Case report: Fatal hepatic failure after aortic valve replacement and sevoflurane exposure

Abstract

Purpose: To report a case of lethal hepatotoxicity possibly caused by sevoflurane. Clinical features:A 76-yr-old woman with a history of four previous minor surgical procedures developed acute liver failure after general anesthesia with sevoflurane, sufentanil and propofol for aortic valve replacement. After an uneventful procedure the patient was extubated 4.5 hr after surgery. On the second postoperative day, serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) increased. On the third postoperative day liver failure occurred, ALT peaked at 10504 U·L -1 and AST at 15516 U·L -1 , and coagulopathy with an international normalized ratio of 4.6 developed. Liver transplantation was considered but rejected as a therapeutic option. The patient died three days after the operation in multiple organ failure triggered by hepatic failure. Other possible causes for liver failure were excluded. Conclusions:Sevoflurane hepatitis as a cause for liver failure may be implicated in this patient undergoing valve surgery. Unlike other halogenated anesthetic drugs, sevoflurane is not metabolized to hepatotoxic trifluroacetyl proteins. However, compound A may react with proteins and may be transformed into antigenic material. We suggest that all halogenated anesthetics may be implicated with acute liver injury.

Halothane: how should it be used in a developing country?

“…Hepatitis following anaesthesia induced by other inhalation anaesthetics has also been reported although it is rare [23][24][25]. …”

Oxidative stress and antioxidant activity of female rat liver tissue after sevoflurane anaesthesia: young versus old

“…In the clinical studies, Kharasch (25) and Kharasch et al (26) reported no hepatotoxic effects of sevofl urane, the new volatile anaesthetics, and insignifi cant rates of hepatic dysfunction (25,27); nevertheless, the number of reported cases with hepatotoxicity associated with sevofl urane has increased in recent years (8)(9)(10)(11)(12)(13).…”

“…It has a low blood solubility, which results in a rapid induction and faster recovery (7). Although there are reports of sevofl urane-associated liver injury in the literature (8)(9)(10)(11)(12)(13), sevofl urane is considered less hepatotoxic than the older inhalational agents (14).…”

Perioperatives anästhesiologisches Management bei ausgedehnten Leberteilresektionen

“…In der Studiengruppe zeigte sich ein geringerer postoperativer Anstieg der leberspezifischen Transaminasen (AST, ALT; [5]). Es liegt jedoch der Fallbericht eines fulminant verlaufenden Leberversagens nach Aortenklappenersatz vor, der in Zusammenhang mit einer Sevofluranexposition gebracht wurde [66]. Trotz dieser fatalen, einzelnen Komplikation ist aufgrund der Anwendung von Sevofluran in verschiedenen leberchirurgischen Zentren und bei zahlreichen herzchirurgischen Patienten von einem klinisch akzeptablen Sicherheitsprofil auszugehen.…”