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

Background: Neuromuscular blocking agents (NMBAs) are the leading cause of perioperative anaphylaxis. In confirmed cases with limited non-cross-reactive options, safe anesthesia requires coordination and muscle relaxant-free strategies.Case: A 64-year-old woman with confirmed rocuronium-induced anaphylaxis and multiple comorbidities—including poorly controlled diabetes, coronary artery disease, chronic obstructive pulmonary disease, and obesity—underwent laparoscopic anterior resection of the sigmoid colon. General anesthesia was induced and maintained without muscle relaxants using total intravenous anesthesia and regional blocks. Airway topicalization and deep anesthesia enabled smooth intubation. Bilateral transversus abdominis plane and rectus sheath blocks provided effective somatic analgesia and abdominal relaxation. Ventilation and hemodynamic parameters remained stable throughout. The patient recovered uneventfully, without agitation or delayed arousal, and was discharged uneventfully on postoperative day 5.Conclusions: This report describes the feasibility of NMBA-free general anesthesia using intravenous agents and targeted regional blocks in high-risk patients with confirmed anaphylaxis, even in laparoscopic procedures.