Ca2+ cytochemical changes of hepatotoxicity caused by halothane and sevoflurane in enzyme-induced hypoxic rats

Severe hepatic impairment after sevoflurane anesthesia in a 10-month-old child: Case report

Introduction

Like other halogenated agents, sevoflurane can potentially cause a toxic reaction including severe hepatic failure which can lead to the death of the patient. However, Halogen immuno-allergic hepatitis is a very rare complication of anesthesia. We reported a 10 months' child who presented a severe hepatic injury after sevoflurane exposure.

Case management

A 10-month-old child was scheduled for acute intussusception anesthesia, induction was done with sevoflurane and propofol while maintenance of anesthesia was provided by sevoflurane alone. Three days after the operation, he was developed jaundice and altered general condition. A dramatic increase in liver enzymes was observed. The evolution was marked by an alteration of his consciousness and his hemodynamic state, he was intubated. Without improvement, the patient died on the 4th postoperative day. The autopsy was refused by the family.

Conclusion

These results underscore the need findings for a global and comprehensive understanding of the potential hepatotoxicity of exposure to volatile anesthetics including sevoflurane in infants and its long-term side effects which can be fatal.

Comparison of the Level of Free Hexafluoro-isopropanol in Adults' Blood and the Incidence of Emergence Agitation After Anesthesia With Different Concentrations of Sevoflurane in Laparoscopic Gastrointestinal Surgery: A Randomized Controlled Clinical Trial

PURPOSE

The aim of the study is to compare the free hexafluoro-isopropanol (HFIP) concentration in adults' blood and the incidence of emergence agitation (EA) after inhaled different concentrations of sevoflurane.

METHODS

Sixty adult patients planning to undergo laparoscopic gastrointestinal surgery were randomly assigned to 3 groups. Each group received sevoflurane as the volatile anesthetic at different concentrations: 0.5 minimum alveolar concentration (MAC), 1.0 MAC, and 1.5 MAC. The use of sevoflurane was continued until the end of surgery. Venous blood samples were obtained at 30, 60, 120, and 180 minutes after starting the use of sevoflurane and subsequently at 60, 180, and 300 minutes after discontinuation of volatile anesthetic administration. Blood concentrations of sevoflurane and free HFIP were determined using gas chromatography. The recovery time and the incidence of EA at different time points were evaluated among the 3 groups.

FINDINGS

Changes in the blood concentrations of sevoflurane and free HFIP during and after the use of sevoflurane were similar in all 3 groups. The peak blood concentration of free HFIP occurred 60 minutes after onset of sevoflurane anesthesia in all 3 groups (P < 0.05). The lowest level of free HFIP and the longest recovery time were found in the 1.5-MAC group (P < 0.05). No significant difference was found in the incidence of EA or moderate pain among the 3 groups during recovery.

IMPLICATIONS

The generation of HFIP would be inhibited when the inhaled sevoflurane concentration increased to 1.5 MAC. However, the incidence of EA during recovery had nothing to do with the inhaled different sevoflurane concentrations (within 1.5 MAC) in adults. ChicCTR.org identifier: ChiCTR-IPD-17011558.

A Fatal Case of Fulminant Hepatic Necrosis Following Sevoflurane Anesthesia

Volatile anesthetics can elevate cytosolic free Ca2+ by releasing calcium from internal calcium stores and uptaking calcium from extracellular medium. Sevoflurane is an inhaled anesthetic used worldwide. A clear understanding of the exact mechanism of hepatic injury induced by sevoflurane remains elusive. A 69-year-old man with preexisting mild renal dysfunction, having undergone sevoflurane general anesthesia twice in 2 days, developed moderate jaundice. Liver enzymes strongly increased and remained elevated until death, which occurred on the 6th day after the first surgical intervention. The microscopic liver examination revealed an extensive and confluent hepatic necrosis, characterised by a large amount of calcium deposition in hepatic cell cytoplasm. These data were confirmed by confocal laser scanning microscopy and a 3-D visualization of calcium depositions was evident in hepatocytes cytoplasm. Our findings are suggestive with the previous experimental reports that consider elevation of cytoplasmic calcium may be the basis of sevoflurane – induced hepatotoxicity.

