Rapid pre-operative immunotherapy in a patient allergic to muscle relaxants

Allergic reactions to muscle relaxants are not uncommon. Although, in most instances, divalent quaternary ammonium salts are involved in these reactions, some monovalent quaternary ammonium compounds can trigger IgE-mediated reactions. A woman who suffered from several episodes of anaphylaxis with divalent (suxamethonium) and monovalent quaternary ammonium salts (tiemonium) needed surgery. Regional anaesthesia was contra-indicated owing to a possible intolerance to local anaesthetics. Investigation confirmed an allergy to monovalent quaternary ammonium salts. Rapid immunotherapy was started with a monovalent quaternary ammonium salt (tiemonium) and subsequently followed by a general anaesthesia using vecuronium. The patient did not develop anaphylactic symptoms.