| Peer-Reviewed

Diagnosis and Management of Rocuronium-induced Perioperative Anaphylaxis

Received: 28 August 2021     Accepted: 18 September 2021     Published: 24 November 2021
Views:       Downloads:
Abstract

Introduction - Perioperative anaphylaxis is a hypersensitivity reaction that occurs after exposure to drugs used for anaesthesia during a surgical procedure. The most common triggers are neuromuscular blocking agents and antibiotics. Case report - A 71-old man, with a history of anaphylaxis during previous anaesthesia, was scheduled for elective coronary surgery. The clinical signs included skin rash, swelling of the upper part of the body with angioedema of the eyelids and lips, without bronchospasm. Based on the assumption that rocuronium was the most likely causative agent, percutaneous coronary intervention was performed during the same hospitalization. After recovery, he was sent for a prick skin test and intradermal test, where sensitivity to rocuronium and insensitivity to the anaesthetics used were determined. Two months later, he developed an acute myocardial infarction. Chronic total occlusive percutaneous coronary intervention was attempted, but without optimal results, so the patient was prepared for elective surgery. Due to potential further complications during anaesthesia, the medical team decided to send him for a skin allergy test for neuromuscular blocking agents. The only neuromuscular relaxant available was Cisatracurium, and it was tested for sensitivity by intradermal test. The intradermal test showed insensitivity to Cisatracurium and Suxamethonium chloride. Conclusion - Early recognition and management of anaphylaxis is based on clinical presentation. The diagnosis by in-vivo and in-vitro tests is useful to determine the cause of anaphylactic reaction and safe alternatives for future anaesthesia.

Published in American Journal of Internal Medicine (Volume 9, Issue 6)
DOI 10.11648/j.ajim.20210906.12
Page(s) 253-256
Creative Commons

This is an Open Access article, distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution and reproduction in any medium or format, provided the original work is properly cited.

Copyright

Copyright © The Author(s), 2021. Published by Science Publishing Group

Keywords

Rocuronium, Anaphylaxis, Perioperative Period, Drug Hypersensitivity, Anesthesia, Signs and Symptoms, Skin Tests, Cisatracurium

References
[1] Turner P, Worm M, Ansotegui I, El-Gamal Y, Fernandez Rivas M, Fineman S. Time to revisit the definition and clinical criteria for anaphylaxis? World Allergy Organ J 2019; 12 (10): 100066.
[2] Harper NJN, Cook TM, Garcez T, Farmer L, Floss K, Marinho S 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.
[3] Mertes P, Didier E, Garcez T, Rose M, Sabato V, Takazawa T et al. Comparative epidemiology of suspected perioperative hypersensitivity reactions. Br J Anaesth 2019; 123 (1): 16-28.
[4] Reitter M, Petitpain N, Latarche C, Cottin J, Massy N, Demoly P et al. Fatal anaphylaxis with neuromuscular blocking agents: a risk factor and management analysis. Allergy 2014; 69 (7): 954-9.
[5] Dewachter P, Savic L. Perioperative anaphylaxis: pathophysiology, clinical presentation, and management. Br J Anaesth 2019; 19 (10) 313-20.
[6] Garvey LH. Perioperative hypersensitivity reactions: diagnosis, treatment and evaluation. Curr Treat Options Allergy 2016; 3: 113-28.
[7] Rose MA, Green SL, Crilly HM, Kolawole H. Perioperative anaphylaxis grading system: ‘making the grade’. Br J Anaesth 2016; 117 (5): 551–3.
[8] Mayorga C, Celik G, Rouzaire P, Whitaker P, Bonadonna P, Rodrigues-Cernadas J et al. In vitro tests for drug hypersensitivity reactions: an ENDA/EAACI Drug Allergy Interest Group position paper. Allergy 2016; 71: 1103-34.
[9] Mertes PM, Moneret-Vautrin DA, Leynadier F, Laxenaire MC. Skin reactions to intradermal neuromuscular blocking agent injections—a randomized multicenter trial in healthy volunteers. Anesthesiology 2007; 107 (2): 245–52.
[10] Aberer W, Bircher A, Romano A, Blanca M, Campi P, Fernandez J et al. Drug provocation testing in the diagnosis of drug hypersensitivity reactions: general considerations. Allergy 2003; 58: 854-63.
[11] Takazawa T, Sabato V, Ebo DG. In vitro diagnostic tests for perioperative hypersensitivity, a narrative review: potential, limitations, and perspectives. Br J Anaesth. 2019; 123 (1): e117-e125.
[12] Berroa F, Lafuente A, Javaloyes G, Ferrer M, Moncada R, Goikoetxea MJ et al. The usefulness of plasma histamine and different tryptase cut-off points in the diagnosis of preanaesthetic hypersensitivity reactions. Clin Exp Allergy 2014; 44: 270-7.
[13] Leysen J, Uyttebroek A, Sabato V, Bridts CH, De Clerck LS, Ebo DG. Predictive value of allergy tests for neuromuscular blocking agents: tackling an unmet need. Clin Exp Allergy 2014; 44: 1069-75.
[14] Hoffmann HJ, Santos AF, Mayorga C, Nopp A, Eberlein B, Ferrer M et al. The clinical utility of basophil activation testing in diagnosis and monitoring of allergic disease. Allergy 2015; 70: 1393-405.
[15] Porebski G, Gschwend-Zawodniak A, Pichler WJ. In vitro diagnosis of T cell-mediated drug allergy. Clin Exp Allergy 2011; 41: 461-70.
[16] Porebski G. In vitro assays in severe cutaneous adverse drug reactions: are they still research tools or diagnostic tests already? Int J Mol Sci 2017; 18 (8): 1737.
[17] Mayorga C, Didier E, Lang D, Atanaskovic-Markovic M, Bonadonna P, Jares E. Controversis in drug allergy: In vitro testing. J Allergy Clin Immunol 2018; 143: 56-65.
Cite This Article
  • APA Style

