(425) Acute Liver Failure and Volatile Anesthetics: A Case Report

Introduction: 'Acute liver failure' is a serious critical illness characterized by acute liver dysfunction, coagulopathy and encephalopathy in the absence of pre-existing liver disease. Drugs of various classes such as acetaminophen, anti-cancer drugs, herbal medications, antibiotics, anti-retrovirals and anesthetics have been implicated; either through direct toxicity or indirectly through their metabolites.

Description: A 76-year-old man with squamous cell lung cancer underwent robotic-assisted right upper lobectomy with mediastinal lymphadenectomy. Initial post-operative course was notable for dyspnea. He underwent IR lymphoscintigraphy under anesthesia on day 5 which revealed a chylous pleural effusion and a thoracostomy tube was placed.

Following this, he became progressively somnolent and disoriented. Labs showed acute kidney injury and lactic acidosis. AST and ALT were elevated to 2233 and 2995 respectively (from a normal baseline) but rapidly rose to 7200 and 14000. Liver imaging showed patent hepatic vasculature with heterogeneous hepatic parenchyma. Viral hepatitis serologies, HSV, CMV, EBV, VZV, autoantibody screen and metabolic screen were negative. There was no history of illicit drug use or acetaminophen overdose. Liver dysfunction was attributed to a side effect of sevoflurane which he had received twice - on days 0 and 5.

On day 6, he was intubated, transferred to ICU and subsequently developed severe shock requiring fluid resuscitation and vasopressor support. Treatment with IV NAC was started. Empiric vancomycin, piperacillin tazobactam and anidulafungin were administered. His hyperammonemia progressed to cerebral edema. Despite blood product replacement, coagulopathy correction, therapy for hepatic encephalopathy, mechanical ventilatory support, CKRT, and MARS; the patient’s multiorgan failure continued to deteriorate and eventually he was transitioned to comfort measures.

Discussion: Sevoflurane is a volatile anesthetic with an excellent safety record. Liver injury associated with sevoflurane is extremely rare and is a diagnosis of exclusion. Factors favoring sevoflurane hepatotoxicity were onset after 4 days, fever preceding his jaundice, prior exposure to sevoflurane, negative workup for alternate etiologies, RUMAC score 9 and Naranjo score of 5.