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Gonzalez-Estrada A, Carrillo-Martin I, Morgenstern-Kaplan D, Garzon-Siatoya WT, Renew JR, Hernandez-Torres V, Volcheck GW. The Nonirritating Concentrations of Neuromuscular Blocking Agents and Related Compounds. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:466-473.e5. [PMID: 36108924 DOI: 10.1016/j.jaip.2022.08.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 08/29/2022] [Accepted: 08/31/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Skin testing (ST) concentrations of neuromuscular blocking agents (NMBAs), NMBA-reversal agents, and the sugammadex-rocuronium inclusion complex (S-R-Cx) vary widely among reports. OBJECTIVE To determine maximal ST nonirritant concentrations (NICs) of NMBAs (cisatracurium, rocuronium, succinylcholine, and vecuronium), NMBA-reversal agents (neostigmine and sugammadex), and S-R-Cx in NMBA-tolerant and NMBA-naïve participants. METHODS A single-center, prospective study between October 2019 and November 2021 of adult participants with or without a planned surgical procedure. The reference standard was tolerance of medication tested during a procedure (NMBA-tolerant group) before ST. Participants received skin prick testing (SPT) and intradermal test (IDT) injections at 5-7 increasing concentrations of 1 or more medications. All medications were reconstituted according to package insert instructions and diluted with 0.9% saline. A concentration was considered irritant when more than 5% of participants had a positive test per ST positivity criteria (wheal ≥3 mm than initial wheal and associated erythema of the same size or greater than wheal). We also compared our results with current guidelines. RESULTS A total of 187 participants (78% NMBA-tolerant) underwent 7812 skin tests. All undiluted SPT concentrations were nonirritant. We found the following maximal IDT NICs (mg/mL): cisatracurium (0.02), rocuronium (0.05), succinylcholine (0.8), vecuronium (0.01), neostigmine (0.2), sugammadex (50), and S-R-Cx (sugammadex 7.14 + rocuronium 2). CONCLUSION Our results suggest that SPT may be performed with undiluted stock concentrations. We confirm maximal IDT NICs for cisatracurium and rocuronium. We also propose that currently recommended maximal IDT NICs of succinylcholine, neostigmine, sugammadex, and S-R-Cx could be increased, whereas the maximal IDT NIC of vecuronium could be decreased compared with current guidelines and prior reports.
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Affiliation(s)
- Alexei Gonzalez-Estrada
- Division of Pulmonary, Allergy and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla.
| | - Ismael Carrillo-Martin
- Division of Pulmonary, Allergy and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla
| | - Dan Morgenstern-Kaplan
- Division of Pulmonary, Allergy and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla
| | - W Tatiana Garzon-Siatoya
- Division of Pulmonary, Allergy and Sleep Medicine, Department of Medicine, Mayo Clinic, Jacksonville, Fla
| | - J Ross Renew
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Fla
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Broyles AD, Banerji A, Barmettler S, Biggs CM, Blumenthal K, Brennan PJ, Breslow RG, Brockow K, Buchheit KM, Cahill KN, Cernadas J, Chiriac AM, Crestani E, Demoly P, Dewachter P, Dilley M, Farmer JR, Foer D, Fried AJ, Garon SL, Giannetti MP, Hepner DL, Hong DI, Hsu JT, Kothari PH, Kyin T, Lax T, Lee MJ, Lee-Sarwar K, Liu A, Logsdon S, Louisias M, MacGinnitie A, Maciag M, Minnicozzi S, Norton AE, Otani IM, Park M, Patil S, Phillips EJ, Picard M, Platt CD, Rachid R, Rodriguez T, Romano A, Stone CA, Torres MJ, Verdú M, Wang AL, Wickner P, Wolfson AR, Wong JT, Yee C, Zhou J, Castells M. Practical Guidance for the Evaluation and Management of Drug Hypersensitivity: Specific Drugs. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 8:S16-S116. [PMID: 33039007 DOI: 10.1016/j.jaip.2020.08.006] [Citation(s) in RCA: 89] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 08/10/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Ana Dioun Broyles
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Aleena Banerji
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Sara Barmettler
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Catherine M Biggs
- Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, Vancouver, Canada
| | - Kimberly Blumenthal
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Patrick J Brennan
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Rebecca G Breslow
- Division of Sports Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, Munich, Germany
| | - Kathleen M Buchheit
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Katherine N Cahill
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Josefina Cernadas
- Allergology and Immunology Service, Centro Hospitalar Universitário de S.João Hospital, Porto, Portugal
| | - Anca Mirela Chiriac
- Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France
| | - Elena Crestani
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Pascal Demoly
- Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France
| | - Pascale Dewachter
- Department of Anesthesiology and Intensive Care Medicine, Groupe Hospitalier Paris-Seine-Saint-Denis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Meredith Dilley
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Jocelyn R Farmer
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Dinah Foer
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Ari J Fried
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Sarah L Garon
- Associated Allergists and Asthma Specialists, Chicago, Ill
| | - Matthew P Giannetti
