Desflurane

May cause decrease in hepatic and/or renal blood flow.

May cause sensitivity hepatitis in patients who have been sensitized by previous exposure to halogenated anesthetics.

Use of inhaled anesthetics has been associated with rare cases of perioperative hyperkalemia (including fatalities) in pediatric patients; concomitant use of succinylcholine was associated with many of the reported cases, but not all. Risk of hyperkalemia is increased in patients with underlying neuromuscular disease (eg, Duchenne muscular dystrophy). Other abnormalities may include elevation in CK and myoglobinuria. Monitor closely for arrhythmias. Aggressively identify and treat hyperkalemia.

May dilate the cerebral vasculature and may, in certain conditions, increase intracranial pressure. In patients with intracranial space-occupying lesions, administer at ≤0.8 MAC in conjunction with a barbiturate induction and hyperventilation in the period before cranial decompression; maintain cerebral perfusion pressure.

May trigger malignant hyperthermia (MH); some reported cases have been fatal. Use is contraindicated in patients susceptible to MH.

Cases of QT prolongation in association with torsade de pointes (some fatal) have been reported with inhaled anesthetic agents; 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. Hypoxic pulmonary vasoconstriction is blunted which may lead to increased pulmonary shunt. May produce elevated carbon monoxide levels and carboxyhemoglobin in the presence of a desiccated dry carbon dioxide absorbent within the circle breathing system of an anesthetic machine; barium hydroxide and soda lime desiccation have been reported when fresh gasses are passed over a carbon dioxide canister at high flow rates over many hours or days. Maintain fresh absorbent as per manufacturer guidelines regardless of state of colorimetric indicator. Disease-related concerns:

Do not use as a single agent to induce anesthesia in patients with CAD or in whom an increase in heart rate or blood pressure should be avoided. Abrupt increases in inspired concentrations >1 MAC can produce a transient increase in blood pressure and heart rate due to increased plasma catecholamine levels. Acute, rapid increases in desflurane concentration can produce increased sympathetic cardiovascular stimulation which lasts for 2 to 4 minutes; can be blunted by concurrent use of nitrous oxide, opioids, beta-blockers, and alpha-2 agonists (Weiskopf 1994). Hypotensive effect due to peripheral vasodilation is dose dependent and increases as anesthesia is deepened. In a scientific statement from the American Heart Association, desflurane has been determined to be an agent that may exacerbate underlying myocardial dysfunction (magnitude: major) (AHA [Page 2016]).

Due to the risk of hepatitis with halogenated anesthetics, use in patients with cirrhosis, viral hepatitis, or other preexisting hepatic disease should be approached with caution; disruption of hepatic function, icterus, and fatal liver necrosis have been reported and may indicate hypersensitivity. Consider the use of an anesthetic other than a halogenated anesthetic. Special populations:

Postoperative agitation may occur in children while emerging from anesthesia. Contraindicated for induction of general anesthesia in pediatric patients due to the higher incidence of moderate to severe upper airway adverse events (eg, laryngospasm, coughing, breath-holding, increased secretions). Do not use to maintain anesthesia in nonintubated pediatric patients. Use with caution when used to maintain anesthesia in children ≤6 years when a laryngeal mask airway (LMA) is in place due to the increased potential for adverse respiratory effects especially with removal of the LMA under deep anesthesia. Use with caution in children with asthma or recent upper respiratory infection; increased risk for airway narrowing and increased airway resistance.

In pediatric and neonatal patients Special handling:

Although there are no documented adverse effects of chronic occupational exposure to halogenated anesthetic vapors, like desflurane, some epidemiological studies suggest a link between these anesthetics and increased health problems (particularly spontaneous abortion). There is no specific work exposure limit established for desflurane. However, the National Institute for Occupational Safety and Health (NIOSH) has recommended that workers should not be exposed to ceiling concentrations greater than 2 ppm of any halogenated anesthetic agent over a period ≤1 hour. The predicted effects of acute overexposure by inhalation of desflurane include headache, dizziness, or (in extreme cases) unconsciousness. Precautions (eg, adequate ventilation, scavenging-systems, minimizing leaks/spills) can help to lessen any potential risk. Other warnings/precautions:

Transient elevations in white blood cell count and glucose may occur.