I have been intrigued since the first case reports appeared describing the use of sugammadex in rocuronium anaphylaxis. It sounds beautiful and elegant. A drug that magically mops up the offending molecule, removing it from circulation; quickly reversing the cardiovascular collapse as rapidly as it reverses muscle relaxation.
The little we know
- There have been case reports from 5 countries showing dramatic improvement of rocuronium-confirmed anaphylaxis after administration of sugammadex.
- One case study showed a dose-dependent effect of sugammadex on modifying anaphylaxis.
- There are not yet any published cases of rocuronium anaphylaxis where sugammadex was administered without clinical improvement (though beware).
- Sugammadex although incompletely encapsulating rocuronium, does prevent the rocuronium epitope from binding IgE.
- Cutaneous and in vitro models of hypersensitivity have shown no or limited ability of sugammadex to modify type 1 hypersensitivty after triggering.
- Our understanding of the pathophysiology of anaphylaxis is over-simplified and incomplete.
Unfortunately the truth is not quite as clear. Case reports showing impressive recovery of rocuronium anaphylaxis minutes after giving sugammadex are tempered by in vitro and in vivoimmunological studies suggesting an inability of sugammadex to modify a type 1 hypersensitivity reaction. The reality is likely somewhere in between, highlighting our limited understanding of anaphylaxis and our tendency to rush to over-simplified models of disease processes.
The story so far...
Jones and Turkstra first raised the possibility of using sugammadex to treat rocuronium anaphylaxis in 2010.1 One year later Nolan McDonnell and team published the first case report of a remarkable use of sugammadex to manage rocuronium anaphylaxis.2 McDonnell described a 33 year old having an elective diagnostic laparoscopy suffering anaphylaxis to rocuronium. After 19 min of conventional resuscitation, involving CPR, 3500 mL of intravenous fluids and 4 mg of epinephrine/adrenaline - 500 mg of sugammadex was given with remarkable effect:
"A dose of 500 mg (6.5 mg kg21) was given while chest compressions were in progress. The last dose of epinephrine had been given 4 min previously. Approximately 45 s after administration and while chest compressions were in progress, the patient suddenly opened her eyes and reached for her tracheal tube.
Jones PM, Turkstra TP. Mitigation of rocuronium-induced anaphylaxis by sugammadex: the great unknown. Anaesthesia. 2010 Jan;65(1):89-90; author reply 90. ↩
McDonnell NJ, Pavy TJ, Green LK, Platt PR. Sugammadex in the management of rocuronium-induced anaphylaxis. Br J Anaesth. 2011 Feb;106(2):199-201. ↩