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Dejoux A, Zhu Q, Ganneau C, Goff ORL, Godon O, Lemaitre J, Relouzat F, Huetz F, Sokal A, Vandenberghe A, Pecalvel C, Hunault L, Derenne T, Gillis CM, Iannascoli B, Wang Y, Rose T, Mertens C, Nicaise-Roland P, England P, Mahévas M, de Chaisemartin L, Le Grand R, Letscher H, Saul F, Pissis C, Haouz A, Reber LL, Chappert P, Jönsson F, Ebo DG, Millot GA, Bay S, Chollet-Martin S, Gouel-Chéron A, Bruhns P. Rocuronium-specific antibodies drive perioperative anaphylaxis but can also function as reversal agents in preclinical models. Sci Transl Med 2024; 16:eado4463. [PMID: 39259810 DOI: 10.1126/scitranslmed.ado4463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 06/06/2024] [Accepted: 08/05/2024] [Indexed: 09/13/2024]
Abstract
Neuromuscular blocking agents (NMBAs) relax skeletal muscles to facilitate surgeries and ease intubation but can lead to adverse reactions, including complications because of postoperative residual neuromuscular blockade (rNMB) and, in rare cases, anaphylaxis. Both adverse reactions vary between types of NMBAs, with rocuronium, a widely used nondepolarizing NMBA, inducing one of the longest rNMB durations and highest anaphylaxis incidences. rNMB induced by rocuronium can be reversed by the synthetic γ-cyclodextrin sugammadex. However, in rare cases, sugammadex can provoke anaphylaxis. Thus, additional therapeutic options are needed. Rocuronium-induced anaphylaxis is proposed to rely on preexisting rocuronium-binding antibodies. To understand the pathogenesis of rocuronium-induced anaphylaxis and to identify potential therapeutics, we investigated the memory B cell antibody repertoire of patients with suspected hypersensitivity to rocuronium. We identified polyclonal antibody repertoires with a high diversity among V(D)J genes without evidence of clonal groups. When recombinantly expressed, these antibodies demonstrated specificity and low affinity for rocuronium without cross-reactivity for other NMBAs. Moreover, when these antibodies were expressed as human immunoglobulin E (IgE), they triggered human mast cell activation and passive systemic anaphylaxis in transgenic mice, although their affinities were insufficient to serve as reversal agents. Rocuronium-specific, high-affinity antibodies were thus isolated from rocuronium-immunized mice. The highest-affinity antibody was able to reverse rocuronium-induced neuromuscular blockade in nonhuman primates with kinetics comparable to that of sugammadex. Together, these data support the hypothesis that antibodies cause anaphylactic reactions to rocuronium and pave the way for improved diagnostics and neuromuscular blockade reversal agents.
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Affiliation(s)
- Alice Dejoux
- Institut Pasteur, Université Paris Cité, INSERM UMR1222, Antibodies in Therapy and Pathology, 75015 Paris, France
- Sorbonne Université, Collège Doctoral, 75005 Paris, France
| | - Qianqian Zhu
- Institut Pasteur, Université Paris Cité, INSERM UMR1222, Antibodies in Therapy and Pathology, 75015 Paris, France
- Université Paris-Saclay, INSERM, Inflammation Microbiome Immunosurveillance, 91400 Orsay, France
| | - Christelle Ganneau
- Institut Pasteur, Université Paris Cité, CNRS UMR3523, Chimie des Biomolécules, 75015 Paris, France
| | - Odile Richard-Le Goff
- Institut Pasteur, Université Paris Cité, INSERM UMR1222, Antibodies in Therapy and Pathology, 75015 Paris, France
| | - Ophélie Godon
- Institut Pasteur, Université Paris Cité, INSERM UMR1222, Antibodies in Therapy and Pathology, 75015 Paris, France
| | - Julien Lemaitre
- Université Paris-Saclay, INSERM, CEA, Center for Immunology of Viral, Autoimmune, Hematological and Bacterial Diseases, 92260 Fontenay-aux-Roses and 94250 Le Kremlin-Bicêtre, France
| | - Francis Relouzat
- Université Paris-Saclay, INSERM, CEA, Center for Immunology of Viral, Autoimmune, Hematological and Bacterial Diseases, 92260 Fontenay-aux-Roses and 94250 Le Kremlin-Bicêtre, France
| | - François Huetz
- Institut Pasteur, Université Paris Cité, INSERM UMR1222, Antibodies in Therapy and Pathology, 75015 Paris, France
| | - Aurélien Sokal
- Institut Necker Enfants Malades, INSERM U1151/CNRS UMR 8253, Action thématique incitative sur programme-Avenir Team, Auto-Immune and Immune B cells, Université Paris Cité, Université Paris Est-Créteil, 94000 Créteil, France; INSERM U955, équipe 2. Institut Mondor de Recherche Biomédicale, Université Paris-Est Créteil, 94000 Créteil, France
- Service de Médecine interne, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris (AP-HP), Université de Paris Cité, 92110 Clichy, France
| | - Alexis Vandenberghe
- Institut Necker Enfants Malades, INSERM U1151/CNRS UMR 8253, Action thématique incitative sur programme-Avenir Team, Auto-Immune and Immune B cells, Université Paris Cité, Université Paris Est-Créteil, 94000 Créteil, France; INSERM U955, équipe 2. Institut Mondor de Recherche Biomédicale, Université Paris-Est Créteil, 94000 Créteil, France
| | - Cyprien Pecalvel
- Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), INSERM UMR1291, CNRS UMR5051, University Toulouse III, 31000 Toulouse, France
| | - Lise Hunault
- Institut Pasteur, Université Paris Cité, INSERM UMR1222, Antibodies in Therapy and Pathology, 75015 Paris, France