The common anesthetic, sevoflurane, induces apoptosis in A549 lung alveolar epithelial cells

Lung alveolar epithelial cells are the first barrier exposed to volatile anesthetics, such as sevoflurane, prior to reaching the targeted neuronal cells. Previously, the effects of volatile anesthetics on lung surfactant were studied primarily with physicochemical models and there has been little experimental data from cell cultures. Therefore it was investigated whether sevoflurane induces apoptosis of A549 lung epithelial cells. A549 cells were exposed to sevoflurane via a calibrated vaporizer with a 2 l/min flow in a gas‑tight chamber at 37˚C. The concentration of sevoflurane in Dulbecco's modified Eagle's medium was detected with gas chromatography. Untreated cells and cells treated with 2 µM daunorubicin hydrochloride (DRB) were used as negative and positive controls, respectively. Apoptosis factors, including the level of ATP, apoptotic‑bodies by terminal deoxynucleotidyl transferase‑mediated dUTP nick end labeling (TUNEL) assay, DNA damage and the level of caspase 3/7 were analyzed. Cells treated with sevoflurane showed a significant reduction in ATP compared with untreated cells. Effects in the DRB group were greater than in the sevoflurane group. The difference of TUNEL staining between the sevoflurane and untreated groups was statistically significant. DNA degradation was observed in the sevoflurane and DRB groups, however this was not observed in the untreated group. The sevoflurane and DRB groups induced increased caspase 3/7 activation compared with untreated cells. These results suggest that sevoflurane induces apoptosis in A549 cells. In conclusion, 5% sevoflurane induced apoptosis of A549 lung alveolar epithelial cells, which resulted in decreased cell viability, increased apoptotic bodies, impaired DNA integrality and increased levels of caspase 3/7.

Fatal subacute liver failure after repeated administration of sevoflurane anaesthesia

Sevoflurane is a widely used halogenated inhalation anaesthetic. In comparison with other similar anaesthetics, it is not metabolized to potentially hepatotoxic trifluoroacetylated proteins. In this case report, we present a 66-year-old woman with breast carcinoma, who underwent sevoflurane general anaesthesia twice in 25 days. Soon after the second elective surgical procedure, jaundice and marked elevations in serum transaminases developed. The patient died 66 days thereafter. Autopsy results denied evidence of major cardiovascular abnormality, and histological examination confirmed massive liver cell necrosis with no feature of chronic liver injury. Sevoflurane anaesthesia was imputed as the cause after exclusion of other possible aetiological agents. Besides, coexistent malignant tumours found in the patient could have modulated the immunological response to the applied anaesthetic followed by fatal consequences.

Mitochondria are involved in stress response of A549 alveolar cells to halothane toxicity

During inhalation anaesthesia lung epithelial cells are directly exposed to halogenated hydrocarbons such as halothane. Information about the effects of volatile anaesthetics on lung cells is rather limited although their noxious effect on the A549 alveolar cells has been shown recently. The present study indicated that halothane decreases cell viability, impairs DNA integrity and provokes stress-induced apoptosis in A549 cells when applied at clinically relevant concentrations. Data obtained clearly demonstrated intensive expression of anti-apoptotic Bcl-2 protein during treatment with all tested concentrations. In post-treatment periods the increased DNA injury was accompanied by reduction of Bcl-2 expression. We concluded that the in vitro effect of halothane on lung cells involved alteration in the expression of proteins of the mitochondrial apoptotic pathway.

Drug-induced liver disease

PURPOSE OF REVIEW

To summarize the pertinent case reports, case series and clinical studies that described clinical, histological, epidemiological and mechanistic features of drug-induced liver disease in 2005.

RECENT FINDINGS

Acetaminophen, highly active antiretroviral therapy and drugs for tuberculosis retained their preeminent position as the most commonly reported agents causing drug-induced liver disease, with acetaminophen continuing to be the leading cause of acute liver failure in the USA. While the frequency of drug-induced liver disease remains low, a large case-series of acute drug-induced liver disease from Spain and Sweden supported the observation that acute hepatocellular jaundice from a drug is associated with death or the need for transplant in at least 10% (known as Hy's Law). With respect to using potentially hepatotoxic medications in patients with underlying liver disease, statins and second-generation thiazolidinediones were shown to be safe when used in patients with elevated baseline alanine aminotransferase or aspartate aminotransferase levels.

SUMMARY

Drug-induced liver disease remains an important cause of acute liver failure, and research efforts by the National Institutes of Health and others are underway to better determine the risk factors and other host susceptibilities that will allow for the safer use of drugs in the future.