Sevoflurane Induced Diffuse Alveolar Hemorrhage in a young patient

Abstract

We report a very rare case of Sevoflurane Induced Diffuse Alveolar Hemorrhage in a previously healthy young adult in the post-operative period following general anesthesia. Diffuse alveolar hemorrhage (DAH) associated with inhalation injury from halogenated gases is a unique entity in the literature that practicing clinicians should be cognizant of and considered in post-operative cases of acute respiratory distress whereby other etiologies have been excluded.

Diffuse alveolar haemorrhage: a volatile situation

“…There is similarity between our case and previously documented reports of DAH following elective pilonidal cyst removal in a 31-year-old [6] and urethral dilatation in a 20-year-old [4]. In both cases, the patients had a reasonably healthy premorbid state, with rapid onset and cessation of symptoms following exposure and removal of the agent respectively.…”

“…This can result in fluid extravasation or haemorrhage and it may be that sevoflurane mirrors other volatile agents in this respect [4]. This is only the fourth reported case of DAH following sevoflurane inhalation to maintain anaesthesia [4][5][6]. There is also one reported case of desflurane causing similar pathology, presumably through a similar mechanism [7].…”

“…There are however, suggested mechanisms of increased arachidonic cascade potentiation when using other halogenated agents that cause alveolar inflammation and increased permeability [3]. This can result in fluid extravasation or haemorrhage and it may be that sevoflurane mirrors other volatile agents in this respect [4]. This is only the fourth reported case of DAH following sevoflurane inhalation to maintain anaesthesia [4][5][6].…”

Postoperative diffuse alveolar haemorrhage: insidious negative pressure or sevoflurane induced?

“…Again, there was a large-volume haemoptysis, with a resultant haemoglobin fall from 14.4 to 12.1g/dL. The fourth case described DAH in a 20-year-old man following an unremarkable anaesthetic (using sevoflurane vapour) for a cystoscopy and urethral stricture dilation, again with no other apparent cause for the haemorrhage, the authors in this case attributing the presentation directly to the use of sevoflurane vapour 10. The volume of haemorrhage or haemoglobin drop is not described in this case report.…”

“…The mechanism by which inhalational anaesthetic agent may lead to DAH is not yet clear. Mechanisms suggested by previous writers include physical pressure from the anaesthetic gas injuring the very thin blood–gas barrier in the alveoli,4 pulmonary endothelial damage from the highly lipid-soluble anaesthetic potentiating the arachidonic cascade in the cell membrane causing increased oxidative stress and inflammatory response10 or an exothermic reaction (known to occasionally occur) between sevoflurane and the carbon dioxide absorbents in the anaesthetic circuit leading to thermal airway injury 10…”