Introduction: Anaphylaxis is a severe multisystem allergic phenomenon. Neuromuscular blocking drugs such as rocuronium is the culprit in 60 - 70% of anesthetic medication reactions. Sugammadex reverses rocuronium by encapsulating the drug, preventing binding to acetylcholine receptors. This potentiates the hypothesis that sugammadex may aid in removing rocuronium antigens in the event of rocuronium-induced anaphylaxis.
Description: A 62-year-old male with history of osteoradionecrosis of the mandible, squamous cell carcinoma, trismus, and obstructive sleep apnea presented for repeat mandibulectomy. Awake fiberoptic intubation was performed with lidocaine, fentanyl, and remimazolam. Propofol was used for induction. Rocuronium was the chosen paralytic but 1 minute after administration, the patient developed hypotension, bronchospasm, erythema, and hypoxia. Peak inspiratory pressure was 37 cmH2O and oxygen saturation was 84%. The team initially gave multiple IV epinephrine boluses with minimal effects. With rocuronium being the suspect agent, 200 mg sugammadex was administered, followed by rapid improvement in hemodynamics, oxygenation, and airway pressure. Lab findings confirmed anaphylaxis with elevated tryptase. The procedure was aborted, and the patient remained stable and discharged on postoperative day one.
Discussion: Rocuronium is the most frequently implicated cause of perioperative anaphylaxis in response to anesthesia. Epinephrine is the principal treatment, which addresses the systemic immune cascade and maintains blood pressure. However, it does not neutralize the antigen, causing delayed or incomplete responses. Sugammadex has been proposed as a treatment adjunct due to its encapsulating mechanism. The current discourse has mixed opinions on whether sugammadex acts on the hypersensitivity cascade and aids in rocuronium-induced anaphylaxis. In our case, the patient experienced accelerated and sustained improvement after receiving sugammadex, despite the initial epinephrine. Sugammadex avoided the need for additional epinephrine, IV fluids, and complex airway procedures. Our findings add to the limited literature and suggest a novel consideration of including sugammadex with epinephrine as first line treatment for rocuronium-induced anaphylaxis.
