“Roc’d” by Anaphylaxis, Saved by Sugammadex

Alexander Mai MPH MSII1, Alec Hendon MD2, Julie M. Mani MD2

1Sam Houston State University College of Osteopathic Medicine

2Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX

Introduction Anaphylaxis is a severe multisystem allergic phenomenon.

Nondepolarizing neuromuscular blocking drugs such as rocuronium

is the culprit in 60 - 70% of anesthetic medication reactions.

Sugammadex is a drug that reverses rocuronium by encapsulating

the drug & preventing binding to acetylcholine receptors. This case

tests the hypothesis that Sugammadex may aid in removing

rocuronium antigens or lessening its Ach R interaction in the event of

suspected rocuronium-induced anaphylaxis.

Case Background

62-year-old male with history of squamous cell carcinoma

and osteoradionecrosis presents for repeat

mandibulectomy and tracheostomy. Awake fiberoptic

intubation was performed, once airway secured,

rocuronium was given but 1 minute after, patient had

hypotension, increased PIPs, erythema, and hypoxia. Peak

inspiratory pressure increased 22→37 cmH2O and oxygen

saturation dropped to 84%.

Intervention

Initial treatment IV boluses of epinephrine (160 mcg

total) and albuterol, which yielded minimal effects until

200 mg sugammadex administered. This led to rapid

improvement in hemodynamics, oxygenation, airway

pressures, and erythema. Later labs confirmed

anaphylaxis with elevated tryptase levels of 15.3 ng/mL.

The procedure was aborted but patient remained stable

and was discharged.

Figure 3. Most common causes of

anesthesia-related anaphylaxis

Medication Key

Rocuronium 50 mg

Figure 1. Mechanism of sugammadex reversing rocuronium

IV Epinephrine 10 mcg bolus

Treatment for Suspected Anaphylaxis

IV Epinephrine 100 mcg bolus

Sugammadex 200 mg

1. IV Epinephrine (FIRST AND FAST)

Figure 4. Patient’s vitals from the start of anaphylaxis to its treatment along with when medications were given

2. Albuterol

3. H1 agents (famotidine, diphenhydramine)

4. Steroids (hydrocortisone, dexamethasone)

5. Support for shock (IV fluids, vasopressors)

Figure 2. Steps to treat suspected anaphylaxis

Discussion

Rocuronium is the most frequent medication cause of perioperative anaphylaxis. Epinephrine is the definitive treatment, which

addresses the systemic immune cascade and raising blood pressure. However, it does not neutralize the antigen, causing delayed

or incomplete responses. Sugammadex has been proposed as an anaphylactic 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 only after receiving

sugammadex, despite the initial boluses of epinephrine, which yielded limited effects. The sugammadex avoided the need for

additional epinephrine, IV fluids, and intubation. Our findings add to the limited literature and suggest a novel consideration of

including sugammadex as an adjuvant with epinephrine if suspected rocuronium-induced anaphylaxis.