General anesthesia without neuromuscular blocking agents using regional blocks in rocuronium-induced anaphylaxis - A case report -

Article information

Anesth Pain Med. 2026;21(2):252-257

Publication date (electronic) : 2026 March 11

doi : https://doi.org/10.17085/apm.25396

Ji Young Kim¹, Young Chul Yoo¹, Na Young Kim¹, Hyeon Woo Bae², Soo Jung Park^,1

¹Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea

²Division of Colon and Rectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea

Corresponding author Soo Jung Park, M.D. Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea Tel: 82-2-2228-4430 Fax: 82-2-2227-6517 E-mail: crystal@yuhs.ac

Received 2025 September 9; Revised 2025 October 31; Accepted 2025 November 9.

Abstract

CASE REPORT

A 64-year-old woman (154 cm, 64 kg; body mass index 27.0 kg/m²) with sigmoid colon cancer was scheduled to undergo a laparoscopic low anterior resection. Comorbidities included hypertension, poorly controlled diabetes mellitus (HbA1c, 10.3%), and chronic kidney disease. She also had mild chronic obstructive pulmonary disease, coronary artery disease, and a history of failed percutaneous coronary interventions. Functional capacity was less than four Metabolic Equivalents of Tasks. She was assigned an American Society of Anesthesiologists physical status class III owing to multiple comorbidities and increased perioperative risk.

One month earlier, the patient had experienced a severe anaphylactic reaction during anesthesia induction with rocuronium at another hospital, resulting in profound hypotension requiring epinephrine and postoperative intensive care.

After recovery, she was referred to the Department of Allergy at our institution for further evaluation. A standardized allergy work-up was performed according to the European Network for Drug Allergy/European Academy of Allergy and Clinical Immunology (ENDA/EAACI) guidelines [4,5], including skin prick testing, intradermal testing, and serum IgE assessment for all perioperative agents used during the prior anesthesia and other commonly used anesthetics. The results demonstrated a strong intradermal reaction to rocuronium, while all other agents tested negative, confirming rocuronium-induced anaphylaxis. The patient was issued an adverse drug reaction alert card and advised to avoid all aminosteroid NMBAs due to their high cross-reactivity potential (Fig. 1).

Fig. 1.

Diagnostic workflow confirming rocuronium-induced anaphylaxis. The patient, who experienced perioperative anaphylaxis following rocuronium administration, underwent a standardized allergy evaluation. SPT was negative for all agents, while IDT showed a strongly positive response to rocuronium. Rocuronium-induced anaphylaxis was confirmed, and NMBA-free anesthesia was subsequently planned. SPT: skin prick testing, IDT: intradermal testing, ImmunoCAP: fluorescence enzyme immunoassay for allergen-specific IgE, IgE: immunoglobulin E, ADR: adverse drug reaction, NMBA: neuromuscular blocking agent.

Because benzylisoquinoline NMBAs such as cisatracurium were unavailable at our institution, an NMBA-free anesthetic strategy combining TIVA and regional blocks was implemented for the subsequent laparoscopic procedure. In the absence of safe alternative NMBAs, the anesthetic plan focused on three goals: (1) ensuring smooth airway management without muscle relaxants via airway topicalization; (2) maintaining effective ventilation during pneumoperitoneum with adequate regional analgesia; and (3) avoiding hemodynamic instability related to deep anesthesia in patients with cardiovascular comorbidities.

Upon arrival in the operating room, standard monitoring (IntelliVue MX700, Philips Healthcare) was applied, including noninvasive blood pressure, pulse oximetry, electrocardiography, and processed electroencephalography (Patient State Index [PSI]). Her initial vital signs were as follows: blood pressure, 213/76 mmHg; SpO₂ 96%; heart rate, 86 beats per min. To reduce preoperative anxiety and sympathetic overactivity, intravenous midazolam (1 mg) was administered, after which her blood pressure decreased to 107/59 mmHg. An awake arterial line was inserted under local anesthesia for continuous blood pressure monitoring. For airway topicalization, approximately 3–5 puffs (30–50 mg) of lidocaine 10% spray (Sungkwang Pharm Co.) was applied to the oropharynx and the endotracheal tube two minutes before intubation to attenuate gag and cough reflexes [6].

An additional 1 mg of midazolam was given, and general anesthesia was initiated with target-controlled infusion of remifentanil (GlaxoSmithKline) and 2% propofol (Fresenius Kabi), using the Injectomat TIVA Agilia pump (Fresenius Kabi), with effect-site concentrations (Ce) of 3.0 ng/ml for remifentanil and 5.0 μg/ml for propofol, respectively. After confirming deep anesthesia and absence of coughing or vocal cord movement, video laryngoscopy was performed, and tracheal intubation was completed using an endotracheal tube pretreated with a topical anesthetic. A 7-Fr central venous catheter was placed in the right internal jugular vein to prepare for hemodynamic instability.

