What are the side effects of sevoflurane (anesthetic agent)?

From the Guidelines

Sevoflurane is associated with several potential side effects, including nausea, vomiting, emergence delirium, dose-dependent cardiovascular depression, respiratory depression, shivering, and rare but life-threatening conditions such as malignant hyperthermia and hepatotoxicity, as reported in various studies 1.

Common Side Effects

• Nausea and vomiting, affecting approximately 20-30% of patients postoperatively
• Emergence delirium, particularly in children, characterized by confusion, agitation, and combativeness upon awakening
• Dose-dependent cardiovascular depression, resulting in hypotension and decreased cardiac output
• Respiratory depression, potentially causing decreased respiratory rate and tidal volume
• Shivering during recovery

Rare but Serious Side Effects

• Malignant hyperthermia, a life-threatening condition requiring immediate treatment with dantrolene, as noted in the European Malignant Hyperthermia Group guidelines 1
• Hepatotoxicity in susceptible individuals
• Interaction with dry CO2 absorbents to produce Compound A, a potentially nephrotoxic substance, though clinical significance remains debated

Patient-Specific Considerations

• Elderly patients and those with pre-existing cardiac or respiratory conditions are at higher risk for adverse effects
• The use of sevoflurane in patients with coronary artery disease may have cardioprotective effects, as suggested by studies comparing volatile anesthetics to propofol or midazolam 1
• The choice of anesthetic technique, including the use of sevoflurane, should be individualized based on patient factors and surgical procedure, as recommended in the ACC/AHA guidelines 1 and the ERAS society recommendations 1

From the FDA Drug Label

The following adverse events have been identified during post-approval use of sevoflurane. Due to the spontaneous nature of these reports, the actual incidence and relationship of sevoflurane to these events cannot be established with certainty. Central Nervous System • Seizures — Post-marketing reports indicate that sevoflurane use has been associated with seizures • Delirium Cardiac • Cardiac arrest • QT prolongation associated with Torsade de Pointe • Bradycardia in patients with Down syndrome Hepatic • Cases of mild, moderate and severe post-operative hepatic dysfunction or hepatitis with or without jaundice have been reported. • Hepatic necrosis • Hepatic failure Other • Malignant hyperthermia • Allergic reactions, such as rash, urticaria, pruritus, bronchospasm, and anaphylactic reactions • Reports of hypersensitivity (including contact dermatitis, rash, dyspnea, wheezing, chest discomfort, swelling face, or anaphylactic reaction) have been received, particularly in association with long-term occupational exposure to inhaled anesthetic agents, including sevoflurane Laboratory Findings • Transient elevations in glucose, liver function tests, and white blood cell count may occur as with use of other anesthetic agents.

The side effects of sevoflurane include:

• Central Nervous System: seizures, delirium
• Cardiac: cardiac arrest, QT prolongation associated with Torsade de Pointe, bradycardia in patients with Down syndrome
• Hepatic: post-operative hepatic dysfunction or hepatitis, hepatic necrosis, hepatic failure
• Other: malignant hyperthermia, allergic reactions, hypersensitivity reactions
• Laboratory Findings: transient elevations in glucose, liver function tests, and white blood cell count 2

From the Research

Side Effects of Sevoflurane

• Postoperative nausea and vomiting (PONV) are common side effects of sevoflurane, with a frequency of 9.3-10.8% 3, 4
• Sevoflurane may cause respiratory depression, with a decrease in tidal volume and an increase in PaCO2 5
• Compared to desflurane, sevoflurane may have a lower incidence of late postoperative vomiting and nausea 4
• Sevoflurane may cause cough, but the incidence is lower compared to isoflurane 6
• There is no significant difference in the risk of postoperative respiratory complications between sevoflurane and desflurane 7

Comparison with Other Anesthetics

• Sevoflurane has a similar effect on PONV compared to isoflurane and desflurane 3, 4
• Sevoflurane may have a lower incidence of cough compared to isoflurane 6
• Desflurane may have a shorter time to extubation and emergence compared to sevoflurane 4

Respiratory Effects

• Sevoflurane can cause respiratory depression, with a decrease in tidal volume and an increase in PaCO2 5
• The respiratory effects of sevoflurane are similar to those of halothane, with a decrease in minute volume and an increase in PaCO2 5
• There is no significant difference in the risk of postoperative respiratory complications between sevoflurane and desflurane 7