A Biphasic Anaphylactic Attack from Sugammadex with a Severe Second Attack

A 74-year-old man was scheduled for transurethral resection of the prostate under general anesthesia. Anesthesia was induced by propofol, rocuronium, remifentanil and maintained with sevoflurane. The operation was finished in 56 minutes without trouble. After operation, sugammadex was administered, and after about 2 minutes, redness, tachycardia, hypotension and itchiness appeared. Treatment was initiated using steroids, adrenaline, and antihistamine upon diagnosis of anaphylaxis caused by sugammadex. Reaction to the treatment was good and the general condition improved to normal; however, the patient was moved to the intensive care unit for follow-up observation. Furthermore, no upper respiratory tract symptoms were observed during the follow-up along with no decline in SpO2. The condition progressed without any particularly major abnormalities after entering the intensive care unit; however, a sudden decline in blood pressure and dyspnea occurred again 3 hours following entering the intensive care unit. These were considered to be biphasic reactions due to anaphylaxis, and treatment was carried out again with intravenous injection of adrenaline, steroids and inhalation of beta-agonist. No symptoms were observed since and the patient was discharged from the intensive care unit the following day.