inhalation anesthetic induced hepatitis

[amyl]

anybody ever seen it or is it something you just read about? (the fulminant type, not the mild elevation of LFTs)
is it associated with all inhaled anesthetics (found a reference that said it could be) or is it a thing of the past now that less halothane is used?

Just hoping to get some real world info to add to the stuff in the books

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[Noyac]

One of my partners had a case of anesthetic induced hepatits this year. I don't think it was the fulminant type though. He used Sevo if I remember right. No apparent sequelae.

 

[jwk]

anybody ever seen it or is it something you just read about? (the fulminant type, not the mild elevation of LFTs)
is it associated with all inhaled anesthetics (found a reference that said it could be) or is it a thing of the past now that less halothane is used?

Just hoping to get some real world info to add to the stuff in the books

It was a pretty rare event in the past, and almost always associated with the use of halothane.

It's incredibly rare now. Noy - how did they determine your partner's case was due to an inhaled anesthetic? Anesthesia is often the scapegoat for any number of post-op complications. You know - Back pain that suddenly appears 6 months after an epidural for labor is almost always due to the epidural, right?

 

[Noyac]

It was a pretty rare event in the past, and almost always associated with the use of halothane.

It's incredibly rare now. Noy - how did they determine your partner's case was due to an inhaled anesthetic? Anesthesia is often the scapegoat for any number of post-op complications. You know - Back pain that suddenly appears 6 months after an epidural for labor is almost always due to the epidural, right?

I don't remember the particulars of the case but I do remember that when it came up we were all surprised. It appeared to truely be a case of anesthetic related hepatitis. I guess I could go back a investigate some more but it was over a year ago and that partner is gone.

 

[VolatileAgent]

interesting, noy. i'd like to hear more about that case. isoflurane has been associated with hepatic enzyme elevation, but i'm not sure that it's been directly implicated in hepatic damage (like halo). sevo, from what i recall, is even less hepatotoxic.

so, i wonder if there was some sort of interplay between agents (and maybe other meds the patient was on) and perhaps a genetic predisposition in that patient. in the future, pharmacogenomics may help us better identify people who may be pre-disposed and susceptible. for instance, we could quickly assay patients and identify who are deficient in certain cytochrome isoenzymes, and adjust our anesthetic plan accordingly. i happen to know that such studies are being undertaken, including some interesting research at our institution.

 

[core0]

anybody ever seen it or is it something you just read about? (the fulminant type, not the mild elevation of LFTs)
is it associated with all inhaled anesthetics (found a reference that said it could be) or is it a thing of the past now that less halothane is used?

Just hoping to get some real world info to add to the stuff in the books

We saw three cases in a two week time two years ago. They were all breast implants. Healthy females. They all had Sevoflurane and Celebrex. This happened after the surgeon went from Vicodin for post op pain to Celebrex. Told him to stop using Celebrex and we didn't see any more. Couldn't even begin to speculate on what the interaction is here.

As far as purely anesthesia induced hepatitis (fulminant) I can say that in 5 years on a busy GI and Liver service I have not seen any. You can see mild elevations. We have seen fulminant autoimmune hepatitis after surgery (which the surgeons always blame on anesthesia). What the preciptitating factor here is unknown. It does seem to happen a little more with Desflurane (observation only).

There is also a phenomenon which is not really commented on which is occupational exposure. We do see anesthesiologists with elevated LFT's not infrequently. Some of these seem to be related to environmental exposure of inhaled anesthetics. There is an interesting paper on autoantibodies and pediatric anesthesiology.
http://www.anesthesia-analgesia.org...fd66e3c7a6e526b42f1ec633&keytype2=tf_ipsecsha

David Carpenter, PA-C

 

[Planktonmd]

We saw three cases in a two week time two years ago. They were all breast implants. Healthy females. They all had Sevoflurane and Celebrex. This happened after the surgeon went from Vicodin for post op pain to Celebrex. Told him to stop using Celebrex and we didn't see any more. Couldn't even begin to speculate on what the interaction is here.

As far as purely anesthesia induced hepatitis (fulminant) I can say that in 5 years on a busy GI and Liver service I have not seen any. You can see mild elevations. We have seen fulminant autoimmune hepatitis after surgery (which the surgeons always blame on anesthesia). What the preciptitating factor here is unknown. It does seem to happen a little more with Desflurane (observation only).

There is also a phenomenon which is not really commented on which is occupational exposure. We do see anesthesiologists with elevated LFT's not infrequently. Some of these seem to be related to environmental exposure of inhaled anesthetics. There is an interesting paper on autoantibodies and pediatric anesthesiology.
http://www.anesthesia-analgesia.org...fd66e3c7a6e526b42f1ec633&keytype2=tf_ipsecsha

David Carpenter, PA-C

Anesthesiologist with elevated LFTS: how about too many Margaritas?

 

[core0]

Anesthesiologist with elevated LFTS: how about too many Margaritas?

Well that is always one consideration . These are usually picked up on routine labs. Once you get rid of the NASH/NAFLD, autoimmune etc. Also they don't have the typical 2:1 AST/ALT ratio you see with alcohol. Usually is 1:1 or ALT >AST which is more compatible with drug induced. With that there are still a few left over with persistently elevated LFT's. We checked one after a long vacation and they had normalized (even when accounting for the Margaritas). Seems to be a little higher in peds and those who work in day surgery a lot. N is very small here.

David Carpenter, PA-C

 

[militarymd]

I would say that hypotension and other causes of hypoperfusion are a more common cause of post op transaminitis than volatile anesthetic related.

 

[CremeSickle]

Just read an article on des. induced hep...

Anyone else heard of that happening in practice? It only cited 2 cases.