Diagnosis and management of rocuronium-induced perioperative anaphylaxis

Introduction - Perioperative anaphylaxis is a hypersensitivity reaction that occurs after exposure to drugs used for anaesthesia during a surgical procedure. The most common triggers are neuromuscular blocking agents and antibiotics. Case report - A 71-old man, with a history of anaphylaxis during previous anaesthesia, was scheduled for elective coronary surgery. The clinical signs included skin rash, swelling of the upper part of the body with angioedema of the eyelids and lips, without bronchospasm. Based on the assumption that rocuronium was the most likely causative agent, percutaneous coronary intervention was performed during the same hospitalization. After recovery, he was sent for a prick skin test and intradermal test, where sensitivity to rocuronium and insensitivity to the anaesthetics used were determined. Two months later, he developed an acute myocardial infarction. Chronic total occlusive percutaneous coronary intervention was attempted, but without optimal results, so the patient was prepared for elective surgery. Due to potential further complications during anaesthesia, the medical team decided to send him for a skin allergy test for neuromuscular blocking agents. The only neuromuscular relaxant available was Cisatracurium, and it was tested for sensitivity by intradermal test. The intradermal test showed insensitivity to Cisatracurium and Suxamethonium chloride. Conclusion - Early recognition and management of anaphylaxis is based on clinical presentation. The diagnosis by in-vivo and in-vitro tests is useful to determine the cause of anaphylactic reaction and safe alternatives for future anaesthesia.