Repeat anaesthesia: hepatic injury

Abstract

Hepatic injury following repeat anaesthesia is a rare complication that may be precipitated by several of the commonly used volatile anaesthetic agents. Halothane is the most common culprit, causing either a mild dysfunction or a more severe fulminant liver injury. Similar immune-mediated reactions may occur with enflurane, isoflurane and desflurane. There are no investigations that can accurately predict who will be affected, therefore those with a history of recent halothane anaesthesia or unexplained fever or jaundice after a previous anaesthetic should avoid repeat volatile anaesthesia. No cases of propofol-induced liver failure in adults have been published, therefore total intravenous anaesthesia may be suitable for these patients. Postoperative hepatic injury has profound effects on the future conduct of anaesthesia. The injury ranges from asymptomatic derangement of liver enzymes to fatal liver failure. The major precipitants are non-anaesthetic such as sepsis, hypotension, hypoxaemia, transfusion-related viral infection (hepatitis B, hepatitis C, cytomegalovirus, herpes virus), transfusion reaction, surgical trauma to the liver or biliary tract, prolonged nutritional deficiency, or a combination of factors in patients with pre-existing liver dysfunction. Aside from the usual measures to minimize physiological stress by careful attention to oxygenation, blood pressure and fluid status, there is little the anaesthetist can do to prevent recurrent hepatic injury during repeat anaesthesia.