Sevoflurane

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Red flags

• Sevoflurane IS a trigger of malignant hyperthermia — like every volatile agent, it must never be given to the known or suspected MH-susceptible patient; use a total intravenous technique with a vapour-free machine.
• Sevoflurane is degraded to compound A by desiccated soda lime (especially at low fresh-gas flows), a nephrotoxin in rats; avoid desiccated absorbent, use fresh absorbent, and do not run prolonged low flows below 1 L/min with old soda lime.
• Carbon monoxide is formed when sevoflurane passes through desiccated baralyme or strongly desiccated soda lime; desiccated absorbent can deliver dangerous CO — change absorbent regularly and turn vapourisers off when the machine is left standing.
• Emergence agitation and delirium occur especially in children aged 1 to 5 years after sevoflurane anaesthesia; reduce it with an alpha-2 agonist (dexmedetomidine), propofol at the end of the case, or by switching to desflurane or propofol for maintenance.
• Epileptiform EEG activity and seizures have been reported at high concentrations of sevoflurane, especially in patients with epilepsy; it is not an absolute contraindication but warrants caution and avoidance of high inspired concentrations for prolonged periods.
• Sevoflurane is a greenhouse gas with a measurable global-warming potential and atmospheric lifetime; theatre scavenging is mandatory and the agent should be used at low fresh-gas flows where compound A limits allow.