    Ivana Stojanovic, Jelena Vuckovic, Matej Suntic. (2021). Diagnosis and Management of Rocuronium-induced Perioperative Anaphylaxis. American Journal of Internal Medicine, 9(6), 253-256. https://doi.org/10.11648/j.ajim.20210906.12

    Copy | Download

    ACS Style

    Ivana Stojanovic; Jelena Vuckovic; Matej Suntic. Diagnosis and Management of Rocuronium-induced Perioperative Anaphylaxis. Am. J. Intern. Med. 2021, 9(6), 253-256. doi: 10.11648/j.ajim.20210906.12

    Copy | Download

    AMA Style

    Ivana Stojanovic, Jelena Vuckovic, Matej Suntic. Diagnosis and Management of Rocuronium-induced Perioperative Anaphylaxis. Am J Intern Med. 2021;9(6):253-256. doi: 10.11648/j.ajim.20210906.12

    Copy | Download

  • @article{10.11648/j.ajim.20210906.12,
      author = {Ivana Stojanovic and Jelena Vuckovic and Matej Suntic},
      title = {Diagnosis and Management of Rocuronium-induced Perioperative Anaphylaxis},
      journal = {American Journal of Internal Medicine},
      volume = {9},
      number = {6},
      pages = {253-256},
      doi = {10.11648/j.ajim.20210906.12},
      url = {https://doi.org/10.11648/j.ajim.20210906.12},
      eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.ajim.20210906.12},
      abstract = {Introduction - Perioperative anaphylaxis is a hypersensitivity reaction that occurs after exposure to drugs used for anaesthesia during a surgical procedure. The most common triggers are neuromuscular blocking agents and antibiotics. Case report - A 71-old man, with a history of anaphylaxis during previous anaesthesia, was scheduled for elective coronary surgery. The clinical signs included skin rash, swelling of the upper part of the body with angioedema of the eyelids and lips, without bronchospasm. Based on the assumption that rocuronium was the most likely causative agent, percutaneous coronary intervention was performed during the same hospitalization. After recovery, he was sent for a prick skin test and intradermal test, where sensitivity to rocuronium and insensitivity to the anaesthetics used were determined. Two months later, he developed an acute myocardial infarction. Chronic total occlusive percutaneous coronary intervention was attempted, but without optimal results, so the patient was prepared for elective surgery. Due to potential further complications during anaesthesia, the medical team decided to send him for a skin allergy test for neuromuscular blocking agents. The only neuromuscular relaxant available was Cisatracurium, and it was tested for sensitivity by intradermal test. The intradermal test showed insensitivity to Cisatracurium and Suxamethonium chloride. Conclusion - Early recognition and management of anaphylaxis is based on clinical presentation. The diagnosis by in-vivo and in-vitro tests is useful to determine the cause of anaphylactic reaction and safe alternatives for future anaesthesia.},
     year = {2021}
    }
    

    Copy | Download

  • TY  - JOUR
    T1  - Diagnosis and Management of Rocuronium-induced Perioperative Anaphylaxis
    AU  - Ivana Stojanovic
    AU  - Jelena Vuckovic
    AU  - Matej Suntic
    Y1  - 2021/11/24
    PY  - 2021
    N1  - https://doi.org/10.11648/j.ajim.20210906.12
    DO  - 10.11648/j.ajim.20210906.12
    T2  - American Journal of Internal Medicine
    JF  - American Journal of Internal Medicine
    JO  - American Journal of Internal Medicine
    SP  - 253
    EP  - 256
    PB  - Science Publishing Group
    SN  - 2330-4324
    UR  - https://doi.org/10.11648/j.ajim.20210906.12
    AB  - Introduction - Perioperative anaphylaxis is a hypersensitivity reaction that occurs after exposure to drugs used for anaesthesia during a surgical procedure. The most common triggers are neuromuscular blocking agents and antibiotics. Case report - A 71-old man, with a history of anaphylaxis during previous anaesthesia, was scheduled for elective coronary surgery. The clinical signs included skin rash, swelling of the upper part of the body with angioedema of the eyelids and lips, without bronchospasm. Based on the assumption that rocuronium was the most likely causative agent, percutaneous coronary intervention was performed during the same hospitalization. After recovery, he was sent for a prick skin test and intradermal test, where sensitivity to rocuronium and insensitivity to the anaesthetics used were determined. Two months later, he developed an acute myocardial infarction. Chronic total occlusive percutaneous coronary intervention was attempted, but without optimal results, so the patient was prepared for elective surgery. Due to potential further complications during anaesthesia, the medical team decided to send him for a skin allergy test for neuromuscular blocking agents. The only neuromuscular relaxant available was Cisatracurium, and it was tested for sensitivity by intradermal test. The intradermal test showed insensitivity to Cisatracurium and Suxamethonium chloride. Conclusion - Early recognition and management of anaphylaxis is based on clinical presentation. The diagnosis by in-vivo and in-vitro tests is useful to determine the cause of anaphylactic reaction and safe alternatives for future anaesthesia.
    VL  - 9
    IS  - 6
    ER  - 

    Copy | Download

Author Information
  • Medical Faculty Novi Sad, Institute for Cardiovascular Diseases of Vojvodina, Sremska Kamenica, Serbia

  • Medical Faculty Novi Sad, Institute for Cardiovascular Diseases of Vojvodina, Sremska Kamenica, Serbia

  • Medical Faculty Novi Sad, Institute for Cardiovascular Diseases of Vojvodina, Sremska Kamenica, Serbia

  • Sections