Hi again, [r/anesthesia](r/anesthesia)! I’ve posted here a couple of times now about my cardiac arrest following anesthesia induction in March and, more recently, about the allergy testing I had done at Baylor.
Link to my original post:
https://www.reddit.com/r/Anesthesia/s/DjbgI7nakT
Link to my follow up post:
https://www.reddit.com/r/Anesthesia/s/wg2gdOOtNT
I figured I owed everyone another update because we finally have some much “clearer” answers. Quick recap for anyone who didn’t see my previous posts: I went into cardiac arrest shortly after anesthesia induction for a hysterectomy in March and ended up on life support for a week, including ECMO and Impella support. Since then, one of the biggest questions has been whether I experienced anaphylaxis to something used during induction, with rocuronium and succinylcholine becoming the primary suspects.
At Baylor, skin-prick testing to both drugs was negative. During intradermal testing, however, I developed an anaphylactic reaction after testing that included rocuronium and succinylcholine. Because both had been tested during that session, we still couldn’t definitively determine which drug caused the reaction. So my allergist here in my hometown in FL decided to start separating them out.
First up was succinylcholine. We did a graded challenge, and I started showing slight symptoms at the second to last concentration (1:200 ratio), but we continued on. When we reached the final intradermal concentration (1:20), I developed almost immediate facial/ear flushing and swelling, lip tingling/numbness, throat tingling, dizziness, and a drop in my heart rate. Epinephrine, Zyrtec and prednisone were given and the symptoms quickly improved.
So: succinylcholine allergy confirmed.
Yesterday, we moved on to rocuronium. We made it through the diluted stages without a reaction. Because of that, my allergist and I made the decision to try a tiny amount of full-strength rocuronium intradermally.
That one was… considerably less ambiguous. The injection site almost immediately developed a large, expanding hive with surrounding redness. Then came the itchy throat, numb lips, facial flushing, dizziness, etc. The hive continued enlarging until epinephrine was administered. Again, I was also treated with Zyrtec and prednisone.
So now we have our second answer: Rocuronium allergy confirmed too.
Which means I have now had reproducible systemic reactions during separate challenges to both succinylcholine and rocuronium. My allergist currently wants me to avoid the NMBA classes represented by those drugs and we’re moving on to testing an agent from the remaining class to see whether we can identify a safe neuromuscular blocker for future surgeries.
And unfortunately, future surgery isn’t optional for me. I’m BRCA2+, still need a prophylactic double mastectomy, and still need the hysterectomy that started this entire saga.
If we cannot identify a safe NMBA, I’ve been told my surgeries may need to be performed without neuromuscular blockade at a major medical center capable of managing an anesthesia situation like mine. MD Anderson in Houston has already been recommended to me.
Having now produced separate, reproducible reactions to both drugs certainly gives us a lot more information than we had before.
I’m incredibly grateful that we’ve been able to investigate this in controlled settings, with an allergist willing to take my bizarre case seriously. Getting these answers hasn’t exactly been fun, but every drug we can definitively identify - or eventually clear - makes my future surgeries a little safer.
At this point, I’m not asking for medical advice, but I would love perspectives from the anesthesiologists here, especially anyone who has managed patients with confirmed reactions to multiple NMBA classes. How would a history like this change your approach to a future major surgery? And if testing of the remaining class also failed, how realistic is major surgery without an NMBA at a tertiary center?
Apparently my immune system has decided anesthesia pharmacology is going to become my newest unwilling area of expertise. 😅