Anaphylactic Reaction Case After Sugammadex Application

Sugammadex is a synthetic gamma-cyclodextrin-derived agent that selectively encapsules nondepolarizing neuromuscular blockers (NMBAs) such as rocuronium. This case report aims to present a life-threatening anaphylactic shock that is thought to be related to sugammadex application after reversal of the neuromuscular blockade. The patient was a 59-year-old male who hada history of uncomplicated inguinal hernia repair under general anesthesia 10 years ago and hadno additional disease. Endovascular coil embolization of cerebral aneurysm was planned undergeneral anesthesia by the interventional radiology clinic. No complications related to surgery oranesthesia were observed during the operation. At the end of the operation, intravenous (IV) 200mg sugammadex was administered to the patient. Approximately 2 minutes after extubation, thepatient developed an anaphylactic reaction, which was thought to be due to sugammadex injection. The symptoms of the patient regressed with the administration of ephedrine, adrenalineand methylprednisolone. We should be aware of the fact that life-threatening anaphylactic reactions may develop after administration of sugammadex.

Sugammadeks Uygulaması Sonrası Anafilaktik Reaksiyon Olgusu

Sugammadeks, roküronyum gibi steroid yapılı nondepolarizan nöromüsküler ajanları (NMBAs) selektif olarak enkapsüle eden, sentetik gamma-siklodekstrin yapısında bir ajandır. Bu olgu sunumunun amacı, nöromüsküler blokajın geri döndürülmesi sırasında sugammadekse bağlı olduğu düşünülen, hayatı tehdit eden anaflaktik şok tablosunu sunmaktır. Hasta 10 yıl öncesine ait genel anestezi altında komplikasyonsuz inguinal herni onarımı öyküsü olan ve ek hastalığı olmayan 59 yaşında erkek idi. Girişimsel radyoloji kliniği tarafından genel anestezi altında serebral anevrizmanın endovasküler koil embolizasyonu planlandı. Operasyon esnasında cerrahi veya anesteziye bağlı herhangi bir komplikasyon gözlemlenmedi. Operasyon sonunda hastaya intravenöz (IV) 200 mg sugammadeks enjeksiyonuna uygulandı. Ekstübasyondan yaklaşık 2 dakika sonra hastada sugammadekse bağlı olduğu düşünülen anaflaktik reaksiyon gelişti. Efedrin, adrenalin ve metilprednizolon uygulanan hastanın semptomları geriledi. Sugammadeks uygulanmasından sonra hayatı tehdit eden anaflaktik reaksiyonların gelişebileceğinin farkında olmalıyız.

PDF

___

1. Hepner DL, Castells MC. Anaphylaxis During the Perioperative Period. Anesth Analg. 2003;97:1381-95. https://doi.org/10.1213/01.ANE.0000082993.84883.7D

2. Bilgi M, Demirhan A, Akkaya A, Tekelioglu U, Kocoglu H. Sugammadex associate persistant bradycardia. Int J Med Sci Public Heal. 2014;3:372. https://doi.org/10.5455/ijmsph.2013.251220131

3. Orihara M, Takazawa T, Horiuchi T, et al. Comparison of incidence of anaphylaxis between sugammadex and neostigmine: a retrospective multicentre observational study. Br J Anaesth. 2019;10:1-10. https://doi.org/10.1016/j.bja.2019.10.016

4. Hunter JM, Naguib M. Sugammadex-induced bradycardia and asystole: how great is the risk?. Br J Anaesth. 2018;121:8-12. https://doi.org/10.1016/j.bja.2018.03.003

5. Center for Drug Evaluation and Research-US Food and Administration. FDA adverse event reporting system (FAERS). https://www.fda.gov/Drugs/Information On Drugs/ucm 135151.htm; 2020 [accessed 13 March 2020]

6. Hopkins PM, Cooke PJ, Clarke RJ, et al. Consensus clinical scoring for suspected perioperative immediate hypersensitivity reactions. Br J Anaesth. 2019;123:e29-37. https://doi.org/10.1016/j.bja.2019.02.029

7. Harper NJN, Cook TM, Garcez T, et al. Anaesthesia, surgery, and life-threatening allergic reactions: epidemiology and clinical features of perioperative anaphylaxis in the 6th National Audit Project (NAP6). Br J Anaesth. 2018;121:159-71. https://doi.org/10.1016/j.bja.2018.04.014

"8. Levy JH, Castells MC. Perioperative Anaphylaxis and the United States Perspective. Anesth Analg. 2011;113:979-81. https://doi.org/10.1213/ANE.0b013e31822d68a5

9. Pierre P, Michiel H, Emiel H, et al. Safety, Tolerability and Pharmacokinetics of Sugammadex Using Single High Doses (Up to 96 mg/kg) in Healthy Adult Subjects. 2010;30:867-74. https://doi.org/10.1007/BF03256915

10. Godai K, Hasegawa-Moriyama M, Kuniyoshi T, et al. Case report Three cases of suspected sugammadexinduced hypersensitivity reactions. British Journal of Anaesthesia. 2010;109:216-8. https://doi.org/10.1093/bja/aes137

11. Min KC, Bondiskey P, Schulz V, et al. Hypersensitivity incidence after sugammadex administration in healthy subjects: a randomised controlled trial. British Journal of Anaesthesia. 2018;121:749-57. https://doi.org/10.1016/j.bja.2018.05.056

12. Simons FER, Ebisawa M, Sanchez-Borges M, et al. 2015 update of the evidence base: World Allergy Organization anaphylaxis guidelines. World Allergy Organization Journal. 2015;8:1-16. https://doi.org/10.1186/s40413-015-0080-1

13. Information for the user. https://www.merckconnect. com/bridion/dosing-administration/; 2020 [accessed 13 August 2020]

14. Tsur A, Kalansky A. Hypersensitivity associated with sugammadex administration: a systematic review. Anaesthesia. 2014;69:1251-7. https://doi.org/10.1111/anae.12736

15. McDonnell NJ, Pavy TJG, Green LK, et al. Sugammadex in the management of rocuronium-induced anaphylaxis. Br J Anaesth. 2011;106:199-201. https://doi.org/10.1093/bja/aeq366

16. Masakazu Y, Miki D, Kiichiro N, et al. A suspected case of rocuronium-sugammadex complex induced anaphylactic shock after cesarean section. J Anesth. 2017;31:148-51. https://doi.org/10.1007/s00540-016-2280-4