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - David L Hepner
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Mass
| | - David I Hong
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Joyce T Hsu
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Parul H Kothari
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Timothy Kyin
- Division of Asthma, Allergy & Immunology, University of Virginia, Charlottesville, Va
| | - Timothy Lax
- Division of Allergy and Inflammation, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Min Jung Lee
- Allergy and Immunology at Hoag Medical Group, Newport Beach, Calif
| | - Kathleen Lee-Sarwar
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Anne Liu
- Division of Allergy / Immunology, Stanford University School of Medicine, Palo Alto, Calif
| | - Stephanie Logsdon
- Division of Allergy and Immunology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Margee Louisias
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Andrew MacGinnitie
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Michelle Maciag
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Samantha Minnicozzi
- Division of Allergy and Clinical Immunology, Respiratory Medicine, Department of Pediatrics, University of Virginia, Charlottesville, Va
| | - Allison E Norton
- Division of Allergy, Immunology and Pulmonology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tenn
| | - Iris M Otani
- Division of Pulmonary, Critical Care, Allergy, and Sleep, Department of Medicine, University of California, San Francisco Medical Center, San Francisco, Calif
| | - Miguel Park
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minn
| | - Sarita Patil
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Elizabeth J Phillips
- Department of Medicine & Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tenn
| | - Matthieu Picard
- Division of Allergy and Clinical Immunology, Department of Medicine, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Craig D Platt
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Rima Rachid
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Tito Rodriguez
- Drug Allergy Department, Al-Rashed Allergy Center, Sulaibikhat, Al-Kuwait, Kuwait
| | - Antonino Romano
- IRCCS Oasi Maria S.S., Troina, Italy & Fondazione Mediterranea G.B. Morgagni, Catania, Italy
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Maria Jose Torres
- Allergy Unit and Research Group, Hospital Regional Universitario de Málaga, UMA-IBIMA-BIONAND, ARADyAL, Málaga, Spain
| | - Miriam Verdú
- Allergy Unit, Hospital Universitario de Ceuta, Ceuta, Spain
| | - Alberta L Wang
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Paige Wickner
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass
| | - Anna R Wolfson
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Johnson T Wong
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Christina Yee
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Joseph Zhou
- Division of Allergy/Immunology, Boston Children's Hospital, Boston, Mass
| | - Mariana Castells
- Drug hypersensitivity and Desensitization Center, Brigham and Women's Hospital, Boston, Mass
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Franz AM, Chiem J, Martin LD, Rampersad S, Phillips J, Grigg EB. Case series of 331 cases of sugammadex compared to neostigmine in patients under 2 years of age. Paediatr Anaesth 2019; 29:591-596. [PMID: 30934160 DOI: 10.1111/pan.13643] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 03/26/2019] [Accepted: 03/27/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Sugammadex is a novel neuromuscular blockade reversal agent approved by the Food and Drug Administration in 2015, but little literature exists for patients less than 2 years of age. AIMS The aims of this study were to: describe a cohort of patients 2 years old and younger who received sugammadex; describe any adverse effects of sugammadex in this age group; compare time from end of surgery to out of operating room for sugammadex versus neostigmine; compare time between last dose of neuromuscular blocking drug and reversal; and use train-of-four data to assess reversal. METHODS Chart review of the medical record and the anesthesia information system captured all patients in this age cohort who received sugammadex or neostigmine over a two-year period. Adverse medication events were pulled from a mandatory quality improvement field in the electronic anesthesia record. T-tests were used for analyses. RESULTS No adverse effects were reported with 331 doses of sugammadex. The average time in minutes between end of surgery and out of operating room was similar for neostigmine (19.6) versus sugammadex (19.4) (mean difference 0.2, 95% CI -1.5-1.8, P = 0.85). The average time in minutes between last dose of neuromuscular blocking drug and reversal agent was longer for neostigmine (103) than for sugammadex (84) (mean difference 19, 95% CI 13-26, P < 0.001). CONCLUSIONS Sugammadex administration in this young population did not result in any adverse effects. It appears to be equally effective as neostigmine in patients under 2 years of age.
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Affiliation(s)
- Amber M Franz
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Jennifer Chiem
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Lizabeth D Martin
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Sally Rampersad
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Jennifer Phillips
- Research Informatics, Enterprise Analytics, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Eliot B Grigg
- Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington, Seattle, Washington
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