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Halothane Hepatotoxicity: Follow-up

Author: Ruben Peralta, MD, FACS, Professor of Surgery, Anesthesia and Emergency Medicine, Senior Medical Advisor, Board of Directors, Program Chief of Trauma, Emergency and Critical Care, Consulting Staff, Professor Juan Bosch Trauma Hospital, Dominican Republic
Coauthor(s): Karl A Poterack, MD, Consulting Staff, Department of Anesthesiology, Mayo Clinic Scottsdale; Sarah Guzofski, MD, Staff Physician, Department of Psychiatry, University of Massachusetts Medical School
Contributor Information and Disclosures

Updated: Jun 17, 2008

Follow-up

Further Inpatient Care

Because clinical deterioration may be rapid and because of the high risk of mortality, patients may require monitoring in an intensive care unit.

Transfer

  • Hospitalized patients may be discharged when the following criteria are met:
    • Significant improvement in symptoms
    • Normalization of prothrombin time
    • A substantial downward trend in the serum aminotransferase and bilirubin values occurs. Mildly elevated aminotransferase levels should not be considered contraindications to the gradual resumption of normal activity as tolerated.

Deterrence/Prevention

  • The most conservative approach is to avoid halothane when reasonable alternatives exist. For example, because of the medicolegal climate in the United States, halothane is infrequently used in adults since several alternatives exist and any postanesthetic liver dysfunction is likely to be ascribed to halothane. In many other countries with different medicolegal climates, halothane is still widely used because of economic reasons.
  • Carefully consider halothane use in any adult patient with recent exposure in the past 6 weeks. Recent exposure is the most important risk factor for type II fulminant hepatotoxicity.
  • In patients with a history of jaundice and fever following previous halothane exposure, all volatile anesthetics (ie, halothane, enflurane, isoflurane, sevoflurane, desflurane) should be used with caution and indications should be documented.
  • Patients with unexplained elevations of liver functions should not undergo anesthesia and elective surgery until a diagnosis has been confirmed. Any type of surgery and anesthesia in the setting of acute hepatitis carries the potential for increased mortality and morbidity.

Complications

  • Fulminant liver failure is possible.
  • In rare cases, cirrhosis may develop following halothane hepatitis. However, in most cases, liver function returns to normal.
  • Halothane given with succinylcholine for induction anesthetic is associated with masseter spasm.

Prognosis

  • If fulminant liver failure does not occur, patients usually make a full recovery.
  • If fulminant liver failure occurs, the mortality rate can be 50%.
  • If hepatic encephalopathy is present, the mortality rate can be 80%.

Patient Education

  • Full informed consent should always be obtained and should include the indications for use and the possible risk of hepatotoxicity.
  • Patients with a history of fever and jaundice following halothane exposure should be sure to communicate this to anesthesiologists and surgeons.
  • General anesthesia is not contraindicated for future surgery because it can be provided without the use of volatile agents.
  • For excellent patient education resources, visit eMedicine's Hepatitis Center and Liver, Gallbladder, and Pancreas Center. Also, see eMedicine's patient education articles Hepatitis A, Hepatitis B, Hepatitis C, and Cirrhosis.

Miscellaneous

Medicolegal Pitfalls

  • The routine use of halothane for general anesthesia in adults is difficult to justify.
    • Hepatic dysfunction following anesthesia and surgery is likely to be blamed on halothane, even though it is statistically unlikely that the specific significant liver insult was due to halothane.
    • In adults, only a few specific indications exist for using halothane over other volatile agents.
  • The extremely low incidence of halothane hepatitis in children and the suitability of halothane for inhalation inductions commonly used in children give clearer indications for its use in the pediatric population.
 


More on Halothane Hepatotoxicity

Overview: Halothane Hepatotoxicity
Differential Diagnoses & Workup: Halothane Hepatotoxicity
Treatment & Medication: Halothane Hepatotoxicity
Follow-up: Halothane Hepatotoxicity
References
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References

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Further Reading

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Keywords

halothane hepatotoxicity, halothane hepatitis, post-halothane liver dysfunction, hepatic toxicity, halogenated inhalational anesthetic agents, enflurane, isoflurane, sevoflurane, desflurane, centrilobular liver cell necrosis, fulminant liver failure, hepatic encephalopathy, orthotopic liver transplantation

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Contributor Information and Disclosures

Author

Ruben Peralta, MD, FACS, Professor of Surgery, Anesthesia and Emergency Medicine, Senior Medical Advisor, Board of Directors, Program Chief of Trauma, Emergency and Critical Care, Consulting Staff, Professor Juan Bosch Trauma Hospital, Dominican Republic
Ruben Peralta, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, Association for Academic Surgery, Eastern Association for the Surgery of Trauma, Massachusetts Medical Society, Society of Critical Care Medicine, and Society of Laparoendoscopic Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Karl A Poterack, MD, Consulting Staff, Department of Anesthesiology, Mayo Clinic Scottsdale
Karl A Poterack, MD is a member of the following medical societies: American Society of Anesthesiologists
Disclosure: Nothing to disclose.

Sarah Guzofski, MD, Staff Physician, Department of Psychiatry, University of Massachusetts Medical School
Sarah Guzofski, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, and Massachusetts Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Laurie Robin Grier, MD, Medical Director of MICU, Associate Professor of Medicine, Section of Pulmonary and Critical Care Medicine, Louisiana State University Health Science Center at Shreveport
Laurie Robin Grier, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Society for Parenteral and Enteral Nutrition, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Harold L Manning, MD, Associate Professor, Departments of Medicine, Anesthesiology and Physiology, Section of Pulmonary and Critical Care Medicine, Dartmouth Medical School
Harold L Manning, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and American Thoracic Society
Disclosure: Nothing to disclose.

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michael R Pinsky, MD, CM, Professor of Critical Care Medicine, Bioengineering, Cardiovascular Diseases and Anesthesiology, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center
Michael R Pinsky, MD, CM is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American Heart Association, American Thoracic Society, Association of University Anesthetists, Shock Society, and Society of Critical Care Medicine
Disclosure: LiDCO Ltd Honoraria Consulting; iNTELOMED Intellectual property rights Board membership; Edwards Lifesciences Honoraria Consulting; Applied Physiology, Ltd Honoraria Consulting

 
 
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