A Case of Rocuronium-Induced, Adrenaline-Refractory Anaphylaxis Successfully Treated With Sugammadex

Anaphylaxis during general anesthesia is a rare but life-threatening event, and rocuronium is a leading perioperative trigger. Sugammadex reverses rocuronium-induced neuromuscular blockade by encapsulating free rocuronium molecules. Although sugammadex has been proposed as a potential intervention for rocuronium-induced anaphylaxis, its clinical effectiveness has not been clearly demonstrated. We report an 80-year-old woman who developed severe, adrenaline-refractory anaphylaxis immediately after anesthetic induction for total knee arthroplasty (TKA). Despite fluid resuscitation and repeated doses of adrenaline totaling 3 mg, profound hypotension persisted, and transient pulselessness occurred, requiring brief chest compressions. Sugammadex 400 mg was administered 25 minutes after the onset, while fluid resuscitation and norepinephrine infusion were continued. Within five minutes, the systolic blood pressure improved, and no further adrenaline was required. Subsequent skin testing identified rocuronium as the sole culprit. While experimental and clinical data suggest that sugammadex may not reverse an established immunologic cascade, reducing circulating rocuronium might theoretically limit further antigenic stimulation. Given the dismal prognosis of adrenaline-refractory anaphylaxis, sugammadex may represent a rational adjunctive measure after completion of guideline-directed resuscitation in cases where rocuronium-induced anaphylaxis is strongly suspected. This case underscores both the potential role and ongoing uncertainty surrounding sugammadex in cases of rocuronium-induced anaphylaxis and highlights the need for cautious application and further accumulation of clinical evidence.