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NMBA Cross-Reactivity Allergy — FRCA Final MCQ

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HardPreoperative AssessmentNMBA Cross-Reactivity AllergyFRCA Final

A 50-year-old man (ASA II) presents for elective laparoscopic cholecystectomy. He had a confirmed anaphylaxis to atracurium 3 years ago. Skin prick testing confirmed atracurium allergy but was negative to all other tested agents including rocuronium. Can rocuronium be safely used?

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Correct answer: D — Yes – negative skin testing to rocuronium combined with positive testing to atracurium supports safe use of rocuronium

Cross-reactivity between neuromuscular blocking agents occurs in approximately 60-80% of patients allergic to one NMBA (due to shared quaternary/tertiary ammonium group epitopes). However, it is not 100%. Negative skin testing (SPT and intradermal testing) to an alternative NMBA supports its safe use. This patient's negative rocuronium skin testing suggests rocuronium can be used, though the first dose should be given slowly in a monitored setting with full anaphylaxis treatment available. Sugammadex should be available for immediate reversal if needed.

Reference: Association of Anaesthetists – 2019 – Anaphylaxis investigation; RCUK – 2024 – Perioperative anaphylaxis