- Sorbonne Université, Collège Doctoral, 75005 Paris, France
| | - Thomas Derenne
- Institut Pasteur, Université Paris Cité, INSERM UMR1222, Antibodies in Therapy and Pathology, 75015 Paris, France
- Sorbonne Université, Collège Doctoral, 75005 Paris, France
| | - Caitlin M Gillis
- Institut Pasteur, Université Paris Cité, INSERM UMR1222, Antibodies in Therapy and Pathology, 75015 Paris, France
| | - Bruno Iannascoli
- Institut Pasteur, Université Paris Cité, INSERM UMR1222, Antibodies in Therapy and Pathology, 75015 Paris, France
| | - Yidan Wang
- Institut Pasteur, Université Paris Cité, INSERM UMR1222, Antibodies in Therapy and Pathology, 75015 Paris, France
| | - Thierry Rose
- Institut Pasteur, Université Paris Cité, INSERM UMR1224, Biologie Cellulaire des Lymphocytes, Ligue Nationale Contre le Cancer, Équipe Labellisée Ligue 2018, 75015 Paris, France
| | - Christel Mertens
- Faculty of Medicine and Health Science, Department of Immunology-Allergology-Rheumatology, Antwerp University Hospital and the Infla-Med Center of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology and Allergology, AZ Jan Palfijn Ghent, 9000 Ghent, Belgium
| | - Pascale Nicaise-Roland
- Service d'immunologie Biologique, DMU BIOGEM, Hôpital Bichat, APHP, 75018, Paris, France
| | - Patrick England
- Institut Pasteur, Université Paris Cité, CNRS UMR3528, Molecular Biophysics Core Facility, 75015 Paris, France
| | - Matthieu Mahévas
- Institut Necker Enfants Malades, INSERM U1151/CNRS UMR 8253, Action thématique incitative sur programme-Avenir Team, Auto-Immune and Immune B cells, Université Paris Cité, Université Paris Est-Créteil, 94000 Créteil, France; INSERM U955, équipe 2. Institut Mondor de Recherche Biomédicale, Université Paris-Est Créteil, 94000 Créteil, France
| | - Luc de Chaisemartin
- Université Paris-Saclay, INSERM, Inflammation Microbiome Immunosurveillance, 91400 Orsay, France
- Service d'immunologie Biologique, DMU BIOGEM, Hôpital Bichat, APHP, 75018, Paris, France
| | - Roger Le Grand
- Université Paris-Saclay, INSERM, CEA, Center for Immunology of Viral, Autoimmune, Hematological and Bacterial Diseases, 92260 Fontenay-aux-Roses and 94250 Le Kremlin-Bicêtre, France
| | - Hélène Letscher
- Université Paris-Saclay, INSERM, CEA, Center for Immunology of Viral, Autoimmune, Hematological and Bacterial Diseases, 92260 Fontenay-aux-Roses and 94250 Le Kremlin-Bicêtre, France
| | - Frederick Saul
- Institut Pasteur, Université Paris Cité, CNRS UMR3528, Plate-forme Cristallographie-C2RT, 75015 Paris, France
| | - Cédric Pissis
- Institut Pasteur, Université Paris Cité, CNRS UMR3528, Plate-forme Cristallographie-C2RT, 75015 Paris, France
| | - Ahmed Haouz
- Institut Pasteur, Université Paris Cité, CNRS UMR3528, Plate-forme Cristallographie-C2RT, 75015 Paris, France
| | - Laurent L Reber
- Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), INSERM UMR1291, CNRS UMR5051, University Toulouse III, 31000 Toulouse, France
| | - Pascal Chappert
- Institut Necker Enfants Malades, INSERM U1151/CNRS UMR 8253, Action thématique incitative sur programme-Avenir Team, Auto-Immune and Immune B cells, Université Paris Cité, Université Paris Est-Créteil, 94000 Créteil, France; INSERM U955, équipe 2. Institut Mondor de Recherche Biomédicale, Université Paris-Est Créteil, 94000 Créteil, France
| | - Friederike Jönsson
- Institut Pasteur, Université Paris Cité, INSERM UMR1222, Antibodies in Therapy and Pathology, 75015 Paris, France
- CNRS, F-75015 Paris, France
| | - Didier G Ebo
- Faculty of Medicine and Health Science, Department of Immunology-Allergology-Rheumatology, Antwerp University Hospital and the Infla-Med Center of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology and Allergology, AZ Jan Palfijn Ghent, 9000 Ghent, Belgium
| | - Gaël A Millot
- Institut Pasteur, Université Paris Cité, INSERM UMR1222, Antibodies in Therapy and Pathology, 75015 Paris, France
- Institut Pasteur, Université Paris Cité, Bioinformatics and Biostatistics Hub, 75015 Paris, France
| | - Sylvie Bay
- Institut Pasteur, Université Paris Cité, CNRS UMR3523, Chimie des Biomolécules, 75015 Paris, France
| | - Sylvie Chollet-Martin
- Université Paris-Saclay, INSERM, Inflammation Microbiome Immunosurveillance, 91400 Orsay, France
- Service d'immunologie Biologique, DMU BIOGEM, Hôpital Bichat, APHP, 75018, Paris, France
| | - Aurélie Gouel-Chéron
- Institut Pasteur, Université Paris Cité, INSERM UMR1222, Antibodies in Therapy and Pathology, 75015 Paris, France
- Anaesthesiology and Critical Care Medicine Department, DMU Parabol, Bichat-Claude Bernard Hospital, AP-HP, 75018 Paris, France
- Université Paris Cité, 75010 Paris, France
| | - Pierre Bruhns
- Institut Pasteur, Université Paris Cité, INSERM UMR1222, Antibodies in Therapy and Pathology, 75015 Paris, France
- INSERM 1152, DHU FIRE, Labex Inflamex, Université Paris Diderot Paris 7, 75018 Paris, France
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Arora V, Lee A. Perioperative Anaphylaxis: Comment. Anesthesiology 2023; 139:361. [PMID: 37247347 DOI: 10.1097/aln.0000000000004597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Vivek Arora
- VA Puget Sound Health Care System, University of Washington, Seattle, Washington (V.A.).
