A comprehensive literature search of PubMed and Scopus was performed in accordance with the PRISMA 2020 (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. In addition, a search was performed on Google Scholar to identify articles not reported in PubMed or Scopus. The search for publications was undertaken using the following keywords: “anaphylactic shock,” “rocuronium,” and “Sugammadex.” The search extended to all available English-language articles from 2010 to May 2023. All included articles were case reports, and according to the Oxford Centre for Evidence-Based Medicine table, they were labeled as Level IV studies.

Cases were included in the final review only if the article showed adequate clinical and biological information. The following studies were excluded: literature reviews, animal studies, correspondence or letters, articles not available in full text, articles reporting an anaphylactic reaction to Suggamadex, and articles with incomplete clinical information. Titles and abstracts were initially reviewed to identify articles with positive exclusion criteria.

Extraction data was performed from eligible cases. Specific information was obtained from eligible articles. Collected data included age, history of allergic reactions, type of surgery, anaphylactic reaction grade, time between injection of rocuronium and start of anaphylaxis, time between the start of anaphylaxis and injection of Sugammadex, dose of Sugammadex andministred, clinical response and finally confirmation test. Not all articles provided information about each item; therefore, a comparative analysis was limited by the nature and the limited number of the source data.

M.F. A 46-year-old north african female patient was scheduled for laparoscopic cholecystectomy due to gallstones. Her medical history included well-controlled hypothyroidism on Levothyroxine and cesarean section under spinal anesthesia without notable allergic events. She had no known drug, food, or other allergies, including cosmetics.

Preoperative evaluation revealed a patient in good general condition, weighing 64 kg with a BMI of 22 kg.m⁻², blood pressure at 120/80 mmHg, heart rate at 86 bpm, SpO₂ at 99%, and good exercise tolerance with a functional capacity > 4 METs. Additionally, the anesthesia assessment found good venous access and no criteria indicating difficult ventilation or intubation.

Premedication consisted of 75 mg of hydroxyzine the night before and the morning of the procedure. Perioperative monitoring data, which included a three-lead EKG, continuous SpO₂, and non-invasive blood pressure measurements every minute, were systematically recorded on the monitor and documented in the anesthesia record.

After establishing an 18 G IV canula, the patient was pre-oxygenated and received 500 ml of 0.9% normal saline. Anesthesia induction involved 170 mg of propofol, 20 mg of 2% lidocaine, and 200 μg of fentanyl. Following loss of consciousness, 40 mg of rocuronium was administered, and orotracheal intubation was performed two minutes later. Maintenance anesthesia was achieved with 2% sevoflurane. Notably, the patient did not receive antibiotic prophylaxis as this was a straightforward laparoscopic cholecystectomy.

Five minutes after induction, the patient developed a rash on her chest and limbs, followed rapidly by a drop in blood pressure to 75/39 mmHg without desaturation or increased airway pressures. After rapidly excluding obstructive or cardiogenic shock through pleuro-pulmonary and cardiac ultrasound, which showed no pneumothorax, right heart dysfunction, and indicated good contractility, grade III anaphylactic shock (Ring and Messner classification) was promptly suspected. The management included halting halogenated agents, administering 1 L of 0.9% normal saline, giving five 100 μg boluses of adrenaline, and initiating a continuous adrenaline infusion at 0.05 μg/kg/min via another IV line in the opposite arm.

Due to the lack of significant hemodynamic improvement, a decision was made to antagonize the NMBAs with a rescue dose of 1000 mg of Sugammadex, administered nine minutes after the onset of symptoms. One minute later, there was an improvement in hemodynamic parameters and the rash resolved ( Figure 1 ).

Invasive blood pressure monitoring via an arterial catheter was performed, fluid resuscitation continued with normal saline, adrenaline support was gradually reduced, and a blood sample was obtained.

The decision to proceed with the surgery without NMBAs was made in consultation with the surgical team, using propofol for maintenance in a TIVA approach. Hemodynamic parameters remained stable without vasopressor support throughout the surgery, and the patient was extubated 30 minutes post-surgery and transferred to the ICU for 24-hour observation.

The patient was informed of the anesthetic incident. Given the positive serum tryptase and histamine levels (anti-AQ IgE testing was unavailable at our hospital), she was referred to an allergy-anesthesia consultation one month later. All drugs used during anesthesia (propofol, fentanyl, lidocaine, rocuronium) were tested; only the skin tests for rocuronium were positive (those for succinylcholine and atracurium were negative).

The literature search yielded 334 articles. After removal of duplicates, the title and abstract of 247 articles were screened, and based on exclusion criteria, 232 articles were eliminated. After this initial filter, 15 articles were assessed for eligibility, of which 4 were excluded for different reasons. Thus, 11 articles with a total of 11 patients were eligible for analysis ( Figure 2 ).

Table 1 summarizes the characteristics of these 11 cases in addition to our own case, totaling 12 patients.

Table 2 shows the characteristics of these patients with suspected anaphylactic reaction to rocuronium treated with Sugammadex.

Most patients were female (83%) with a median age of 56 years. The onset of the anaphylactic reaction had a median time of 2 minutes, with 75% of the reactions classified as Type III. Regarding the administered dose of sugammadex, the median dose was 450 mg. Finally, the outcome was favorable in 100% of cases, with a median response time of 2 minutes.

¹expressed as median [interquartile range]; ²expressed as headcount (percentage).

However, with the advent of allergology-anesthesia consultations, skin testing, the gold standard, allows for the diagnosis of NMBA allergy. If the administered NMBA tests positive, cross-sensitivity to other NMBAs is assessed during the same consultation. This process provides clear and safe guidance for anesthesiologists in choosing an NMBA for future anesthesia by suggesting the one with a negative skin test. Several clinical cases and case series [19] [24] [27] confirm the good tolerance of the NMBA with a negative test.