D3.380 - The Most Serious Threat in Perioperative Hypersensitivity Reactions (PHRs): Neuromuscular Blocking Agent (NMBA) Hypersensitivity and Cisatracurium as a Safe Haven in the Setting of Cross-Reactivity

Perioperative hypersensitivity reactions (PHRs) may be triggered by anesthetic agents such as opioids, hypnotics, and neuromuscular blocking agents (NMBAs), as well as by other drugs, disinfectants, and latex sensitization. NMBAs are the most important cause of PHRs. In our clinical practice, we observed that NMBAs are not only the most frequently identified drug group responsible for PHRs but are also associated with the severity of the reactions. Furthermore, cross-reactivity among NMBAs is common, which complicates patient management. In this study, we aimed to share our experience in the management of patients with NMBA hypersensitivity, who presented with a history of PHR and experienced frequent and severe reactions.

In this study, patients who were referred to our center for evaluation of perioperative hypersensitivity reactions (PHRs) were assessed retrospectively. Skin testing was performed using prick and intradermal test (IDT) methods at the recommended non-irritant concentrations. In patients with confirmed NMBA hypersensitivity, additional skin testing with cisatracurium was carried out to assess cross-reactivity, particularly in cases showing positive responses to rocuronium and vecuronium. Premedication was recommended prior to surgery. To evaluate the effectiveness of the allergic work-up, patients were contacted by phone in the postoperative period and questioned regarding the occurrence of any hypersensitivity reactions. Patients with positive skin or provocation test results were recorded, taking into account the severity of the reaction.

Among the 102 patients evaluated for perioperative hypersensitivity reactions (PHRs), the mean age was 45 ± 14 years, with a predominance of female patients (83%). Asthma was the most common comorbidity. The severity of reactions was most frequently classified as Grade 3, and two patients required intervention due to cardiac arrest. The rates of positive skin test results were 40.2% for neuromuscular blocking agents (NMBAs), 22.5% for opioids, and 18.6% for hypnotic agents. In six patients who reported reactions following anesthetic administration containing midazolam, skin tests were negative; therefore, oral provocation testing with midazolam was performed, and no reactions were observed. Among patients who experienced severe reactions (n = 19), vecuronium was the most frequently identified positive agent (n = 10; 60%), while rocuronium hypersensitivity was detected in 2 patients (10.5%). Additional NMBA sensitizations were evaluated among patients with positive skin tests to vecuronium, rocuronium, and cisatracurium. Following allergological evaluation, only one patient who subsequently underwent surgery developed a Grade 1 reaction despite premedication.

In patients with a history of perioperative hypersensitivity reactions (PHRs), the most frequent and most severe reactions were associated with vecuronium, and due to the frequent cross-reactivity with rocuronium, cisatracurium should be considered a safe alternative. Comprehensive allergological evaluation and appropriate premedication may help prevent potential PHRs.