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Baldo BA. Allergic and other adverse reactions to drugs used in anesthesia and surgery. ANESTHESIOLOGY AND PERIOPERATIVE SCIENCE 2023; 1:16. [PMCID: PMC10264870 DOI: 10.1007/s44254-023-00018-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/02/2023] [Accepted: 04/11/2023] [Indexed: 11/13/2023]
Abstract
The list of drugs patients may be exposed to during the perioperative and postoperative periods is potentially extensive. It includes induction agents, neuromuscular blocking drugs (NMBDs), opioids, antibiotics, sugammadex, colloids, local anesthetics, polypeptides, antifibrinolytic agents, heparin and related anticoagulants, blue dyes, chlorhexidine, and a range of other agents depending on several factors related to individual patients’ clinical condition and progress in the postoperative recovery period. To avoid poor or ultrarapid metabolizers to a particular drug (for example tramadol and codeine) or possible adverse drug reactions (ADRs), some drugs may need to be avoided during or after surgery. This will be the case for patients with a history of anaphylaxis or other adverse events/intolerances to a known drug. Other drugs may be ceased for a period before surgery, e.g., anticoagulants that increase the chance of bleeding; diuretics for patients with acute renal failure; antihypertensives relative to kidney injury after major vascular surgery; and serotonergic drugs that together with some opioids may rarely induce serotonin toxicity. Studies of germline variations shown by genotyping and phenotyping to identify a predisposition of genetic factors to ADRs offer an increasingly important approach to individualize drug therapy. Studies of associations of human leukocyte antigen (HLA) genes with some serious delayed immune-mediated reactions are ongoing and variations of drug-metabolizing cytochrome CYP450 enzymes, P-glycoprotein, and catechol-O -methyltransferase show promise for the assessment of ADRs and non-responses to drugs, particularly opioids and other analgesics. Surveys of ADRs from an increasing number of institutions often cover small numbers of patients, are retrospective in nature, fail to clearly identify culprit drugs, and do not adequately distinguish immune-mediated from non-immune-mediated anaphylactoid reactions. From the many surveys undertaken, the large list of agents identified during and after anesthesia and surgery are examined for their ADR involvement. Drugs are classified into those most often involved, (NMBD and antibiotics); drugs that are becoming more frequently implicated, namely antibiotics (particularly teicoplanin), and blue dyes; those becoming less frequently involved; and drugs more rarely involved in perioperative, and postoperative adverse reactions but still important and necessary to keep in mind for the occasional potential sensitive patient. Clinicians should be aware of the similarities between drug-induced true allergic type I IgE/FcεRI- and pseudoallergic MRGPRX2-mediated ADRs, the clinical features of each, and their distinguishing characteristics. Procedures for identifying MRGPRX2 agonists and diagnosing and distinguishing pseudoallergic from allergic reaction mechanisms are discussed.
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Affiliation(s)
- Brian A. Baldo
- Molecular Immunology Unit, Kolling Institute of Medical Research, Royal North Shore Hospital of Sydney, St Leonards, Australia
- Department of Medicine, University of Sydney, Sydney, NSW Australia
- Lindfield, Australia
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Hung SK, Yeh CC, Ting PC, Chen CH, Kao MC. Successful management of rocuronium-induced anaphylaxis with sugammadex: A case report. J Int Med Res 2022; 50:3000605221113913. [PMID: 35869623 PMCID: PMC9315254 DOI: 10.1177/03000605221113913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Although anaphylaxis during anaesthesia is a rare event, neuromuscular
blocking drugs are responsible for 62% of anaesthesia-related
anaphylaxis. However, sugammadex, a modified gamma-cyclodextrin, can
encapsulate rocuronium molecules and cause the rapid reversal of the
neuromuscular blockade. A 68-year-old man who presented for a radical
prostatectomy was induced with IV fentanyl/propofol/rocuronium. He had
not received rocuronium previously but had received cisatracurium.
Shortly after anaesthesia, the patient’s heart rate abruptly
increased, and systolic blood pressure (SBP) dropped to 40 mm Hg.
Despite cardiopulmonary resuscitation and intensive management, his
haemodynamic stability did not improve until he received IV
sugammadex, 200 mg. Intradermal skin tests showed he was positive for
cisatracurium, rocuronium and succinylcholine. The patient was
suspected to have cross-reactivity of rocuronium with cisatracurium.
