title: Case report: fatal hepatic failure after aortic valve replacement and sevoflurane exposure.
abstract: OBJECTIVE
  To report a case of lethal hepatotoxicity possibly caused by sevoflurane.
  
  
  METHODS
  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 UxL(-1) and AST at 15516 UxL(-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 trifluoroacetyl 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.
authors.affiliation: Department of Anesthesiology and Intensive Care Medicine, Klinikum der Stadt Ludwigshafen, Postfach 21 73 52, D-67073 Ludwigshafen, Germany. lehmanna@klilu.de
authors.forename: Andreas
authors.initials: A
authors.lastname: Lehmann
authors.forename: Michael
authors.initials: M
authors.lastname: Neher
authors.forename: Arndt-Holger
authors.initials: AH
authors.lastname: Kiessling
authors.forename: Frank
authors.initials: F
authors.lastname: Isgro
authors.forename: Anette
authors.initials: A
authors.lastname: Koloska
authors.forename: Joachim
authors.initials: J
authors.lastname: Boldt
mesh_terms: D000368:Aged; D018685:Anesthetics, Inhalation / Q000009:adverse effects*; D001021:Aortic Valve / Q000601:surgery*; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D017093:Liver Failure / Q000139:chemically induced*; D008738:Methyl Ethers / Q000009:adverse effects* / Q000378:metabolism; D000077149:Sevoflurane
chemical_list: D018685:Anesthetics, Inhalation; D008738:Methyl Ethers; D000077149:Sevoflurane