Multiple cross-reactivity to several types of neuromuscular blocking agents in a patient with rocuronium anaphylaxis

provided the original work is properly cited. CC Anaphylaxis that occurs during anesthesia is a major cause of morbidity and mortality. Muscle relaxant is the most frequent cause of perioperative anaphylaxis [1]. Although it is believed that there is a risk of anaphylaxis to the drug in some patients, a similar incidence of anaphylaxis has been observed with use of other members of the same drug class. We report on a case of anaphylactic reaction to rocuronium in a male patient confirmed as having multiple cross-reactivity to various neuromuscular blocking agents (NMBAs) on an allergic skin test at three months after discharge. A 31-year-old, 174 cm, 85 kg man with congenital cystic adenomatoid malformation was scheduled to undergo lobectomy of the right lower lung. He did not have a history of allergy or surgery. Results of routine preoperative tests showed no abnormalities. In the operating room, routine monitoring devices, including a blood pressure (BP) cuff, pulse oximetry, and electrocardiography (ECG) were placed on the patient. He showed stable vital signs, including oxygen saturation (SpO2) 100%, BP 115/78 mmHg, and heart rate (HR) 90 beats/min. Epidural catheter insertion was performed for control of intraoperative and postoperative pain. Propofol target-controlled infusion was performed for induction of general anesthesia. After loss of eyelash reflex, rocuronium 60 mg was administered, and endotracheal intubation was performed after two minutes of facemask ventilation. After endotracheal intubation, his vital signs showed moderate hypotension; BP 85/40 mmHg, HR 75 beats/min. However, his breath sounds were normal. A 20-gauge arterial cannula was inserted into the left radial artery for continuous monitoring of arterial BP and a central venous catheter was placed in the right subclavian vein. He was treated with intravenous injection of ephedrine 10 mg and rapid infusion of Ringer’s lactate solution. BP did not improve; therefore, we stopped propofol infusion. We injected midazolam 3 mg and rocuronium 20 mg. A few minutes after injection, his vital signs indicated severe hypotension (BP 50/30 mmHg). We observed a skin rash, urticaria, and edema on his face, neck, arms, and legs. On arterial blood gas analysis, the measured values were pH 7.230, PCO2 50.4 mmHg, PO2 124 mmHg and SpO2 98%. The patient was treated with intravenous injection of epinephrine 0.1 mg and continuous infusion of dopamine, dobutamine, and phenylephrine. After a few minutes of infusion, his vital signs became stable; BP 90/45 mmHg, HR 105 beats/min, and SpO2 100%. Hydrocortisone 100 mg and chloropheniramine 4 mg were administered intravenously. Seventy