This case highlights the potential benefit of sugammadex as an adjunct
to conventional measures during rocuronium-induced anaphylaxis.
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Affiliation(s)
- Sheng-Kai Hung
- Department of Anaesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Chia-Chi Yeh
- Department of Family Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Pei-Chi Ting
- Department of Anaesthesiology, New Taipei Municipal TuCheng Hospital (Built and Operated by Chang Gung Medical Foundation), New Taipei City, Taiwan
| | - Cay-Huyen Chen
- Department of Anaesthesiology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Ming-Chang Kao
- Department of Anaesthesiology, New Taipei Municipal TuCheng Hospital (Built and Operated by Chang Gung Medical Foundation), New Taipei City, Taiwan.,Department of Anaesthesiology, New Taipei Municipal TuCheng Hospital, No. 6, Sec. 2, Jincheng Rd., Tucheng Dist., New Taipei City, Taiwan
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Ghimire A, Olbrecht VA, Tobias JD. Role of sugammadex in the treatment of anaphylaxis due to rocuronium in children: Extrapolation from adult and animal reports. Paediatr Anaesth 2022; 32:706-715. [PMID: 35212434 DOI: 10.1111/pan.14424] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/14/2022] [Accepted: 02/18/2022] [Indexed: 12/01/2022]
Abstract
Allergic reactions are generalized hypersensitivity processes triggered by different antigenic stimuli, resulting in the end effect of mast cell degranulation and adverse physiologic effects. During the perioperative period, the most commonly identified agents include antibiotics, neuromuscular blocking agents (rocuronium and succinylcholine), chlorhexidine, and iodinated dyes for radiologic imaging. Sugammadex is a novel agent for the reversal of neuromuscular blockade achieved with rocuronium or vecuronium. Its unique mechanism of action, whereby it encapsulates and forms a one-to-one complex with rocuronium, has led to its anecdotal use as an adjunct in the treatment of anaphylactic and anaphylactoid reactions following rocuronium. The current manuscript discusses the potential use of sugammadex in the treatment of allergic reactions following the administration of rocuronium, reviews previous anecdotal reports of its use in these scenarios, and provides recommendations for future care.
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Affiliation(s)
- Anuranjan Ghimire
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Vanessa A Olbrecht
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Kim SM, Oh SH, Ryu SA. Treatment of rocuronium-induced anaphylaxis using sugammadex - A case report. Anesth Pain Med (Seoul) 2020; 16:56-59. [PMID: 33348946 PMCID: PMC7861895 DOI: 10.17085/apm.20074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 10/28/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Perioperative anaphylaxis is a life-threatening clinical condition characterized by severe respiratory and cardiovascular manifestations. Neuromuscular blocking agents are the most common cause of anaphylaxis during anesthesia. CASE We report a case of rocuronium-induced anaphylaxis treated with sugammadex. A 75-year-old female was scheduled to undergo spinal surgery. She had no history of allergies. After the injection of rocuronium, she developed hypotension and tachycardia, and skin rashes and urticaria appeared. The patient received sugammadex to delay the operation, and her vital signs were stabilized. On the 76th postoperative day, we performed intradermal tests for rocuronium, propofol, and cefazolin. Diluted rocuronium alone induced 14 mm of flare and 8 mm of wheal within 5 min, both of which disappeared within 15 min after the intradermal injection. CONCLUSIONS Sugammadex is a useful rocuronium antagonist that can be used to treat rocuronium-induced anaphylaxis.
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Affiliation(s)
- Sun-Min Kim
- Department of Anesthesiology and Pain Medicine, Seoul Medical Center, Seoul, Korea
| | - Sei-Hoon Oh
- Department of Anesthesiology and Pain Medicine, Seoul Medical Center, Seoul, Korea
| | - Seung-Ah Ryu
- Department of Anesthesiology and Pain Medicine, Seoul Medical Center, Seoul, Korea
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Lee HY, Jung KT. Advantages and pitfalls of clinical application of sugammadex. Anesth Pain Med (Seoul) 2020; 15:259-268. [PMID: 33329823 PMCID: PMC7713848 DOI: 10.17085/apm.19099] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 05/25/2020] [Accepted: 06/02/2020] [Indexed: 12/18/2022] Open
Abstract
Sugammadex, a modified γ-cyclodextrin, is one of the drugs focused on in the anesthetic field because it provides rapid and complete reversal from neuromuscular blockade (NMB) by encapsulating rocuronium. Its introduction has revolutionized anesthesia practice because it is a safe, predictable, and reliable neuromuscular antagonist. Hence, its use has increased worldwide. Further, it has been in the spotlight for recovering from deep NMB in laparoscopic surgery and improving the surgical condition. Recently, studies have been conducted on the postoperative outcome after deep NMB and use of sugammadex in various clinical conditions. However, with increase in sugammadex use, reports regarding its complications are increasing. Appropriate dosing of sugammadex with quantitative neuromuscular monitoring is emphasized because under-dosing or over-dosing of sugammadex might be associated with unexperienced complications. Sugammadex is now leaping into an ideal reversal agent, changing the anesthesia practice.
