True anaphylaxis to suxamethonium chloride: a case report. Br J Anaesth 1978; 50: 611±5. 13 Vervloet D, Nizankowska M, Arnaud A, et al. Adverse reactions.
British Journal of Anaesthesia 85 (6): 844±9 (2000)
Weal and ¯are responses to intradermal rocuronium and cisatracurium in humans² J. H. Levy1*, M. Gottge1, F. Szlam1, R. Zaffer1 and C. McCall2 1
Department of Anesthesiology, Emory University Hospital, 1364 Clifton Road, NE, Atlanta, GA 30322, USA. 2Department of Dermatology, Emory University Hospital, 1364 Clifton Road, NE, Atlanta, GA 30322, USA. *Corresponding author Thirty volunteers underwent intradermal skin testing with increasing concentrations of rocuronium and cisatracurium to evaluate weal and ¯are responses, and whether either agent would cause mast cell degranulation and sensitization upon re-exposure. We found that intradermal injection of rocuronium and cisatracurium at concentrations >10±4 M resulted in positive weal (>8 mm) responses, and positive ¯are responses at >10±4 and >10±5 M respectively. Only cisatracurium caused mild to moderate mast cell degranulation, and neither drug caused signi®cant in vitro histamine release from whole blood collected from study subjects 4 weeks after skin testing. Skin testing with rocuronium and cisatracurium should be performed at concentrations 75% of the diameter of the histamine control weal). If a subject had more than one positive response to the study drug(s), the weal produced by the lowest concentration of the study drug(s) that induced a positive weal response was biopsied. Biopsies of the sites of saline control treatments were also taken from the same subjects. The physician performing the punch biopsies was blinded to the study drugs and the corresponding concentrations that gave positive responses. A 3 mm punch biopsy specimen was taken after injecting lignocaine without preservative around the site to be biopsied using deep subcutaneous injection. The skin specimens were cut into 1.5 mm pieces and immediately placed in ®xative solution for light microscopy, or immersed in Karnofsky's ®xative and processed for transmission electron microscopy. After processing, semi-thin sections were cut and stained with Giemsa for light microscopy. These were examined for degranulation and to select areas with mast cells for
thin sectioning. Thin sections (70.0 nm) were cut and counterstained with lead citrate and uranyl acetate. An assessor who was blinded to the study medications examined these specimens under a Phillips 201 electron microscope. The presence of degranulation, the mast cell morphology, granule architecture and comments on the histology were recorded. Degranulation was recorded as 0, 1+, 2+, 3+ or 4+, where 0 represents normal mast cell morphology without evidence of degranulation and 4+ represents complete degranulation. Blood samples for in vitro histamine release were collected from each subject at the screening visit, before intradermal drug administration and at the follow-up visit 4 weeks after skin testing. For each subject, 10 ml of venous blood was collected into a vacutainer tube containing sodium heparin. Whole blood was diluted (1:5) with the releasing buffer (supplied as a part of the immunoassay kit used for histamine determination; Beckman-Coulter, Miami, Florida, USA). The potential for rocuronium and cisatracurium to mediate allergic sensitization was assessed by adding predetermined concentrations of either drug to separate plastic tubes containing 200 ml of diluted whole blood preparation and 100 ml of releasing agent. The rocuronium (2.5310±5 M) and cisatracurium besylate (4310±6 M) concentrations were chosen to correspond to the blood levels that would be seen clinically. The calcium ionophore A23187 (3.33310±5 M; Sigma Chemical, St Louis, MI, USA) and anti-IgE (Sigma Chemical) were used as positive controls. Negative control tubes (baseline release) had only diluted whole blood and buffer added to the tubes (no drugs). The tubes were incubated in a shaking water bath for 30 min at 37°C. At the end of the incubation, the tubes were immediately placed on ice and then centrifuged for 10 min at 900 g at 4°C. The supernatant was separated and stored at ±70°C until analysed. For total histamine determination, 50 ml of undiluted blood was added to 950 ml of distilled water (1:20 dilution), frozen, and thawed three times in order to lyse the cells. The sensitivity of the method allows histamine quantitation down to 0.5 nM (0.05 ng ml±1). The percentage of histamine release from 1 ml of blood by buffer, anti-IgE, calcium ionophore, rocuronium and cisatracurium besylate treatments was calculated using the formula: 1003D/T=% histamine release, where D=concentration of histamine in the sample containing the drug/buffer and T=total concentration of histamine in the frozen and thawed sample. The Wilcoxon signed-rank test was used to compare the percentage of positive reactions with the percentage in the control (saline) group. A paired Student's t-test was used to compare mean weal and ¯are diameters with the mean for the saline control. Student's t-test was used to compare mean percentage histamine release for rocuronium and cisatracurium between the ®rst visit and the follow-up and with the mean percentage histamine release for the positive
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Fig 1 Number of subjects with positive responses to increasing concentrations of rocuronium, cisatracurium and to positive and negative controls (n=30). *P10±5 M in all volunteers, and 25 out of 30 volunteers had positive cutaneous responses at 10±4 M (P
