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.
Résumé
Éléments cliniques
Une insuffisance hépatique aiguë s’est développée chez une femme de 76 ans, déjà opérée quatre fois à l’occasion d’interventions chirurgicales mineures, à la suite d’une anesthésie générale avec sévoflurane, sufentanil et propofol lors du remplacement de sa valve aortique. Après une intervention sans particularité, la patiente a été extubée 4,5 h après la chirurgie. Le deuxième jour postopératoire, l’alanine aminotransférase (ALT) et l’aspartate aminotransférase sériques (AST) ont augmenté. L’insuffisance hépatique est survenue le troisième jour après l’opération, et l’ALT et l’AST ont présenté des valeurs maximales de 10504 U·L-1 et 15516 U·L-1 respectivement. Le même jour, une coagulopathie avec un rapport international normalisé de 4,6 s’est développée. Une transplantation hépatique a été envisagée, mais cette option thérapeutique a été refusée. La patiente est décédée trois jours après l’opération d’une défaillance multisystémique provoquée par l’insuffisance hépatique. D’autres causes possibles de l’insuffisance hépatique ont été écartées.
Conclusion
Une hépatite au sévoflurane provoquant une insuffisance hépatique peut être en cause chez cette patiente de chirurgie valvulaire. Au contraire d’autres agents anesthésiques halogénés, le sévoflurane n’est pas métabolisé en protéines de trifluoroacétyl hépatotoxique. Toutefois, le composé A peut réagir avec des protéines et peut être transformé en matériel antigénique. Ce cas laisse à penser que tous les anesthétiques halogénés pourraient causer des lésions hépatiques aiguës.
Objectif
Présenter un cas d’hépatotoxicité létale causée probablement par le sévoflurane.
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Lehmann, A., Neher, M., Kiessling, AH. et al. Case report: Fatal hepatic failure after aortic valve replacement and sevoflurane exposure. Can J Anesth 54, 917–921 (2007). https://doi.org/10.1007/BF03026797
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DOI: https://doi.org/10.1007/BF03026797