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Affiliation(s)
- Hyung Young Lee
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, School of Medicine, Chosun University, Gwangju, Korea
| | - Ki Tae Jung
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, School of Medicine, Chosun University, Gwangju, Korea
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De La Cruz I, Errando C, Calaforra S. Treatment of Anaphylaxis to Rocuronium with Sugammadex: A Case Report with Bronchospasm as the Only Symptom. Turk J Anaesthesiol Reanim 2019; 47:69-72. [PMID: 31276114 DOI: 10.5152/tjar.2019.21298] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 09/27/2018] [Indexed: 12/26/2022] Open
Abstract
Anaphylaxis during anaesthesia is a rare event occurring in up to 1:20,000 anaesthetics and in 33%-63% neuromuscular blocking agents are involved. Several case reports suggested the effectiveness of sugammadex in the treatment of rocuronium-induced anaphylactic shock refractory to conventional treatment. We report a case of anaphylactic reaction to rocuronium that caused isolated respiratory symptoms and showed no improvement in oxygen saturation after intravenous corticosteroids and intratracheal beta-2 agonists and that was successfully treated with sugammadex. The underlying pathophysiological mechanisms that explain the potential beneficial effect of sugammadex in this context are not completely known. We briefly review the literature regarding this topic.
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Affiliation(s)
- Itziar De La Cruz
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University General Hospital, Valencia, Spain
| | - Carlos Errando
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University General Hospital, Valencia, Spain
| | - Susana Calaforra
- Department of Allergy and Clinical Immunology, La Fe University and Polytechnic Hospital, Valencia, Spain
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Petitpain N, Argoullon L, Masmoudi K, Fedrizzi S, Cottin J, Latarche C, Mertes PM, Gillet P. Neuromuscular blocking agents induced anaphylaxis: Results and trends of a French pharmacovigilance survey from 2000 to 2012. Allergy 2018; 73:2224-2233. [PMID: 29654608 DOI: 10.1111/all.13456] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Perioperative anaphylaxis mainly involves neuromuscular blocking agents (NMBAs) with an IgE-mediated mechanism. In France, this life-threatening condition is reported by anesthetists and allergologists, and two safety alerts concerning suxamethonium were raised in 2011 and 2012. This led to start a national survey over the 2000-2012 period which objectives were to provide a descriptive analysis, to estimate incidence rates, and to analyze the trends over this period. METHODS The French pharmacovigilance database was retrospectively queried for all the available NMBAs. Anaphylaxis cases with elevated tryptase and positive skin tests were qualified as "confirmed cases." Subgroup analysis compared atracurium and cisatracurium vs suxamethonium and rocuronium. RESULTS A total of 680 confirmed cases and 944 nonconfirmed cases were identified. Suxamethonium was the most implied NMBA (64%). Incidence rates (according to sales data) of suxamethonium and rocuronium were, respectively, 10- and 13-folds higher than those of the others NMBAs, regardless the confirmed/nonconfirmed status. Cisatracurium incidence rates remained stable over the period, while suxamethonium and atracurium increased and rocuronium first decreased but re-increased after 2006. Male patients were more frequent in the subgroup "atracurium-cisatracurium" (P = .019), whereas obesity and emergency setting were more frequent in the subgroup "rocuronium-suxamethonium." Shared characteristics were the poorly documented previous exposure to NMBA(s) and an insufficient adherence of patients to perform skin tests, showing the need to improve this procedure. CONCLUSION Suxamethonium and rocuronium are markedly more involved in perioperative anaphylaxis than the other available NMBAs. Patients should be more informed about their perioperative anaphylaxis and its consequences.
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Affiliation(s)
- N. Petitpain
- Regional Pharmacovigilance Centre of Nancy; University Hospital of Nancy; Nancy France
| | - L. Argoullon
- Regional Pharmacovigilance Centre of Nancy; University Hospital of Nancy; Nancy France
| | - K. Masmoudi
- Department of Clinical Pharmacology; Regional Pharmacovigilance Centre of Amiens; University Hospital of Amiens; Amiens France
| | - S. Fedrizzi
- Regional Pharmacovigilance Center of Caen; University Hospital of Caen; Caen France
| | - J. Cottin
- Regional Pharmacovigilance Centre of Lyon; University Hospital of Lyon; Lyon France
| | - C. Latarche
- Department of Epidemiology; University Hospital of Nancy; Nancy France
| | - P. M. Mertes
- Department of Anesthesia; CHRU of Strasbourg; Nouvel Hôpital Civil; Strasbourg France
| | - P. Gillet
- Department of Clinical Pharmacology; University Hospital of Nancy; Nancy France
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11
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Patton K, Borshoff DC. Adverse drug reactions. Anaesthesia 2018; 73 Suppl 1:76-84. [DOI: 10.1111/anae.14143] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2017] [Indexed: 12/23/2022]
Affiliation(s)
- K. Patton
- Department of Anaesthesia; University Hospital Bristol; Bristol UK
| | - D. C. Borshoff
- Department of Anaesthesia and Pain Medicine; St. John of God Murdoch Hospital; Perth Western Australia
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12
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Affiliation(s)
- C. R. Bailey
- Department of Anaesthetics; Guys and St.Thomas’ NHS Foundation Trust; London UK
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13
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Spoerl D, D'Incau S, Roux-Lombard P, Harr T, Czarnetzki C. Non-IgE-Dependent Hypersensitivity to Rocuronium Reversed by Sugammadex: Report of Three Cases and Hypothesis on the Underlying Mechanism. Int Arch Allergy Immunol 2016; 169:256-62. [PMID: 27240836 DOI: 10.1159/000446182] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 04/12/2016] [Indexed: 11/19/2022] Open
Abstract
We present 3 cases of pseudoallergic (anaphylactoid) reactions to perioperatively administered rocuronium, which rapidly resolved after sugammadex injection. Allergological workup showed no evidence for immediate-type hypersensitivity to the drugs used for anesthesia, including rocuronium. However, rocuronium induced an irritative reaction in skin tests in all 3 patients and in 3 healthy individuals. This reaction was specifically suppressed by adding sugammadex at a 1:1 molecular proportion to rocuronium before the skin tests. This observation suggests that the patients suffered from a pseudoallergic reaction, and indicates that sugammadex might act via the inhibition of non-IgE mediated MRGPRX2 (Mas-related G-protein-coupled receptor member X2)-triggered mast cell degranulation induced by rocuronium.
