ROCURONIUM-INDUCED ANAPHYLAXIS: ANY EVIDENCE FOR SUGAMMADEX?

INTRODUCTION: Anaphylaxis during general anesthesia is estimated to occur around 1 in 3,500 cases. 90% of these cases occur at induction of anesthesia. Neuromuscular blocking drugs are thought to be the most responsible trigger, with Rocuronium being the most implicated drug. Sugammadex is a synthetic modified gamma-cyclodextrin derivative that will incompletely encapsulate Rocuronium, preventing the rocuronium epitope from binding IgE; hence it was thought that its use could decrease anaphylaxis severity. The use of sugammadex in suspected rocuronium-induced anaphylaxis (RIA) is based on personal opinion or experience. Current literature and evidence regarding the use of sugammadex in RIA are based only on case reports or series. METHODS: We did a literature search in 3 main databases, Medline, Embase, and Web of science. The final total articles were 356 published cases published in the literature. Two independent reviewers conducted the first screen, and 69 articles with confirmed RIA were selected. These articles were divided into RIA alone in 39 cases and RIA with sugammadex use in 28 cases. We looked at patient characteristics (age, sex, ASA classification), associated symptoms (incidence of bronchospasm or rash, duration of hypotension), discharge disposition to intensive care unit (ICU), and associated morbidity or mortality. RESULTS: On comparing RIA vs. RIA with sugammadex use, we didn\u27t find a statistically significant difference in patient characteristics, associated symptoms, or discharge disposition to ICU. However, there was a statistically significant difference in morbidity (15.4% vs. 0, p-value 0.03). Mortality was 5% in RIA, and no patient died in RIA with sugammadex use (p-value 0.5). The number need to treat (NNT) analysis showed NNT with Sugammadex to prevent mortality = 20 and NNT with Sugammadex to avoid morbidity is 7. CONCLUSIONS: Early recognition and treatment of anaphylaxis with Epinephrine is still the mainstay of treatment. Since muscle relaxants, specifically Rocuronium, are the most common cause, we suggest using sugammadex in case of suspected RIA. We recommend using sugammadex in case of cardiac arrest or refractory anaphylaxis as evidence of NNT to avoid organ dysfunction is 7 and potential evidence of mortality benefit. The recommended dose is 16 mg/kg