Sugammadex-Associated Delayed Laryngeal and Upper Airway Edema: A Novel Adverse Effect

Sugammadex is a new drug that gained FDA approval in 2015 for rapid reversal of aminosteroid neuromuscular blockade as it showed faster action than the traditional drugs, neostigmine and is generally well tolerated. However, hypersensitivity reactions, including anaphylaxis, have been increasingly recognized. These reactions typically occur within minutes of administration and often involve multisystem manifestations. Isolated upper airway edema with delayed onset has not been previously described. We present an 87-year-old woman was admitted for abdominal wall cellulitis complicated by abscess requiring incision and drainage under general anesthesia. She received propofol, rocuronium, and sugammadex without immediate complications and was extubated successfully. Approximately 2.5 hours later, she developed acute tongue and lip swelling, respiratory distress, and stridor. Vital signs showed hypoxia, hypertension and tachycardia without hypotension. She was treated with epinephrine, corticosteroids, and antihistamines but required emergent intubation due to severe airway edema. Laryngoscopy revealed significant glottic swelling. She improved with supportive care in the intensive care unit and was successfully extubated after 2 days. Laboratory evaluation demonstrated normal C1 esterase inhibitor levels and complement levels, excluding hereditary and acquired C1 inhibitor deficiency. Medication review identified sugammadex as the only new exposure. The delayed onset, isolated airway involvement, and absence of systemic features distinguish this case from typical sugammadex hypersensitivity and suggest a possible alternative mechanism, including bradykinin-mediated pathways. This case expands the spectrum of sugammadex-related adverse effects and highlights the need for awareness of delayed, atypical presentations to guide perioperative monitoring and future anesthetic management.