Sevoflurane

Monitor for emergence agitation or delirium (Stachnik 2006).

Postoperative hepatitis or hepatic dysfunction with or without jaundice has rarely been reported; prior exposure to halogenated hydrocarbon anesthetics may increase this risk.

Use of inhaled anesthetics has been associated with rare cases of perioperative hyperkalemia in pediatric patients; concomitant use of succinylcholine was associated with most of the reported cases, but not all. Patients with latent and overt neuromuscular disease (eg, Duchenne muscular dystrophy) are the most vulnerable. Other abnormalities may include elevation in CPK and myoglobinuria. Monitor closely for arrhythmias. Aggressively identify and treat hyperkalemia and resistant arrhythmias.

Sevoflurane produces a dose-dependent reduction in blood pressure during maintenance of anesthesia and may occur more rapidly compared to other inhaled anesthetics.

May dilate the cerebral vasculature and may, in certain conditions, increase intracranial pressure (Stachnik 2006).

May trigger malignant hyperthermia; some reported cases have been fatal. Use is contraindicated in patients susceptible to malignant hyperthermia such as those with certain inherited ryanodine receptor mutations.

Cases of QT prolongation in association with torsade de pointes (some fatal) have been reported with sevoflurane use; use caution when administering to patients at risk of QT prolongation (eg, concurrent use of drugs that can prolong the QT interval such as class Ia and III antiarrhythmic drugs, elderly patients, congenital QT prolongation) (Han 2010; Kang 2006; Nakao 2010).

Causes dose-dependent respiratory depression and blunted ventilatory response to hypoxia and hypercapnia (Golembiewski 2004). Hypoxic pulmonary vasoconstriction is blunted which may lead to increased pulmonary shunt (Miller 2010). Disease-related concerns:

In a scientific statement from the American Heart Association, sevoflurane has been determined to be an agent that may exacerbate underlying myocardial dysfunction (magnitude: major) (AHA [Page 2016]).

Use with caution in patients with hepatic impairment; safety with severe impairment has not been established.

Use with caution in patients with renal impairment (ie, creatinine >1.5 mg/dL); safety with severe impairment has not been established.

Use with caution in patients at risk for seizures; seizures have been reported in children and young adults. Concurrent drug therapy issues:

Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information. Special populations:

In pediatric and neonatal patients Special handling:

There is no specific work exposure limit established for sevoflurane. However, the National Institute for Occupational Safety and Health (NIOSH) has recommended an 8 hour time-weighted average limit of 2 ppm for halogenated anesthetic agents in general (0.5 ppm when coupled with exposure to N2O). Other warnings/precautions:

Reaction of sevoflurane with CO2 absorbents that become desiccated within circle breathing equipment can lead to formation of formaldehyde (causing respiratory irritation) and carbon monoxide; maintain fresh absorbent as per manufacturer guidelines regardless of state of colorimetric indicator. An exothermic reaction occurs when sevoflurane is exposed to CO2 absorbents; this reaction is increased when the CO2 absorbent becomes desiccated. Rare cases of extreme heat, smoke, and/or fire within breathing circuit have been reported. This reaction also leads to formation of a fluorinated byproduct, compound A, which has been reported to cause mild and reversible renal injury in animal studies (Gentz 2001). The theoretical risk of compound A-induced nephrotoxicity in humans may be dose- and exposure time-dependent; minimize exposure risk by not exceeding 2 MAC hours and using fresh flow rates of 1 to 2 absorbents) should be incorporated into routine practice (Miller 2010).