DP01: SUDDEN ONSET ANGIOEDEMA AFTER ADMINISTRATION OF SUGAMMADEX
Didja Hilmara; Nathalie Abitbol
University of Miami/Jackson Memorial Hospital
Introduction/Background: Although rare, there are case reports in the literature that describe perioperative hypersensitivity reactions associated with the use of sugammadex for neuromuscular blockade reversal. In cases of suspected perioperative hypersensitivity reactions, anesthesia providers should promptly recognize adverse reactions and appropriately manage.
Methods: A 72 year-old woman with a history of non-functional pituitary macroadenoma, hypertension, hyperlipidemia, and no known medication allergies was scheduled for endoscopic pituitary tumor removal under general anesthesia. Standard induction and intubation via direct laryngoscopy with a Grade 1 view was performed. General anesthesia was uneventful until the end of the case. Once the surgery was completed, sugammadex 200 mg was given for neuromuscular blockade reversal. Once the drapes were removed, the ENT fellow placed an OGT and removed it without complication. Subsequently, both the fellow and resident noted the patient’s swollen tongue protruding from the mouth. No rashes or hemodynamic instability noted at this time. The anesthesiologist made the decision to keep the patient intubated for angioedema with macroglossia.
Results: Due to suspicion for allergic reaction from one of the medications given towards the end of case, diphenhydramine 25mg, famotidine 20mg and 10mg dexamethasone were administered and labs were drawn for tryptase prior to transport to ICU. The patient was administered additional steroids in the ICU, remained hemodynamically stable, tryptase was 3.5ug/L (within normal limits of 2.2-13.2ug/L), angioedema resolved on POD #1 and the patient was extubated without issues. The patient recovered well and was discharged home on POD #2.
Discussion/Conclusion: Acute onset macroglossia may occur over minutes to hours during general anesthesia. Etiologies include trauma to the oral cavity (e.g traumatic intubation, traumatic OGT placement), allergic or non-allergic angioedema, or patient positioning (i.e prone position). Given the lack of complications with intubation, uneventful surgery and supine position of the patient, we suspected a medication-induced source of angioedema. Given that this patient received ondansetron in the past without complications, our suspicion remained high for sugammadex-mediated angioedema. Early recognition of angioedema is important given that it may cause life-threatening airway obstruction. Management of allergic angioedema in the intubated patient includes antihistamine, steroids, epinephrine, assessment of hemodynamics and other physical findings, tryptase level and continued intubation until airway swelling improves.