Suxamethonium anaphylaxis

The use of suxamethonium is associated with a range of side effects (Table 6.2). Some of these, such as myalgias, are inconvenient and troublesome while others, such as anaphylaxis... 

Anaphylactic reactions result from the interaction of antigens with specific IgE antibodies, which have been formed by previous exposure to the antigen. Anaphylactoid reactions are clinically indistinguishable from anaphylaxis but do not result from prior exposure to a triggering agent and do not involve IgE. Intravenous anaesthetics and muscle relaxants can cause anaphylactic or anaphylactoid reactions and, rarely, they are fatal. Muscle relaxants are responsible for 70% of anaphylactic reactions during anaesthesia and suxamethonium accormts for almost half of these. 

Assem ELS, Symons IE. Anaphylaxis due to suxamethonium in a 7-year-old child a 14-year follow-up with allergy testing. Anaesthesia 1989 44(2) 121. ... 

Mandappa JM, Chandrasekhara PM, Nelvigi RG. Anaphylaxis to suxamethonium. Two case reports. Br J Anaesth 1975 47(4) 523-5. 

Jerums G, Whittingham S, Wilson P. Anaphylaxis to suxamethonium. A case report. Br J Anaesth 1967 39(l) 73-7. 

A man recovering from neuromuseular bloekade with suxamethonium (with some evidence of residual Phase II bloek) developed almost total muscle paralysis and apnoea when given an intravenous infusion of vancomycin. He recovered spontaneously when the vancomycin was stopped, but it took several hours. The neuromuseular blockade due to vecuronium was increased in a patient when given an infusion of vancomycin (I g in 250 mL of saline over 35 minutes). Transient apnoea and apparent cardiac arrest have also been described in a patient following a I-g intravenous injection of vancomycin given over 2 minutes. However, in both of these cases the vancomycin was given more rapidly than the current recommendations. It is now known that rapid infusion of vancomycin can provoke histamine release, which can result in apnoea, hypotension, anaphylaxis and muscular spasm, effects similar to those seen in these two patients. 

The case history and other clinical manifestations in some of the patients with reactions to suxamethonium leaves little doubt that allergy can develop in response to the administration of this agent, which is an acetylcholine analogue. The acute reaction in these cases was therefore very likely to have been due to typical IgE-mediated anaphylaxis. Cases of similar reactions have been reported by other authors, e.g. Jerums et al. (1967), Royston and Wilkes (1978). This aspect, the immune reaction to succinylcholine is considered so fundamentally important as to warrant full consideration. The preliminary studies of Hadji and Benveniste (1980) suggest that sensitization of guinea-pigs to suxamethonium can be induced by repeated injection. 

Hadji L, Benveniste J (1980) Experimental cardiac anaphylaxis to an anaesthetic adjuvant as a model for drug allergy. Allergol Immunopathol (Madr) 8 485-486 Jerums G, Whittingham S, Wilson P (1967) Anaphylaxis to suxamethonium. A case report. Br J Anaesth 39 73-77... 

Royston D, Wilkes RG (1978) True anaphylaxis to suxamethonium chloride. Br J Anaesth 50 611-615... 

Immunologic Refractory shock from anaphylaxis can occur after induction of general anesthesia [4 ]. Raised serum concentrations of tryptase and IgE to suxamethonium confirmed anaphylaxis to suxamethonium in these two patients. Hypotension was refractory to terlipressin in both cases and to extracorporeal membrane oxygenation in one. However, both interventions were instituted after a prolonged period of resuscitation. Methythioninium chloride, glucagon, and Qti-adrenoceptor agonists have been proposed as alternative therapeutic... 

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