Anaphylaxis After a Third Exposure to Sugammadex

We report a rare case of anaphylaxis triggered by a third exposure to sugammadex. The patient was a 49-year-old man who had previously been exposed to sugammadex on two occasions and then developed likely anaphylaxis (severe hypotension and skin, gastrointestinal, and respiratory symptoms) after administration of sugammadex following bilateral mandibular alveoloplasty. He was promptly and successfully managed and recovered fully without any complications. A subsequent sugammadex drug-induced lymphocyte stimulation test was negative. The mechanism via which sugammadex causes anaphylaxis is not well understood. In recent years, there have been reports implicating the rocuronium–sugammadex complex as a cause of anaphylaxis, but some of those cases did not include a positive allergic reaction to sugammadex alone. We suspected that the rocuronium–sugammadex complex might have been the causative agent in this case. Our experience suggests there may be a significant risk of anaphylaxis even in patients who have been exposed to sugammadex safely on previous occasions. The need for sugammadex should be assessed carefully using a muscle relaxation monitor, and providers must remain vigilant for anaphylaxis after administration of sugammadex.