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• W3092603939 abstract "We would like to report two cases of anaphylaxis to rocuronium bromide. The first reaction occurred in a 66-year-old ASA III male smoker scheduled for mediastinoscopy for investigation of a left hilar mass. Previous general anaesthetics had been uneventful. Anaesthesia was induced with alfentanil 1 mg and propofol to a total dose of 200 mg. Following loss of eyelash reflex, rocuronium 30 mg was administered and manual ventilation commenced. Shortly after rocuronium administration, the patient developed bronchospasm, hypotension and tachycardia leading to electromechanical dissociation. The patient was resuscitated with epinephrine 0.3 mg given intravenously and intravenous fluids (1500 ml) and the total duration of circulatory arrest was approximately 2 min. Surgery was abandoned and, following the return of spontaneous circulation, the patient was transferred to the intensive care unit where he was extubated 1 h later. He made an uneventful recovery from this episode. Blood and urine samples obtained at 1, 6 and 24 h after the reaction demonstrated elevations in mast cell tryptase and urinary methylhistamine in keeping with an anaphylactic/anaphylactoid reaction. Skin prick testing demonstrated a positive reaction to rocuronium (20 mm × 20 mm skin wheal) at a 1 : 10 dilution. Our second case occurred in a 21-year-old ASA II female presenting for repair of an ostium secundum atrial septal defect. She had no other past medical history and had never had a general anaesthetic. Induction was achieved with remifentanil infusion at 1 µg.kg−1.min−1 and a target-controlled infusion of propofol with a target concentration of 3 µg ml−1. Following loss of consciousness, rocuronium 50 mg was administered. One minute later, the patient coughed and became difficult to ventilate manually, a narrow complex tachycardia of 165 beat.min−1 developed, the arterial pressure tracing became non-pulsatile and the patient developed florid generalised erythema with urticaria. The trachea was intubated and ventilation continued with 100% oxygen along with chest compressions. Epinephrine (total dose 2.5 mg), intravenous fluids (total volume of 2500 ml, a mixture of colloid and crystalloid) and incremental doses of norepinephrine up to 200 µg were given with no effect. Second-line management continued with hydrocortisone 500 mg, nebulised salbutamol 5 mg and ranitidine 50 mg. In view of the lack of response to our initial therapy, we proceeded to sternotomy in order to perform internal cardiac massage. At no point prior to commencement of cardiopulmonary bypass (33 min after the arrest) was an external pulse palpable and the arterial line continued to register a non-pulsatile pressure. Surgery proceeded uneventfully and the patient was weaned from bypass with relative ease. The postoperative period was complicated by coagulopathy, airway and facial oedema and haemothorax, all of which responded to appropriate therapy. She made a full recovery and was discharged 9 days later. Mast cell tryptase and urinary methylhistamine were elevated in keeping with an anaphylactic reaction. Skin prick testing to rocuronium 6 weeks later was strongly positive (30 mm × 30 mm) at a 1 : 10 dilution. In addition, skin prick testing for vecuronium produced a positive response (20 mm × 20 mm). Both of these cases demonstrated grade IV anaphylaxis (Ring and Messmer Scale [1]) and also met Fisher and Baldo's criteria for an anaphylactic reaction [2]. We present these cases to highlight the fact that although rocuronium causes little or no direct histamine release, it can cause immunologically-mediated histamine release or anaphylaxis. The frequency with which these reactions are occurring is giving cause for concern. Neale et al. in their recent report suggest a crude incidence of reaction of approximately 1 : 3000 [3]. Based upon the number of reactions and the number of vials used, our ‘hospital reaction rate’ is approximately 1 : 6000. The manufacturers estimate that the incidence is approximately 1 : 200 000 worldwide (personal communication Organon- Teknika). The obvious conclusion is that we do not have enough data to state definitively the incidence of reaction. In view of this, it is important that we monitor the use of this drug closely and ensure that any possible reactions are investigated appropriately and reported to the relevant agency to facilitate the gathering of accurate adverse event data." @default.
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• W3092603939 title "Anaphylaxis to rocuronium" @default.
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• W3092603939 doi "https://doi.org/10.1046/j.1365-2044.2000.01798-15.x" @default.
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