Abstract

We report here an intellectually compromised 7-year-old boy with cerebral palsy who developed a hypersensitivity reaction several minutes after the administration of sugammadex for subsequent extubation. He developed signs of upper airway stenosis and decreased oxygen saturation, as well as wheals on his neck, chest, and both upper extremities. He was successfully treated with immediate administration of adrenaline and hydrocortisone. A hypersensitivity reaction to sugammadex was suspected on the basis of the patient's clinical course.

Keywords

anesthesia, general; drug hypersensitivity; gamma-cyclodextrins: sugammadex;

1. Introduction

Sugammadex, an innovative and effective antagonist of neuromuscular blockade by rocuronium, became available in Japan in April 2010 and has been widely used since. However, several cases of allergic responses to sugammadex have occurred since its introduction. For example, 10 cases of anaphylaxis or anaphylactic response to sugammadex were reported at the 31st Annual Meeting of the Japan Society for Clinical Anesthesia, which was held from November 3–5, 2011. Similarly, Godai et al have reported three cases of hypersensitivity reactions to sugammadex.¹ We have also encountered a case of a hypersensitivity response to sugammadex in a boy that occurred several minutes after its administration in the wake of dental treatment under general anesthesia.

2. Case report

An intellectually compromised 7-year-old boy (height 100 cm, weight 12 kg) with cerebral palsy was scheduled for dental treatment under general anesthesia for multiple dental cavities. He had no history of allergic response to any drug or foodstuff, and had never been administered sugammadex. He had undergone orthopedic surgery approximately 1 month previously under uneventful general anesthesia with sevoflurane, nitrous oxide, propofol, remifentanil hydrochloride, rocuronium, levobupivacaine hydrochloride, atropine sulfate, and neostigmine.

On the day of the dental treatment, nasal endotracheal intubation was performed under general anesthesia induced with 12 mg rocuronium, 20 mg propofol, 0.2 mg atropine sulfate, and continuous infusion of propofol at 5.8 mg/kg/h and remifentanil hydrochloride at 0.27 μg/kg/min. Anesthesia was maintained with a continuous infusion of propofol at 5.8 mg/kg/h and remifentanil hydrochloride at 0.14 μg/kg/min. Six teeth were easily treated under 1.8 mL lidocaine hydrochloride.

After 30 minutes of dental treatment, the trachea was extubated following the administration of 40 mg sugammadex. Approximately 3 minutes later, the boy showed signs of upper airway distress, with high-pitched respiratory sounds and external paradoxical respiration. Oxygen saturation decreased to 82% on room air. The in-charge dental anesthesiologist began ventilating the lungs with 3 L/min of 100% oxygen via a face mask, and oxygen saturation was rapidly restored to 100%. Approximately 10 minutes after extubation, a wheal appeared on the patient's neck and spread rapidly all over the chest and both upper extremities. The blood pressure did not decrease at this point.

An anaphylactic response to sugammadex was suspected; therefore, 0.25 mg adrenaline was given intramuscularly into the left shoulder by another dental anesthesiologist, and 100 mg hydrocortisone was administered intravenously by a pediatrician. Prior to treatment of the allergic reaction, the boy's blood pressure was 120–80/90–40 mmHg, and his heart rate was 80–120 bpm. His blood pressure rose to 160/120 mmHg 5 minutes after treatment and fell to 126/84 mmHg after another 5 minutes. Signs of upper airway stenosis and wheals disappeared approximately 8 minutes after the administration of adrenaline and hydrocortisone. Thereafter, the patient was followed up and treated by the pediatrician, and no severe complications occurred.

3. Discussion

We suspected that the anaphylaxis in our patient was caused by the administration of sugammadex for the following three reasons. First, the allergic response occurred 3 minutes after the administration of sugammadex, whereas other drugs had been administered up to 1 hour before the reaction occurred. Second, the patient had had no allergic response to similar anesthetics used in the previous surgery, which had taken place 1 month before, except sugammadex and lidocaine hydrochloride. Third, the symptoms and signs met the criteria of anaphylactic reaction developed by the Working Group of the Resuscitation Council (UK): that rapid development of life-threatening airway difficulty, breathing distress, and circulatory problems usually associated with skin and mucosal changes are salient features.² In this case, we were unable to make a confirmed diagnosis because the patient's parents refused allergy tests.

Several cases of severe allergic reaction to a clinical dose of sugammadex have been reported in Japan, whereas it has rarely been reported in other countries.³ In their report,³ Menéndez-Ozcoidi et al described a severe allergic reaction occurring after the administration of a low clinical dose of sugammadex (3.2 mg/kg) and pointed out that hypersensitivity to this drug occurred more frequently at higher doses.4, 5, 6 However, the report of three cases (3.3 mg/kg) from Godai et al (1.9–2.2 mg/kg)¹ and other case reports (3.0–5.1 mg/kg) presented at the 31st Annual Meeting of the Japan Society for Clinical Anesthesia have indicated that such a reaction could occur with similar doses or even lower doses of the drug.

Godai et al reported that intravenous adrenaline and noradrenaline were used in one case with hypotension, decrease of oxygen saturation, and erythema. On the other hand, methylprednisolone, aminophylline, and antihistamine were administered intravenously in the other two cases.¹ Although we could have administered adrenaline intravenously in this case, we used intramuscular injection because we had not seen this anaphylactic reaction before, and thus adhered to the guidelines suggested by Soar et al.²

Sugammadex is an innovative and effective antagonist of neuromuscular blockade from rocuronium and has been used in the treatment of anaphylaxis to rocuronium.⁷ However, after its administration, anesthesiologists should postpone extubation for a sufficient duration because several cases of severe allergic responses, such as the case we reported here, have occurred immediately after extubation following administration of the drug.