What we already know Most studies have shown that NMBAs are the commonest cause (44-60%)of perioperative anaphylaxis Previous studies have been hampered.

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Presentation transcript:

Neuromuscular Blocking Agents and reversal drugs Prof Nigel Harper Clinical Lead, NAP6

What we already know Most studies have shown that NMBAs are the commonest cause (44-60%)of perioperative anaphylaxis Previous studies have been hampered by limited information on actual NMBA exposure Considerable geographical variation Suxamethonium has the highest anaphylaxis rate Cross-reactivity is frequent Potential future risk from any NMBA Non-allergic anaphylaxis can occur with atracurium and mivacurium

What is uncertain What is the UK pattern of NMBA use? Are NMBAs still at the top of the the anaphylaxis risk ladder? Is NMBA-anaphylaxis more severe? Is rocuronium higher risk than atracurium? Is sugammadex effective in rocuronium-anaphylaxis? Does exposure to pholcodine cough-medicine predispose to NMBA anaphylaxis? How often is anaphylaxis due to reversal drugs?

What is the UK pattern of NMBA use? Atracurium is the UKs favourite NMBA Cisatracurium hasn’t ‘caught-on’ NMBAs used in 47% of general anaesthetics NMBA use is decreasing Suxamethonium use is declining

Are NMBAs still at the top of the the ladder? Antibiotics are the most common cause: 65 cases were due to NMBAs and 94 due to antibiotics The highest-risk antibiotic teicoplanin* is more likely to cause anaphylaxis than the highest-risk NMBA suxamethonium** NMBAs were suspected by the anaesthetist in 81 cases indicating a perception of high risk 67% of anaesthetists avoid an NMBA due to perception of high risk, and only 10.2% antibiotics * 16.4/100,000 administrations. ** 11.1/100,000 administrations

Is NMBA-anaphylaxis more severe? NMBAs responsible for 40% of deaths and 33% of reactions Fatalities: three rocuronium and one suxamethonium Suxamethonium anaphylaxis less likely to be severe

Is rocuronium higher-risk than atracurium? Cases confirmed Proportion of UK NMBA usage Anaphylaxis rate/100,000 uses Suxamethonium 14 11.2% 11.1 Rocuronium 27 40.6% 5.88 Atracurium 23 49.1% 4.15 Mivacurium 1 2.7% 3.25 Vecuronium 2.2% – Cisatracurium 1.6% Pancuronium 0.6% Suxamethonum clearly higher risk Rocuronium v atracurium less clear due to wide 95% Confidence Intervals Sux: 1 in 5, 368 – 1 in 16, 473 Roc: 1 in 11, 686 – 1 in 25, 799 Atra: 1 in 16, 069 – 1 in 38, 034

How often is anaphylaxis caused by reversal drugs? A single case of sugammadex-anaphylaxis was reported Sugammadex use has increased fourfold since 2013 and is now used in 5.7% of patients receiving an NMBA Several cases of sugammadex-anaphylaxis have been reported worldwide. No cases of neostigmine-induced anaphylaxis (used in 57.4%) Seed and Ewan described a single UK case in 2000

Pholcodine exposure There is evidence that exposure to pholcodine cough- medicines may cause sensitisation to NMBAs (Johansson 2010) NMBA anaphylaxis has declined in Norway since withdrawal of pholcodine cough-medicines (de Pater 2017) Previous exposure to pholcodine was sought by the allergy clinic in only 15 patients. Both patients with recorded previous pholcodine exposure had NMBA anaphylaxis

Recommendations - NMBAs Individual Except in cases of known or suspected allergy to specific NMBAs, the risk of anaphylaxis should not be an over-riding factor in choice of NMBA Research Further research on population sensitisation by pholcodine is needed. If a causal association is confirmed, withdrawal of pholcodine-containing medicines from the UK market should be formally considered

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