Anesthesia Management in Patients with Documented Allergy to Rocuronium and Cisatracurium

Recommended Muscle Relaxants

• The American Society of Anesthesiologists recommends using succinylcholine as the first option for muscle relaxation in patients with a documented allergy to rocuronium and cisatracurium, due to its rapid onset and short duration of action, allowing for better control of the airway with minimal risk of complications 1, 2
• The dosage of succinylcholine varies by age: 1.8 mg/kg for patients under 1 month, 2 mg/kg for patients between 1 month and 1 year, 1.2 mg/kg for patients between 1 and 10 years, and 1 mg/kg for patients over 10 years 2

Alternative Muscle Relaxants

• Atracurium may be considered as an alternative to succinylcholine if it is contraindicated, although it carries a higher risk of histamine release, and its metabolism is independent of renal and hepatic function 1, 3, 4
• Mivacurium is another alternative, but it also carries a similar risk of histamine release as atracurium 1
• Cisatracurium may be considered as an alternative when histamine release is a concern, as it has minimal cardiovascular effects and less tendency for mast cell degranulation, according to the American Academy of Anesthesiologists 4, 5

Cross-Reactivity and Skin Testing

• Cross-reactivity between different neuromuscular blockers is relatively common, occurring in up to 30 out of 31 patients in some studies, due to the shared quaternary ammonium epitope 1
• Skin testing with all available neuromuscular blockers should be performed before a new anesthesia to identify safe alternatives 1

Special Considerations

• In pregnancy, succinylcholine has minimal effects on the neonate, although it crosses the placenta, and should be considered if a neuromuscular blocker is absolutely necessary 6
• The use of atracurium may be associated with the production of laudanosine, a neuroactive metabolite with the potential to precipitate seizures 6
• Atracurium's metabolism is largely independent of renal and hepatic function due to its Hofmann elimination pathway, making it valuable in patients with renal or hepatic impairment 3, 4
• Initial dosing of atracurium does not need to be modified in patients with renal or hepatic failure 3
• For patients with acid-base disturbances, close monitoring of neuromuscular function using train-of-four monitoring is recommended, with preparation to adjust dosing based on clinical response 3
• Acidosis may prolong the effect of atracurium, while alkalosis may shorten it, requiring careful consideration in dosing adjustments 3
• The American Society of Anesthesiologists recommends using peripheral nerve stimulation (train-of-four monitoring) to guide dosing and prevent overdosage or underdosage 4
• Atracurium has minimal cardiovascular effects at standard doses, though higher doses (>0.5 mg/kg) may cause histamine release, according to the American Heart Association and the American College of Cardiology 4