Yusuf ÜNAL, Ömer KURTİPEK, Bayazit DİKMEN, Mükerrem UYSAL, Mustafa ARSLAN

Yaşlı Bir Hastada Sevofluran Anestezisi Sonrası Karaciğer Toksisitesi: Olgu Sunumu

Geleneksel inhalasyon anestezik ajanların ılımlı ve bazen de şiddetli karaciğer yetmezliğine yol açabildikleri bilinmektedir. Ancak yeni inhalasyon ajanları primer hepatotoksisitenin nedeni olarak kabul edilmemektedir. Bu yazıda hipertansiyon, peptik ülser ve KOAH tanıları olan 66 yaşında kadın hastada sevoflurana bağlı gelişen karaciğer yetmezliği tablosunu sunduk. Hasta total kalça protezi operasyonu için ASA III risk grubunda ve preoperatif laboratuvar değerleri normaldi. Anestezi indüksiyonunda midazolam, remifentanil, sodyum tiyopental ve vekuronyum idamede sevofluran anestezisi uygulandı. Operasyon 285 dakika sürdü. Serum alanin aminotransferaz ve aspartat aminotransferaz düzeyi postoperatif 1. ve 2. günde sırasıyla 911 ve 1117 U/L idi. Karaciğer enzimleri postoperatif 13. günde normale döndü ve hasta 15. günde taburcu edildi. Bu hastada gelişen hepatotoksisiteyi operasyonda uygulanan sevofluran ile ilişkilendiriyoruz. Gelecekte hasta anestezi alacaksa total intravenöz anestezi veya hasta kabul ederse rejyonel anestezi uygulanabilir.

Hepatotoxicity Following Sevoflurane Anesthesia in an Elderly Patient: A Case Report

It has been well established that traditional inhalational anaesthetic agents can cause mild and sometimes fulminant liver failure. However newer inhalational agents are not accepted as primary causes of hepatotoxicity. Here we presented the case report of sevoflurane-induced acute liver failure in a 66-year-old woman with hypertension, peptic ulcus, and COPD. The patient (ASA III) was scheduled for total hip artroplasty. Her preoperative laboratory findings were normal. In the total hip artroplasty operation anesthesia was induced with midazolam, remifentanil, sodium thiopental and vecuronium and maintained with sevoflurane anesthesia. Duration of operation was 285 minutes. Serum alanine aminotransferase and aspartate aminotransferase levels peaked at postoperative 1st and 2nd days (911 and 1117 U/L, respectively). The liver biochemistry returned normal levels at postoperative 13th day and the patient was discharged from hospital on postoperative 15th day. We believe that hepatotoxicity in this patient was related to sevoflurane exposure at intraoperative period. Also we suggest that total intravenous anesthesia or with patient consent- regional anesthesia are favourable choices for possible surgical interventions that the patient may has in the future.

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Kumar GP, Bhat VJ, Sowdi V. Fulminant hepatic failure following halothane anaesthesia. J Clin Forensic Med 2005; 12: 271-3.
Otedo AE. Halothane induced hepatitis: case report. East Afr Med J 2004; 81: 538-9.
Peter CC, Shyh-Ching C, Jau-Min L, Li AH, Wong CH. Reproducible hepatic dysfunction following separate anesthesia with sevoflurane and desflurane. Chang Gung Med J 2003: 26: 357-62.
Reich A, Everding AS, Bulla, M, Olaf Anselm Brinkmann OA, Van Aken H. Hepatitis after sevoflurane exposure in an infant suffering from primary hyperoxaluria type 1. Anesth Analg 2004; 99: 370 -2.
Youngho J, Insoo K. Severe hepatotoxicity after sevoflurane anesthesia in a child with mild renal dysfunction. Paediatr Anaesth 2005; 15: 1140-4.
Alotaibi WH. Severe hepatic dysfunction after sevoflurane exposure. Saudi Med J 2008; 29: 1344-6.
Turillazzi E, D'Ericco S, Neri M, Riezzo I, Fineschi V. A fatal case of fulminant hepatic necrosis following sevoflurane anesthesia. Toxicol Pathol 2007; 35: 780-5.
Lehman A, Neher M, Kiesling AH, Isgro F, Koloska A, Boldt J. Case report: Fatal hepatic failure after aortic valve replacement and sevoflurane exposure. Can J Anesth 2007; 54: 917-21.
Preckel B, Bolten J. Pharmacology of modern volatile anaesthetics. Best Pract Res Clin Anaesthesiol 2005; 19: 331-48.
Eger EI. Characteristics of anesthetic agents used for induction and maintenance of general anesthesia. Am J Health-Syst Pharm 2004; 61: 3- 10.
Kharasch ED, Thummel KE. Identification of cytochrome P450 2E1 as the predominant enzyme catalyzing human liver microsomal defluorination of sevoflurane, isoflurane, and methoxyflurane. Anesthesiology 1993; 79: 795-807.
Biebuyck JF, Phill MB, Eger I. New inhaled anaesthetics. Anesthesiology 1994; 80: 906-14.
Smith I, Nathanson M, White PF. Sevoflurane- a long awaited volatile anesthetic. Br J Anaesth 1996; 76: 435-45.
Kharasch ED, Karol MD, Lanni C, Sawchuk R. Clinical sevoflurane metabolism and disposition: I Sevoflurane and metabolic pharmacokinetics. Anesthesiology 1995; 82: 1369-78.
Eger EI II, Koblin DD, Bowland T, Ionescu P, Laster MJ, Fang Z, et al. Nephrotoxicity of sevoflurane versus desflurane anesthesia in volunteers. Anesth Analg 1997; 84: 160-8.
Miller RD. Metabolism and Toxicity of Inhaled Anesthetics. In: Miller RD. Miller's Anesthesia. 6rd ed Elsevier Churchill Livingstone. 2005, s .231-72
Morgan GE, Mikhail MS, Murray MJ. Hepatic Physiology and Anesthesia In: Clinical Anesthesiology. 3rd ed. McGraw-Hill Companies. 2002, s; 708-22
Barash PG, Cullen BF, Stoelting RK. Anestezi ve Karaciğer. Klinik Anestezi El Kitabı. 3. Baskı. İzmir, Logos Yayıncılık 1999, 390- 6.
Cote G, Bouchard S. Hepatotoxicity after desflurane anesthesia in a 15- month-old child with Mobius syndrome after previous exposure to isoflurane. Anesthesiology 2007; 107: 843-5.
Fee JP and Thompson GH. Comparative tolerability profiles of the inhaled anaesthetics. Drug Saf 1997; 16: 157-70.
Berghaus TM, Baron A, Geier A, Lamerz R, Paumgartner G. Hepatotoxicity following desflurane anesthesia. Hepatology 1999; 29: 613-4.