Following induction, the patient was placed in the supine position, and an ultrasound-guided transversus abdominis plane (TAP) block and rectus sheath blocks (RSB) were performed using an in-plane technique. We used 30 ml of 0.5% ropivacaine (Hanlim Pharm. Co.); 5 ml was injected on each side of the rectus sheath near the pre-marked incision site, and 10 ml was administered bilaterally to the expected port insertion areas (Fig. 2). No complications or adverse effects from regional blocks were observed.

Fig. 2.

Ultrasound-guided TAP and RSB. (A) In-plane TAP block with the needle tip positioned between the IOM and TAM. The orange dashed line indicates the site of LA deposition. The LA diffused extensively into the plane between the IOM and TAM. The needle is indicated by the white arrowheads. (B) In-plane RSB at the lateral margin of the RAM, targeting the posterior rectus sheath. The needle is indicated by the white arrowheads. TAP: transversus abdominis plane, RSB: rectus sheath block, EOM: external oblique muscle, IOM: internal oblique muscle, TAM: transversus abdominis muscle, LA: local anesthetic, RAM: rectus abdominis muscle.

General anesthesia was maintained with remifentanil (3–5 ng/ml) and propofol (4–5 μg/ml). The patient was ventilated using volume-controlled mechanical ventilation with a tidal volume of 420 ml, respiratory rate of 10 breaths per min, and positive end-expiratory pressure of 7 cmH₂O. Intraoperative hemodynamics were continuously monitored via a radial arterial line, with serial measurements cross-checked against noninvasive blood pressure readings. Mean arterial pressure was maintained at ≥ 70 mmHg and within ± 20% of baseline values throughout the procedure. Heart rate remained between 60 and 80 beats/min without vasopressor requirement. Pneumoperitoneum pressure was maintained at 12 mmHg, with a Trendelenburg position of approximately 25°. Corresponding ventilatory and hemodynamic data were collected concurrently to provide ventilatory mechanics. Airway pressures (peak 18–28 cmH₂O; plateau 15–22 cmH₂O) and dynamic compliance (18–26 ml/cmH₂O) remained stable, with end-tidal carbon dioxide– arterial partial pressure of carbon dioxide (PaCO₂) (EtCO₂–PaCO₂) gradients ≤ 6 mmHg, indicating adequate ventilation and preserved pulmonary compliance under pneumoperitoneum and Trendelenburg positioning (Table 1). The PSI was maintained between 17 and 28, indicating an adequate anesthetic depth. The patient’s hemodynamic status remained stable without the need for vasopressors. Throughout the procedure, the operating surgeon evaluated the quality of the intra-abdominal workspace using a five-point Surgical Rating Scale (SRS) (1 = extremely poor, 2 = poor, 3 = acceptable, 4 = good, 5 = optimal), adapted from validated laparoscopic scoring systems [7,8]. The SRS was assessed at four key stages: (1) after umbilical port insertion, (2) upon laparoscope placement, (3) after establishment of the Trendelenburg position and pneumoperitoneum, and (4) during specimen retrieval at the end of surgery. The average score across all time points was used to represent overall surgical field adequacy. The mean surgeon-rated SRS was 4.3 ± 0.5 (‘good conditions’) across all intraoperative stages, confirming that adequate workspace and surgical visibility were achieved despite the absence of neuromuscular blockade.

Table 1.

Intraoperative Parameters and Surgeon-Rated Surgical Field Scores

Near the end of surgery, the surgeon noted mild discomfort during specimen retrieval with an SRS score of 3; however, no intervention was required. Stage-specific SRS scores were recorded and are presented in Table 1. To enhance postoperative pain control, 8 μg of sufentanil was administered intravenously during surgical closure.

The total anesthesia and surgical durations were 205 and 140 min, respectively, with an estimated blood loss of 20 ml. During anesthesia, 0.2 mg remifentanil and 600 mg (2%) propofol were administered via target-controlled infusion, and 8 μg sufentanil was given intravenously at closure for postoperative analgesia.

In the post-anesthesia care unit, the patient was hemodynamically stable and reported mild pain (numeric rating scale 2/10). No rescue analgesics or antiemetics were required, and the patient was discharged after 35 min of recovery.

In the ward, pain was well controlled with intravenous patient-controlled analgesia (PCA) containing fentanyl 1,000 μg and ramosetron 0.6 mg diluted in 100 ml of normal saline (basal rate: 2 ml/h; bolus: 1.5 ml; lockout interval: 15 min). Pain scores were 3/10 at 6 h and 2/10 at 24 h, with a total opioid use of approximately 22 mg morphine equivalent. Mild nausea at 12 h resolved after temporary PCA suspension and intravenous pethidine 25 mg. Intravenous 300 mg ibuprofen and 1 g acetaminophen (Maxigesic IV, Kyongbo Pharm) were continued thereafter.

The patient was discharged on postoperative day 5 without respiratory or other complications.

