What is the treatment for anaphylaxis caused by sugammadex?

Treatment of Anaphylaxis Caused by Sugammadex

The treatment for anaphylaxis caused by sugammadex follows standard anaphylaxis management protocols with immediate administration of intramuscular epinephrine as the first-line treatment, followed by fluid resuscitation and supportive care. 1, 2, 3

Initial Management

• Administer epinephrine 0.2-0.5 mg (1:1000 concentration) intramuscularly in the anterolateral thigh, which can be repeated every 5-15 minutes as needed 2
• For Grade II reactions (systemic reaction with hypotension/bronchospasm), administer IV epinephrine 20 μg if vasopressor, bronchodilator, or both are clinically indicated 1
• For Grade III reactions (life-threatening hypotension or bronchospasm), administer IV epinephrine 50-100 μg 1
• For Grade IV reactions (cardiac or respiratory arrest), follow local advanced life support guidelines including IV epinephrine 1 mg 1
• Administer crystalloid fluid bolus: 500 ml for Grade II reactions, 1 L for Grade III reactions, escalating to 20-30 ml/kg for refractory cases 1
• Establish intravenous access, provide supplemental oxygen, and continuously monitor vital signs 2

Management of Refractory Anaphylaxis

• If inadequate response after 10 minutes, escalate epinephrine dose by doubling the bolus dose 1
• Consider starting epinephrine infusion (0.05-0.1 μg/kg/min) when more than three epinephrine boluses have been administered 1
• For persistent hypotension, add infusion of norepinephrine (0.05-0.5 μg/kg/min), phenylephrine, or metaraminol 1
• Consider vasopressin as a bolus 1-2 IU with or without infusion (2 units/h) for persistent hypotension 1
• For patients on beta-blockers with refractory symptoms, administer IV glucagon 1-2 mg 1, 2
• For persistent bronchospasm, administer inhaled bronchodilators (e.g., salbutamol) and consider IV bronchodilators (e.g., ketamine, salbutamol) 1

Second-Line Interventions

• After adequate epinephrine and fluid resuscitation, administer IV antihistamines such as chlorphenamine or diphenhydramine 25-50 mg (not a priority) 1, 2
• Consider H2 antihistamines such as ranitidine 50 mg IV in adults (1 mg/kg in children) 1, 2
• Consider systemic glucocorticosteroids for patients with history of idiopathic anaphylaxis, asthma, or severe/prolonged anaphylaxis 1

Post-Event Management

• Observe patient in a monitored area for a minimum of 6 hours or until stable and symptoms are regressing 1
• Obtain mast cell tryptase samples: first sample at 1 hour after reaction onset, second sample at 2-4 hours, and baseline sample at least 24 hours post-reaction 1
• Arrange referral to an allergist for future investigation 2

Important Considerations and Pitfalls

• Sugammadex has no immediate role in the resuscitation of suspected anaphylaxis caused by sugammadex itself 1
• Do not use antihistamines or corticosteroids as first-line treatment instead of epinephrine 2
• Do not administer epinephrine intravenously in non-arrest situations without appropriate monitoring 1, 2
• Avoid premature discharge without adequate observation for biphasic reactions 2
• While some case reports suggest sugammadex may be beneficial in rocuronium-induced anaphylaxis 4, 5, this is not applicable when sugammadex itself is the cause of anaphylaxis 6, 7, 8