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Affiliation(s)
- David Spoerl
- Division of Clinical Immunology and Allergy, Department of Medical Specialties, Geneva University Hospital, Geneva, Switzerland
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14
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Takazawa T, Mitsuhata H, Mertes PM. Sugammadex and rocuronium-induced anaphylaxis. J Anesth 2015; 30:290-7. [PMID: 26646837 PMCID: PMC4819478 DOI: 10.1007/s00540-015-2105-x] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 11/11/2015] [Indexed: 12/19/2022]
Abstract
Perioperative anaphylaxis is a life-threatening clinical condition that is typically the result of drugs or substances used for anesthesia or surgery. The most common cause of anaphylaxis during anesthesia is reportedly neuromuscular blocking agents. Of the many muscle relaxants that are clinically available, rocuronium is becoming popular in many countries. Recent studies have demonstrated that succinylcholine (but also rocuronium use) is associated with a relatively high rate of IgE-mediated anaphylaxis compared with other muscle relaxant agents. Sugammadex is widely used for reversal of the effects of steroidal neuromuscular blocking agents, such as rocuronium and vecuronium. Confirmed cases of allergic reactions to clinical doses of sugammadex have also been recently reported. Given these circumstances, the number of cases of hypersensitivity to either sugammadex or rocuronium is likely to increase. Thus, anesthesiologists should be familiar with the epidemiology, mechanisms, and clinical presentations of anaphylaxis induced by these drugs. In this review, we focus on the diagnosis and treatment of anaphylaxis to sugammadex and neuromuscular blocking agents. Moreover, we discuss recent studies in this field, including the diagnostic utility of flow cytometry and improvement of rocuronium-induced anaphylaxis with the use of sugammadex.
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Affiliation(s)
- Tomonori Takazawa
- Department of Anesthesiology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, 371-8511, Japan.
| | - Hiromasa Mitsuhata
- Department of Anesthesiology, Juntendo Tokyo Koto Geriatric Medical Center, 3-3-20 Shinsuna, Koto-Ku, Tokyo, 136-0075, Japan
| | - Paul Michel Mertes
- Service d'anesthésie-réanimation chirurgicale, Nouvel hôpital civil, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, BP 426, 67091, Strasbourg Cedex, France
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15
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Baldo BA, McDonnell NJ. Sugammadex and anaphylaxis in the operating theater. ACTA ACUST UNITED AC 2014; 61:239-45. [PMID: 24666509 DOI: 10.1016/j.redar.2014.02.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 02/19/2014] [Indexed: 10/25/2022]
Affiliation(s)
- B A Baldo
- Retired. Formerly, Head, Molecular Immunology Unit, Kolling Institute of Medical Research, Royal North Shore Hospital of Sydney and Department of Medicine, University of Sydney, Sydney, NSW, Australia.
| | - N J McDonnell
- Department of Anaesthesia and Pain Medicine, King Edward Memorial Hospital for Women and School of Women's and Infants' Health and School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia
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16
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Kalkan Y, Tumkaya L, Bostan H, Tomak Y, Altuner D, Yilmaz A, Erdivanli B, Bedir R, Yalcin A, Turan A. Effect of sugammadex on rocuronium induced changes in pancreatic mast cells. Toxicol Ind Health 2013; 31:738-46. [PMID: 23552269 DOI: 10.1177/0748233713484654] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Mast cells play a vital role in hypersensitivity reactions. Rocuronium is known to cause mast cell mobilization, hypersensitivity, and pancreatitis. The aim of this study was to investigate the effects of sugammadex on pancreatic changes due to rocuronium. A total of 42 Sprague-Dawley male rats were divided into six equal groups to receive either rocuronium 1 mg/kg intravenously (i.v., R group), rocuronium 1 mg/kg + sugammadex 16 mg/kg i.v. (RS16 group), rocuronium 1 mg/kg + sugammadex 96 mg/kg i.v. (RS96 group), sugammadex 16 mg/kg (S16), sugammadex 96 mg/kg i.v. (S96 group), or 0.9% sodium chloride (control group). Sugammadex was administered 5s later following rocuronium. In R group, mast count was higher, and the distribution rate of granules and nuclear changes were different compared with other groups. Distribution rate of granules in groups S16 and S96 were similar to the control group and lower compared with other groups. The amount of mast cells and granule density in groups RS16 and RS96 was lower compared with R group. The amount of mast cells in groups RS16 and RS96 was significantly lower compared with other treatment groups. These results suggest that sugammadex may have an inhibitory effect on mobilization and morphological changes in pancreatic mast cells induced by administration of rocuronium and sugammadex in rats.
