Anaphylaxis Management in Sugammadex-Induced Reactions

Initial Management

The British Journal of Anaesthesia recommends administering 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, the British Journal of Anaesthesia suggests administering IV epinephrine 20 μg if vasopressor, bronchodilator, or both are clinically indicated 1
For Grade III reactions, the British Journal of Anaesthesia recommends administering IV epinephrine 50-100 μg 1
For Grade IV reactions, the British Journal of Anaesthesia advises following local advanced life support guidelines including IV epinephrine 1 mg 1
The British Journal of Anaesthesia recommends administering 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, as recommended by the British Journal of Anaesthesia 1

If inadequate response after 10 minutes, the British Journal of Anaesthesia suggests escalating epinephrine dose by doubling the bolus dose 3
Consider starting epinephrine infusion (0.05-0.1 μg/kg/min) when more than three epinephrine boluses have been administered, as recommended by the British Journal of Anaesthesia 3
For persistent hypotension, add infusion of norepinephrine (0.05-0.5 μg/kg/min), phenylephrine, or metaraminol, as suggested by the British Journal of Anaesthesia 3
Consider vasopressin as a bolus 1-2 IU with or without infusion (2 units/h) for persistent hypotension, as recommended by the British Journal of Anaesthesia 3
For patients on beta-blockers with refractory symptoms, the British Journal of Anaesthesia advises administering IV glucagon 1-2 mg 1

After adequate epinephrine and fluid resuscitation, the British Journal of Anaesthesia recommends administering 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), as suggested by the Journal of Allergy and Clinical Immunology 5
Consider systemic glucocorticosteroids for patients with history of idiopathic anaphylaxis, asthma, or severe/prolonged anaphylaxis, as recommended by the Journal of Allergy and Clinical Immunology 5

Observe patient in a monitored area for a minimum of 6 hours or until stable and symptoms are regressing, as recommended by the British Journal of Anaesthesia 3
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, as suggested by the British Journal of Anaesthesia 3
Arrange referral to an allergist for future investigation, as recommended by the British Journal of Anaesthesia 3

Sugammadex has no immediate role in the resuscitation of suspected anaphylaxis caused by sugammadex itself, as stated by the British Journal of Anaesthesia 3
Do not use antihistamines or corticosteroids as first-line treatment instead of epinephrine, as recommended by the Journal of Allergy and Clinical Immunology 5
Do not administer epinephrine intravenously in non-arrest situations without appropriate monitoring, as advised by the Journal of Allergy and Clinical Immunology 5
Avoid premature discharge without adequate observation for biphasic reactions, as recommended by the British Journal of Anaesthesia 3