, skin prick testing to sugammadex was positive with a 1:1 concentration and to intradermal testing with a 1:1000 concentration. Skin testing of other agents which were administered prior to sugammadex were negative. <h3>Discussion</h3> Although rare, rapid recognition of possible sugammadex anaphylaxis, despite the lack of rash, is very important for adequate treatment and further testing.