Perioperative Anaphylaxis: A Rare but Severe Reaction to Sugammadex in a High-Risk Patient

Sheetal Bapu, B.S.¹, Jonathan McKinley, M.D.², Divya Cherukupalli, M.D.²

¹Albany Medical College

²Albany Medical Center, Department of Anesthesiology, Albany, NY

 

Main Points

• Perioperative Anaphylaxis from Sugammadex:
  • Sugammadex, a drug used to reverse the neuromuscular blockade, has been associated with rare but life-threatening anaphylactic reactions, which have been increasing with its widespread use.
• Case Report Summary:
  • This is a case of a 63-year-old female with an extensive allergy history who experienced anaphylaxis after being administered sugammadex during surgery. The reaction included severe bronchospasm, hypotension, and required emergency interventions, including epinephrine and a tracheostomy.
• Mechanism and Risks:
  • The exact mechanism of sugammadex-induced anaphylaxis is unclear, but it may involve both allergic and non-allergic pathways. There is speculation that environmental exposure to cyclodextrins, which are structurally like sugammadex, might contribute to hypersensitivity.
• Clinical Presentation and Management:
  • Anaphylactic reactions to sugammadex typically manifest within minutes of administration, with symptoms like hypotension, wheezing, and swelling. Immediate treatment is critical, with epinephrine being the first-line therapy.
• Implications for Practice:
  • Given the risk of anaphylaxis, especially in patients with a history of allergies, preoperative allergy testing for the sugammadex-rocuronium compound might be warranted. Awareness of the potential for severe reactions is essential for anesthesiologists to ensure patient safety.

 

Case Report

• 1) Patient Information:
  • 63-year-old female with cervical disc disease and myelopathy at C6-7.
  • Scheduled for anterior cervical diskectomy and fusion.
• 2) Medical History:
  • Delayed emergence from anesthesia.
  • BMI of 34.32 kg/m².
  • Dysphagia and history of difficult intubation.
  • Conditions: sleep apnea, asthma, hypertension, coronary artery disease, hyperlipidemia, hypothyroidism, peripheral vascular disease, Type 1 diabetes.
  • Allergies: cephalosporins (anaphylactic reactions), hydrocodone (nausea), and penicillin (rash).
• 3) Anesthesia and Intubation:
  • Induced with propofol, fentanyl, and rocuronium.
  • Intubated with a GlideScope due to difficult airway history.
  • Maintained on remifentanil drip.
• 4) Event During Surgery (Figure 1):
  • Sugammadex administration: 2.24 mg/kg given to reverse the paralytic for neuromonitoring.
  • Bronchospasm: Developed within minutes after sugammadex administration.
  • Interventions:
    • Difficulty with bag-mask ventilation, increased peak airway pressures.
    • Switched to 100% FiO2, decreased air entry detected bilaterally.
• 5) Differential Diagnoses and Immediate Actions:
  • Possible causes considered: right main stem intubation, asthma exacerbation, airway circuit occlusion, and mucous plugging.
  • Endotracheal tube (ETT) and circuit checked for migration or occlusion.
  • Albuterol administered without significant improvement.
• 6) Patient Deterioration (Figure 1):
  • Blood pressure drop: Systolic pressure in the 60s, started on phenylephrine drip.
  • Anaphylaxis suspected: Due to lack of oxygen saturation improvement and decreased BP.
  • Treatment for anaphylaxis:
    • Epinephrine administered.
    • Followed by dexamethasone (8 mg) and Benadryl (25 mg), leading to stabilization.
• 7) Additional Observations:
  • Tongue swelling and edema noticed, increasing suspicion for anaphylaxis.
  • Chest X-Ray performed to rule out pneumothorax.
  • Bronchoscopy findings: ETT confirmed in correct position, no mucous plugging found, some secretions removed by suction.
• 8) Post-Surgery Outcomes:
  • Surgery canceled; patient remained intubated on epinephrine drip.
  • Extubated to BiPAP in ICU two days later.
  • Persistent airway swelling led to tracheostomy under general anesthesia.
  • Significant subglottic granulation tissue found, treated with steroid injections twice.
• 9) Follow-Up:
  • Patient continues outpatient management.
  • Tracheostomy remains in place.

 

Figure 1- Intraprocedural Vitals Following Sugammadex Administration

• Sugammadex was administered at 11:37am.
• Within minutes, there was a severe decrease in blood pressure, pulse and oxygen saturation.

 

Discussion

• Perioperative anaphylactic reactions to sugammadex are rare but can be life-threatening.
• Sugammadex is a modified γ-cyclodextrin that encapsulates and inactivates paralytics, providing rapid reversal of the neuromuscular blockade.
• Advantages of Sugammadex:
  • 1.Quick, predictable reversal
  • 2.Lower risk of residual paralysis
• Adverse effects of sugammadex:
  • 1.Inadequate reversal due to improper dosing
  • 2.Cardiac effects including bradycardia and QT interval prolongation
  • 3.Anticoagulant effects
  • 4.Anaphylaxis
• First reported in 2011, anaphylactic reactions to sugammadex have been increasing. A 5-year multi-center retrospective study in Japan (2012-2016) showed a 0.02% incidence of sugammadex-induced anaphylaxis.
• All anaphylaxis case reports were confirmed through a positive skin reaction to the sugammadex-rocuronium compound.
• Tryptase levels are indicative of anaphylaxis. Tryptase levels in this case were in the high normal range at 9.9 ug/L (Normal: 2.2 - 13.2 ug/L ).
• Factors that might increase the patient’s likelihood of experiencing an anaphylactic reaction:
  • Allergy history
  • Genetic susceptibility
  • Environmental exposure to cyclodextrins
    • Cyclodextrins have a similar structure to sugammadex.
    • Cyclodextrins are commonly found in food additives and pharmaceuticals in the United States.
• Long-term outcomes of anaphylaxis can significantly impact quality of life.
• Tracheal stenosis can occur in 10-22% of cases of intubation for > 7 days.
• In this case, tracheal stenosis developed after just two days of intubation, a rare occurrence typically seen in only 1-2% of cases.