All clinical data were retrospectively collected from the electronic medical records system. Written informed consent was obtained from the patient for publication, and the study was approved by the Institutional Review Board (IRB) of Severance Hospital, Yonsei University College of Medicine (IRB No. 4-2025-0600).

DISCUSSION

Avoiding NMBA-induced anaphylaxis is crucial due to its rapid onset, unpredictability, and potentially fatal nature, with high cross-reactivity and often no prior warning [3]. Although rare (approximately 3.8 per 100,000 rocuronium administrations in a large Korean cohort), NMBAs remain among the most commonly implicated drug classes for perioperative anaphylaxis [2]. Notably, approximately 56% of patients with rocuronium-induced anaphylaxis also test positive for other aminosteroid agents such as vecuronium, emphasizing the difficulty of selecting safe alternatives [3].

This case highlights the challenges of managing confirmed NMBA-induced anaphylaxis in settings with limited access to non-cross-reactive alternatives. In such situations, muscle relaxant-free general anesthesia using intravenous agents and regional techniques is a feasible approach.

Neuraxial anesthesia (e.g., spinal or combined spinal-epidural) was initially considered to avoid muscle relaxants. However, due to the surgeon’s preference for a minimally invasive approach and the limited applicability of neuraxial techniques to laparoscopic low anterior resection, general anesthesia was selected.

To ensure safe airway management without neuromuscular blockade, we implemented multiple reflex suppression strategies. Lidocaine spray was applied to the oropharynx and endotracheal tube to reduce mucosal irritation. Midazolam was administered before induction to reduce preoperative anxiety and sympathetic tone. These measures, alongside deep anesthesia, helped suppress airway reflexes and sympathetic surges during intubation. Endotracheal intubation was completed without any patient movement or hemodynamic instability.

TIVA was chosen over volatile agents due to its favorable profile in patients with multiple comorbidities [9]. Propofol suppresses spinal motor neuron excitability and, when combined with remifentanil, reduces somatic responses while maintaining stable anesthetic depth [10]. This combination has also been shown to provide superior muscle relaxation compared with volatile agents with remifentanil, particularly in the absence of NMBAs [9,10]. TIVA minimizes airway irritation and sympathetic stimulation—crucial during laparoscopic surgery. In this case, the patient’s chronic obstructive pulmonary disease, poorly controlled diabetes, obesity, and coronary artery disease, posed a risk of compromised pulmonary and cardiovascular stability during pneumoperitoneum and Trendelenburg positioning. Intraoperative ventilatory and hemodynamic parameters remained stable throughout.

A deep neuromuscular block facilitates laparoscopic surgery by enhancing abdominal compliance and enabling low-pressure pneumoperitoneum [11]. Similar effects can be partially achieved using regional techniques in patients in whom NMBAs are contraindicated. In this case, we selected 0.5% ropivacaine for both TAP and RSB based on previous randomized studies showing its superior analgesic effect compared to lower concentrations in laparoscopic abdominal surgery [12,13]. The TAP block provides extensive lateral abdominal analgesia by targeting the neurofascial plane between the internal oblique and transversus abdominis muscles, covering dermatomes T6–L1 [12]. To complement this, RSB was performed bilaterally at the incision site while anesthetizing the terminal branches of the lower thoracic nerves passing through the posterior rectus sheath [13]. This combined approach allowed for both lateral and midline abdominal wall relaxation, facilitating adequate trocar access and minimizing somatic pain. Although the surgeon reported mild resistance during specimen retrieval, the patient did not experience postoperative somatic pain at the incision site, further confirming the effectiveness of the multimodal regional technique.

Previous reports have shown that either TIVA or regional anesthesia alone can be used in patients with NMBA anaphylaxis. However, our case demonstrates the complementary value of combining these techniques [14,15]. Depth-guided TIVA, meticulous airway topicalization, and multimodal abdominal wall blocks (including TAP and RSB) together provided adequate anesthetic depth, hemodynamic stability, and abdominal wall relaxation, enabling laparoscopic surgery without the need for neuromuscular blockade.

Continuous depth monitoring (e.g., PSI), comprehensive hemodynamic and ventilatory assessment, together with surgeon-rated surgical conditions, provided objective intraoperative evidence supporting the physiological stability and reproducibility of this NMBA-free anesthetic approach.

While this report describes a single high-risk patient managed at a specialized tertiary center, this protocol may be applied to carefully selected patients and surgical settings. Although its applicability will vary depending on patient factors, surgical requirements, and institutional experience, it provides a practical and structured clinical framework that may guide future practice and support prospective evaluation of NMBA-free anesthesia.

In conclusion, this case demonstrates that major laparoscopic surgery can be performed safely without neuromuscular blockers in patients with confirmed NMBA-induced anaphylaxis, using a tailored multimodal strategy that incorporates airway topicalization, depth-guided TIVA, and regional anesthesia.

Article information Continued