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Affiliation(s)
- Yıldıray Kalkan
- Department of Histology and Embryology, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Levent Tumkaya
- Department of Histology and Embryology, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Habib Bostan
- The Ministry of Justice, Institute of Forensic Medicine, Istanbul, Turkey
| | - Yakup Tomak
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Durdu Altuner
- Department of Pharmacology, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Adnan Yilmaz
- Department of Biochemistry, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Başar Erdivanli
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Recep Bedir
- Department of Pathology, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Alper Yalcin
- Department of Histology and Embryology, Faculty of Medicine, Adiyaman University, Adiyaman, Turkey
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Silva-Obregón JA, Gamero-Donis D, Romo-Gonzales JE, Benito-Puncel C, Borrallo-Pérez JM, Marian-Crespo C. [Rocuronium-induced anaphylaxis. Potential off-label use of sugammadex]. Med Intensiva 2013; 38:58-9. [PMID: 23375690 DOI: 10.1016/j.medin.2012.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Revised: 11/05/2012] [Accepted: 11/27/2012] [Indexed: 10/27/2022]
Affiliation(s)
- J A Silva-Obregón
- Servicio de Medicina Intensiva, Hospital Universitario de Guadalajara, Guadalajara, España.
| | - D Gamero-Donis
- Servicio de Medicina Intensiva, Hospital Universitario de Guadalajara, Guadalajara, España
| | - J E Romo-Gonzales
- Servicio de Medicina Intensiva, Hospital Universitario de Guadalajara, Guadalajara, España
| | - C Benito-Puncel
- Servicio de Medicina Intensiva, Hospital Universitario de Guadalajara, Guadalajara, España
| | - J M Borrallo-Pérez
- Servicio de Medicina Intensiva, Hospital Universitario de Guadalajara, Guadalajara, España
| | - C Marian-Crespo
- Servicio de Medicina Intensiva, Hospital Universitario de Guadalajara, Guadalajara, España
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18
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Abstract
Sugammadex is a modified gamma-cyclodextrin which is showing favorable outcomes regarding reversal of neuromuscular blockade, especially by rocuronium. It is designed to encapsulate rocuronium and being considered a new class of drugs as selective relaxant binding agents. It has given countless benefits to the patients at risk of incomplete or delayed recovery after neuromuscular block and has renown for another milestone in anesthesia practice. Recurrence of neuromuscular block has not been reported to be associated with the provided doses of sugammadex that are adequate for selected for reversal. Acceptable profiles are brought to light telling safety of sugammadex. However, some questions related to the twitch characteristics those resembled succinylcholine when reversal, the application for rocuronium anaphylaxis, and the hypersensitivity or anaphylaxis to sugammadex remain and are need of further investigation. It is imperative that potential problems that we need attention may include the patient's history of pulmonary disease and allergic disease for using sugammadex.
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Affiliation(s)
- Jin Young Chon
- Department of Anesthesiology and Pain Medicine, The Catholic University of Korea School of Medicine, Seoul, Korea
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Asahi Y, Omichi S, Adachi S, Kagamiuchi H, Kotani J. Hypersensitivity reaction probably induced by sugammadex. ACTA ACUST UNITED AC 2012; 50:183-4. [DOI: 10.1016/j.aat.2012.08.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Revised: 08/09/2012] [Accepted: 08/14/2012] [Indexed: 12/20/2022]
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20
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Tomak Y, Yılmaz A, Bostan H, Tümkaya L, Altuner D, Kalkan Y, Erdivanlı B. Effects of sugammadex and rocuronium mast cell number and degranulation in rat liver. Anaesthesia 2012; 67:1101-4. [PMID: 22827538 DOI: 10.1111/j.1365-2044.2012.07264.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
We investigated the effect of rocuronium- and sugammadex-induced mast cell increase and degranulation in rat portal triads. Forty-two rats, in six groups, received either rocuronium 1 mg.kg(-1); sugammadex 15 mg.kg(-1); sugammadex 100 mg.kg(-1); rocuronium 1 mg.kg(-1) and 5 min later, sugammadex 15 mg.kg(-1); rocuronium 1 mg.kg(-1) and 5 min later, sugammadex 100 mg.kg(-1); or isotonic saline. Total mast cell numbers were significantly higher with rocuronium only, than in all other groups (p<0.003), although in all active groups, the number was greater than the control. Total mast cell number was significantly higher with rocuronium and low-dose sugammadex compared with low-dose sugammadex only. The number of tryptase-positive mast cells with rocuronium only was significantly higher than in all other groups (p<0.003). Tryptase-positive mast cell numbers in both groups receiving both rocuronium and sugammadex were significantly higher compared with both groups receiving sugammadex only. Rocuronium increased mast cell numbers, and degranulation was mitigated by sugammadex. These results suggest that sugammadex may be beneficial in treatment of rocuronium-induced anaphylaxis.
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Affiliation(s)
- Y Tomak
- Department of Anaesthesiology and Reanimation, Rize University, Medical Faculty, and Rize Education and Research Hospital, Rize, Turkey.
