What is the management of Sugammadex (Bridion) associated anaphylaxis?

Management of Sugammadex-Associated Anaphylaxis

The management of sugammadex-associated anaphylaxis requires immediate administration of epinephrine as the first-line treatment, followed by fluid resuscitation and supportive care based on symptom severity. 1

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 1
• For Grade II reactions: administer IV epinephrine 20 μg if vasopressor or bronchodilator effects are clinically indicated 1
• For Grade III reactions: administer IV epinephrine 50-100 μg 1
• For Grade IV reactions: follow local advanced life support guidelines including IV epinephrine 1 mg 1
• Establish intravenous access, provide supplemental oxygen, and continuously monitor vital signs 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

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
• Rapid volume expansion is mandatory for cardiopulmonary arrest during anaphylaxis 2

Second-Line Interventions

• After adequate epinephrine and fluid resuscitation, administer IV antihistamines such as chlorphenamine or diphenhydramine 25-50 mg (not a priority) 1
• Consider H2 antihistamines such as ranitidine 50 mg IV in adults (1 mg/kg in children) 1
• Consider systemic glucocorticosteroids for patients with history of idiopathic anaphylaxis, asthma, or severe/prolonged anaphylaxis 2, 1
• For cardiopulmonary arrest, consider atropine and transcutaneous pacing if asystole and/or pulseless electrical activity are present 2

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 1
• Consider transportation to emergency department or intensive care facility for continued monitoring 2

Important Considerations and Pitfalls

• Sugammadex has no 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 1
• Do not administer epinephrine intravenously in non-arrest situations without appropriate monitoring 1
• Avoid premature discharge without adequate observation for biphasic reactions 1
• Be aware that anaphylaxis can occur with sugammadex alone or with the sugammadex-rocuronium complex 3
• Clinicians should be prepared for the possibility of drug hypersensitivity reactions and take necessary precautions 4
• Prolonged resuscitation efforts are encouraged if necessary, as they are more likely to be successful in anaphylaxis 2

Recognition of Sugammadex-Induced Anaphylaxis

• Signs and symptoms include mucocutaneous erythema, urticaria, hypotension, tachycardia, and respiratory difficulties 5, 6
• Anaphylaxis typically occurs within minutes after sugammadex administration 5, 6
• In severe cases, reintubation may be required due to difficulty in manual ventilation 5
• The most commonly described clinical features in reports of anaphylaxis are dermatologic symptoms and clinically important hypotension 4