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LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012-.

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LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet].

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Last Update: January 1, 2018.



Desflurane is one of the most commonly used volatile anesthetic agents and has an excellent safety record. Rare single case reports of severe acute liver injury resembling halothane hepatitis due to desflurane have been published.


Desflurane (des flur' ane) is a widely used major anesthetic agent with rapid onset of action and rapid dispersal. Because it can be irritating to the airway, desflurane is typically used to maintain anesthesia after induction with other agents. Desflurane was initially approved for use in the United States in 1992 and is available generically and under the brand name Suprane. Desflurane must be administered in a controlled situation by a properly trained and credentialed anesthesiologist or nurse anesthetist and is typically given in concentrations up to 6% to 8% with oxygen.


Prospective, serial blood testing often demonstrates minor transient elevations in serum aminotransferase levels in the 1 to 2 weeks after major surgery and use of halogenated anesthetics. Appearance of ALT levels above 10 times the upper limit of normal, however, is distinctly unusual and points to significant hepatotoxicity. Clinically apparent, severe hepatic injury from desflurane is very rare, with only isolated case reports having been published and not all of which were very convincing. The injury is marked by acute elevations in serum aminotransferase levels (5- to 50-fold) and appearance of jaundice within 2 to 21 days of surgery. There are usually minimal increases in alkaline phosphatase and gammaglutamyl transpeptidase levels. Jaundice is usually preceded by a day or two of fever and may be accompanied by rash and eosinophilia. The acute liver injury may be self-limited and resolve within 4 to 8 weeks, but can be severe and associated with acute liver failure. A strong risk factor is previous exposure to any of the halogenated anesthetics and particularly a history of halothane hepatitis or unexplained fever and rash after anesthesia with one of these agents. The differential diagnosis of acute liver injury after surgery and anesthesia is often challenging, and a clinical picture similar to desflurane induced hepatitis can be caused by shock or ischemia, sepsis, acetaminophen overdose, acute viral or herpes hepatitis, as well as other idiosyncratic forms of drug induced liver injury.

Likelihood score: C (probable rare cause of clinically apparent liver injury).

Mechanism of Injury

The mechanism of desflurane hepatotoxicity is suspected to be similar to that of halothane and associated with creation of reactive intermediates of desflurane. Desflurane is metabolized to a small but variable extent by the microsomal drug metabolizing enzyme CYP 2E1 to a trifluoroacetylated reactive intermediate (TFA) that is capable of binding to multiple intracytoplasmic proteins, forming potentially immunogenic adducts. The TFA adducts induce antibodies that can be detected in patients with desflurane as well as halothane hepatotoxicity and are also found in a proportion of health care workers exposed to the volatile anesthetics.

Outcome and Management

Severity ranges from mild and transient aminotransferase elevations without symptoms or other evidence of liver injury, to a self limited symptomatic acute hepatitis-like reaction to a severe, acute hepatic failure. The severity and prognosis may relate in part of patient age, being more severe in the elderly and both milder and less common in children. Obesity may also be both a predisposing factor and predictor of outcome. Chronic liver injury from desflurane exposure has not been described. Patients with desflurane induced hepatitis should be cautioned against future exposure to a fluorinated hydrocarbon anesthetic such as halothane, enflurane, isoflurane or sevoflurane.

Drug Class: Halogenated Anesthetics

Other Drugs in the Class: Enflurane, Halothane, Isoflurane, Sevoflurane


Case 1. Acute liver injury from desflurane anesthesia.

[Modified from: Tung D, Yoshida EM, Wang CS, Steinbrecher UP. Severe desflurane hepatotoxicity after colon surgery in an elderly patient. Can J Anaesth 2005; 52: 133-6. PubMed Citation]

An 81 year old overweight woman underwent a right hemicolectomy for colon cancer under desflurane anesthesia and developed clinical evidence of liver disease 6 days later. She had a history of two previous surgeries, but the anesthetics used were not known. She had no history of liver disease or known risk factors or exposures. On postoperative day 6, she became symptomatic with fatigue and was jaundiced, but afebrile. Laboratory testing showed a serum bilirubin of 6.9 mg/dL and marked elevations of ALT with minimal increases in alkaline phosphatase (Table). She had no eosinophilia. She was negative for markers of hepatitis A, B and C and autoantibodies, and liver ultrasound was unrevealing. Over the next several days, she developed evidence of hepatic failure with mild hepatic encephalopathy and INR rising to 2.3. She was treated with methylprednisone (60 mg IV daily for 5 days). She began to recover and laboratory tests had largely returned to close to normal by the time she was discharged 7 weeks after surgery.

Key Points

Medication:Desflurane (6%), 90 min anesthesia time
Pattern:Hepatocellular (R=>30)
Severity:4+ (evidence of acute liver failure, INR>1.5)
Latency:6 days
Recovery:8-12 weeks
Other medications:Anesthesia included fentanyl, propofol and rocuronium

Laboratory Values

Time after SurgeryALT
Alk P
0Right hemicolectomy under desflurane anesthesia
6 days21881496.9Symptoms and jaundice
8 days9052319.8
10 days567296
12 days27712.5Methylprednisone started
14 days250252
16 days2002786.4
18 days1893355.8
20 days1533166.8
34 days452.4
Normal Values<65<200<1.2

*Calculated from µmol/L.


This patient had typical halogenated anesthetic associated acute liver injury with a severe course, but ultimate recovery. Fever and eosinophilia are common at the onset of anesthetic induced hepatitis, but are not invariably present. In this patient and others, prednisone was used, but its benefit in this situation has not been proven. Risk factors for halogenated anesthetic hepatotoxicity included older age, overweight and possible previous exposures to halogenated anesthetics.



Desflurane – Generic, Suprane®


Anesthetics, Halogenated


Product labeling at DailyMed, National Library of Medicine, NIH


Desflurane chemical structure


References updated: 01 January 2018

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