Sevoflurane is considered a safe inhaled anesthetic of choice in patients with liver disease. Compared to other halogenated inhaled anesthetics, Sevoflurane is reported to lessen the severity of decreased hepatic blood flow and undergoes a different mechanism of hepatic metabolism. In patients with preexisting liver disease, there is potential for low-flow Sevoflurane to induce acute liver damage through other mechanisms. Limited data exists to guide clinical decision-making when quantifying the severity of cirrhosis in patients with hepatitis C and its relationship to anesthesia choice. Previous studies have found that exposure to general anesthesia during abdominal surgery may increase the risk of hepatorenal failure. This study has raised a concern that anesthetics may interfere with various hepatic functions secondary to viral infection. The generation of abnormal liver enzymes and hypercoagulation has provided further exploration for such toxicity.
A 53-year-old African American man, with a significant past medical history of controlled hypertension and chronic, uncontrolled Hepatitis C infection, and abdominal trauma in 1983, presented to the community hospital with abdominal discomfort with a 10 x 8 cm ventral hernia. The patient had an underlying hepatitis C infection, but was asymptomatic upon interview. Patient was subsequently scheduled for elective hernia repair for lysis of adhesions, component separation, and mesh placement. General anesthesia, which included low doses of fentanyl, propofol, rocuronium, and ketamine were maintained with sevoflurane, all of which lasted 4 hours. The patient remained hemodynamically stable throughout the procedure. Postoperatively, he showed signs of hemodynamic instability, suggestive of DIC and acute renal failure. Patient expired soon after, and autopsy revealed macronodular cirrhosis with dilated venous collaterals, pulmonary edema, and cardiomyopathy.
This report demonstrates a clinical impact and further evaluation in current patient management. It creates awareness and demonstrates the necessity to evaluate patients with any severe disease and its contraindications to proposed treatment plans. Knowledge of anesthetic induced toxicities and comorbidities has been illustrated, as in the case with sevoflurane and chronic Hepatitis C. Although more studies are needed, physicians should determine the risks and benefits in such patients into operative procedures, as well as management strategies to prevent any possible mortality.
Nickul Shah, Nina Ballone, Raul Zamora, Peter DeVito and Samuel Wilson