Fatal anaphylactic reaction to suxamethonium: new screening test suggests possible prevention

A 40-year-old woman suffered cardiovascular collapse, cardiac ischaemia and arrest during induction of anaesthesia. Severe cerebral ischaemic damage was sustained during this episode and the patient died 4 days later. This fatal reaction was shown to be anaphylactic in origin; the causative agent was suxamethonium. High levels of IgE antibodies specific to the quaternary ammonium group (two of which are present in suxamethonium) were detected by the radioallergosorbent test. Results of the leucocyte histamine release test were less clear, partly as a result of steroid treatment. The two most relevant points were the absence of a history of previous anaesthesia, and involvement of the heart as the principal target of the reaction. This unfortunate and extreme case indicates the necessity for allergy testing (screening) before anaesthesia, and the need for organisation and funding of this procedure, if these fatal or near-fatal reactions are to be prevented. It is a timely reminder that action should be taken, since neuromuscular blockers have been confirmed as the most common culprits, and that specific tests for IgE antibodies are now available against haptenic groups generally common to all neuromuscular blockers.