D2.246 - Anaphylaxis to sugammadex in a 15 year-old-girl
Case report
We report the case of a fifteen-year-old girl had anaphylaxis during laparoscopic appendicectomy. Induction was uneventful and towards the end of surgery, ondansetron, levobupivacaine and sugammadex were administered <10 minutes before the onset of widespread urticarial rash, hypotension and tachycardia. Alfentanil, propofol, suxamethonium, rocuronium, dexamethasone, morphine, paracetamol and teicoplanin were administered 45-60 minutes before the onset of symptoms. No rise in mast cell tryptase was noted. She received four doses of IV adrenaline and Hartmann’s solution. The reaction resolved in 40 minutes.
Eighteen weeks later, intradermal tests caused a significant flare response (40mm) to sugammadex with no increase in weal size. Other drugs were negative, suggesting the culprit agent was either sugammadex or levobupivacaine. She had a levobupivacaine challenge on the day. Repeat intradermal skin tests to sugammadex (after 22 weeks) were positive (weal 8mm, flare 30mm, initial bleb 4mm) and sugammadex rocuronium complex (weal 12mm, flare 30mm, initial bleb 4mm) confirming sugammadex as the causative agent.
Learning points:
Sugammadex is not frequently used in children as paediatric cases are increasingly intubated either without neuromuscular blocking agents or with atracurium. No paediatric cases of anaphylaxis to sugammadex were found in a 1-year study of perioperative anaphylaxis in the UK (NAP6).
The hallmark of sugammadex anaphylaxis is that it presents at the end of anaesthesia. As observed in our case, hypotension is reported as the most common feature of sugammadex anaphylaxis. In our case, anaphylaxis happened 50-60 min after induction, making neuromuscular blocking agents or antibiotics unlikely causes. Existing evidence on hypersensitivity to sugammadex suggests the possibility of both IgE and non-IgE mechanisms. Allergy to the rocuronium – sugammadex complex alone has been reported in adult cases, so it is important to include this in the testing panel. Although mast cell tryptase was negative in our case, positive IDT suggests an IgE-mediated mechanism of action.
Although not recommended, sugammadex has been speculatively used to treat anaphylaxis to rocuronium in adults. Knowing the potential to cause IgE reactions itself, sugammadex should be used with caution in this scenario.