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21
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Case of Anaphylaxis Induced by Rocuronium Treated with Sugammadex. Braz J Anesthesiol 2012; 62:538-42. [DOI: 10.1016/s0034-7094(12)70152-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Accepted: 12/03/2011] [Indexed: 12/17/2022] Open
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22
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Un nouveau cas de choc anaphylactique induit par le rocuronium amélioré par le sugammadex. Can J Anaesth 2012; 59:909-10. [DOI: 10.1007/s12630-012-9740-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Accepted: 05/17/2012] [Indexed: 12/19/2022] Open
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23
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Abad Gurumeta A, Gutiérrez García R. [Sugammadex: the last shot for anaphylactic shock due to rocuronium?]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2012; 59:177-179. [PMID: 22575774 DOI: 10.1016/j.redar.2012.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Accepted: 03/21/2012] [Indexed: 05/31/2023]
Affiliation(s)
- A Abad Gurumeta
- Servicio de Anestesiología y Reanimación, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, España
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24
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Clarke RC, Sadleir PHM, Platt PR. The role of sugammadex in the development and modification of an allergic response to rocuronium: evidence from a cutaneous model. Anaesthesia 2012; 67:266-73. [PMID: 22321083 DOI: 10.1111/j.1365-2044.2011.06995.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The availability of sugammadex as a selective encapsulating agent for rocuronium has led to speculation that it may be useful in mitigating rocuronium-induced anaphylaxis. Off-label use of sugammadex for this indication has already been documented in case reports although there are theoretical objections to the likelihood of an allergen-binding agent's being able to attenuate the immunological cascade of anaphylaxis. Using a cutaneous model of anaphylaxis in rocuronium-sensitised patients, we were unable to demonstrate that sugammadex was effective in attenuating the type-1 hypersensitivity reaction after it has been triggered by rocuronium, but we were able to demonstrate that these patients are anergic to sugammadex-bound rocuronium. These findings demonstrate that a cyclodextrin can bind an allergen and exclude it from interacting with the immune system, and may potentially lead to novel applications in other allergic diseases. However, there is no evidence that sugammadex should be used for the treatment of rocuronium-induced anaphylaxis, and clinical management should follow established protocols.
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Affiliation(s)
- R C Clarke
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.
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25
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Raft J, Leclercq M, Longrois D, Meistelman C. Récupération hémodynamique et ventilatoire rapide après injection de sugammadex lors d’un choc anaphylactique au rocuronium, réfractaire au traitement conventionnel. ACTA ACUST UNITED AC 2012; 31:158-61. [DOI: 10.1016/j.annfar.2011.10.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Accepted: 10/26/2011] [Indexed: 12/17/2022]
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26
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Successful management of rocuronium-induced anaphylactic reactions with sugammadex: a case report. J Clin Anesth 2012; 24:62-4. [DOI: 10.1016/j.jclinane.2011.04.015] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Revised: 04/19/2011] [Accepted: 04/27/2011] [Indexed: 11/18/2022]
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27
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Connaissons-nous toutes les indications et tous les effets secondaires du sugammadex ? ACTA ACUST UNITED AC 2011; 30:709-10. [DOI: 10.1016/j.annfar.2011.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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28
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Sun W, Pei L. Flurbiprofen axetil, nasal polyps, and status asthmaticus: an unusual case report. J Asthma 2011; 48:647-9. [PMID: 21762044 DOI: 10.3109/02770903.2011.587580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Herein, we report a case of life-threatening status asthmaticus in a young male presented with nasal polyps but without any history of anaphylaxis or asthma. DISCUSSION The patient had normal results from preoperative respiratory systemic examinations. The postoperative asthma, which started after an infusion of nonsteroidal anti-inflammatory drugs (NSAIDs), was severe and difficult to manage. A relationship between the NSAID infusion and the asthma attack was indicated. Flurbiprofen axetil, a nonselective COX2 inhibitor, is most likely the causative agent in this case, although there are no prior reports of asthma caused by this agent. CONCLUSION We concluded that flurbiprofen axetil evoked severe bronchospasm in this case. Patients who are sensitive to flurbiprofen axetil will usually react to other NSAIDs; therefore, other ordinary NSAIDs should be used with caution in hypersensitive patients. An intranasal ketorolac challenge in individuals with nasal polyps, which is a novel and safe alternative to aspirin challenge, may be recommended to rule out aspirin-exacerbated respiratory disease, prior to the systemic administration of NSAIDs.
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Affiliation(s)
- Wenchong Sun
- Department of Anesthesiology, The First Affiliated Hospital of China Medical University, Shenyang, PR China
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Kawano T, Yokoyama M. Can sugammadex encapsulation eliminate the antigenic activity of aminosteroidal neuromuscular blocking agent? J Anesth 2011; 25:953-4. [PMID: 21904780 DOI: 10.1007/s00540-011-1223-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Accepted: 08/23/2011] [Indexed: 12/19/2022]
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30
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Leysen J, Bridts CH, De Clerck LS, Ebo DG. Rocuronium-induced anaphylaxis is probably not mitigated by sugammadex: evidence from an in vitro experiment. Anaesthesia 2011; 66:526-7. [DOI: 10.1111/j.1365-2044.2011.06729.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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31
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Menéndez-Ozcoidi L, Ortiz-Gómez JR, Olaguibel-Ribero JM, Salvador-Bravo MJ. Allergy to low dose sugammadex. Anaesthesia 2011; 66:217-9. [DOI: 10.1111/j.1365-2044.2010.06611.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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32
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McDonnell N, Pavy T, Green L, Platt P. Sugammadex in the management of rocuronium-induced anaphylaxis. Br J Anaesth 2011; 106:199-201. [DOI: 10.1093/bja/aeq366] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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