Mortality, morbidity and impact on future anesthesia after perioperative anaphylaxis related to neuromuscular blocking agents: an 11-year retrospective study

Position du problème et objectif(s) de l’étude

Limited data are available regarding the morbidity in patients who have experienced an anaphylactic shock due to neuromuscular blocking agents (NMBAs), as well as the impact on future anaesthetic management of patients who have had such an anaphylactic shock. The aim of this study was to describe the outcomes of these patients.

Matériel et méthodes

This retrospective single-centre study analysed data from adult patients who received NMBA during general anaesthesia between 2012 and 2022 and experienced grade 2, 3, or 4 NMBA-related anaphylactic shock. Data were collected using an electronic data warehouse and through manual review of medical records. Indeed, to identify patients with suspected perioperative anaphylaxis (POA), we reviewed all cases in which the administration of an NMBA, the use of epinephrine or norepinephrine, and the measurement of tryptase or specific IgE levels were documented concurrently. To ensure comprehensive case identification, we also reviewed medical records that referenced “anaphylactic shock,” either explicitly or implicitly. Two groups were formed based on whether or not the patient underwent allergological investigations. Where allergological investigations were unavailable, a minimum score of 15 on the Hopkins clinical scoring system was required (Hopkins et al., British journal of anaesthesia, 2019).

Résultats & Discussion

Among the 158,021 general anaesthetics involving one of the six NMBA selected for the study (rocuronium, vecuronium, suxamethonium, atracurium, cisatracurium, and mivacurium), 94 patients experienced severe anaphylactic shock, of whom 87.2% (n = 82) underwent comprehensive allergological investigations. The incidence was higher than described in the literature as we found 58.1 reactions per 100,000 administrations of NMBAs, all agents combined. Of the 94 cases, only 14 (14.9%) were reported to the Regional Pharmacovigilance Centre. Nineteen patients experienced morbidity, including renal failure (n=12) or cardiovascular complications (n=8). The majority of these morbidity-related events were transient: 12 of the 19 patients fully recovered. Four deaths occurred within 90 days following the anaphylactic event, including one in the operating room. Following the diagnosis of POA, 97 subsequent anaesthetic procedures were carried out in 69 patients, with 94% performed under general anaesthesia. An NMBA was required in 45 cases, while alternative techniques were preferred when possible (2 spinal anaesthesias and 36 epidural anaesthesias). Surgical difficulty was rare; most procedures were successfully completed without the use of NMBAs.

Conclusion

Our study highlighted a significant underestimation of the incidence of perioperative anaphylaxis related to NMBAs and its reporting to local and national pharmacovigilance centres. However, the complication rate associated with these cases of POA is relatively low. The impact on subsequent anaesthetics appears to be quite limited, with the possibility of performing the procedure without the use of an NMBA or by resorting to neuraxial anaesthesia. Nevertheless, these data would benefit from confirmation through larger sample sizes via a multicentre strategy, ultimately aiming to improve perioperative management strategies.

Auteurs

Damien ROUSSELEAU (1) , Pierre D'HEUDIÈRES (1), Gilles LEBUFFE (1), Cédric CIRENEI (1), Alexandre BOURGEOIS (1), Charlotte GEAY (2), Laurine CADART (3), Julien LABREUCHE (3) - (1)Department Of Anaesthesiology And Critical Care, Lille University Hospital, Claude Huriez Hospital, Lille University Hospital, Lille, France, Lille, France, (2)Include Health Data Warehouse, Lille University Hospital, Lille, France, Lille, France, (3)Department Of Biostatistics, Lille University Hospital, Lille, France, Lille, France

Orateur(s)

Pierre D'HEUDIERES ()