Clinical beta

FMBM is currently in clinical beta. Content is for professional review/testing and must not replace local protocols, senior clinical judgment, or official prescribing references.

Drug Monograph

Sevoflurane

USE IF: Induction and maintenance of general anesthesia (adult + pediatric)

AVOID IF: Malignant hyperthermia susceptibility, severe QT prolongation risk

Sevoflurane

Volatile inhalational anesthetic (halogenated ether)

Inhalational anesthesiaMAC-based dosingMH riskRapid onset/offset

Indication

Induction and maintenance of general anesthesia (adult and pediatric)

At a glance

INDICATION -> Rapid-onset inhalational anesthetic with fast recovery

ADULT DOSE -> Induction 6-8% inhaled; maintenance 0.5-1.5 MAC (about 1-3%)

MAX DOSE -> Avoid prolonged exposure above about 2 MAC

CONTRA -> MH susceptibility, severe QT prolongation risk, prolonged high-concentration/low-flow exposure

ANTIDOTE -> None (dantrolene for MH)

Quick facts

Onset

30-60 sec

Duration

Peak in minutes (MAC-dependent); offset is rapid after discontinuation; context-dependent half-life.

Routes

Inhalational ONLY

Pregnancy

Used when GA is required (monitor uterine relaxation/atony risk)

Renal

Use caution with prolonged low-flow exposure

Hepatic

Rare hepatotoxicity; reduce exposure in high-risk patients

Do not miss

Time to action: onset 30-60 sec

MH risk

  • Malignant hyperthermia can be fatal without rapid recognition and treatment.

Critical risks

  • QT prolongation (rare; clinical significance usually low but caution with other QT-prolonging drugs).
  • High concentrations can trigger seizure-like activity (especially in pediatrics).
  • Low-flow with old absorbents may increase Compound A nephrotoxicity risk.

Antidote

  • No direct antidote; dantrolene for MH protocol.

High-risk scenarios

  • Always monitor temperature continuously for early MH detection.

Key interactions

  • QT-prolonging drugs.
  • CNS depressants.
  • Neuromuscular blockers.
  • High-dose epinephrine.

Indications

Primary

  • Induction of anesthesia (mask/circuit)
  • Maintenance of general anesthesia

Secondary

  • Pediatric anesthesia
  • Cardiac anesthesia with hemodynamic control goals

Other

  • ICU inhalational sedation (specialized)
  • Severe bronchospasm (off-label)

Dosing

Standard: Maintenance: 0.5-1.5 MAC

Max daily dose

  • Maintenance typically 0.5-1.5 MAC; avoid prolonged >2 MAC exposure.

Adult - Inhalational

  • Induction: 0.5-8% titrated inhalationally.
  • Maintenance: commonly 1-3% (about 0.5-1.5 MAC).

Route constraints

  • No IV formulation; inhalational delivery only.

Pediatric

  • Induction: 6-8%.
  • Maintenance: often 2-4% depending on age and adjuncts.

Renal adjustment

  • Avoid prolonged low-flow in vulnerable renal-risk settings.

Hepatic adjustment

  • Reduce exposure if significant liver disease or prior volatile-related injury.

Warnings

Clinical warnings

  • Malignant hyperthermia trigger.
  • QT prolongation and arrhythmia risk.
  • Dose-dependent hypotension.
  • Potential increase in ICP.
  • Rare hepatotoxicity.
  • Seizure-like EEG activity at high concentrations.

Adverse effects

  • Common: hypotension, emergence agitation, nausea/vomiting.
  • Serious: MH, severe arrhythmia, significant neuroexcitation at high concentrations.

Contraindications / caution

Do not use

  • Known/suspected malignant hyperthermia susceptibility.
  • Hypersensitivity to volatile anesthetics.
  • Prior anesthetic-induced hepatitis.

Use caution / avoid high doses

  • Long QT syndrome.
  • Intracranial hypertension.
  • Severe renal impairment.
  • Epilepsy.

Drug interactions

  • CNS depressants -> additive sedation and hypotension.
  • QT-prolonging drugs -> higher arrhythmia risk.
  • Neuromuscular blockers -> potentiated blockade.
  • High-dose epinephrine -> arrhythmia risk.

Special populations

Pediatrics

Preferred for mask induction in many settings.

Pregnancy

Use when GA required; monitor uterine tone/bleeding risk.

Breastfeeding

Usually safe after maternal recovery.

Elderly

Lower MAC requirement; reduce concentration.

Liver disease

Avoid repeated exposure if prior injury.

Renal impairment

Monitor closely in prolonged/low-flow settings.

Administration

  • Use a calibrated vaporizer only.
  • Deliver with oxygen with or without nitrous oxide.
  • Maintain fresh gas flow generally at least 1-2 L/min.
  • Use an active scavenging system.
  • No IV or oral form.

Monitoring

  • ECG, BP, SpO2, and EtCO2.
  • End-tidal anesthetic concentration.
  • Temperature for MH detection.
  • Neuromuscular monitoring when paralytics are used.
  • Post-op airway and cognitive recovery.

Overdose / toxicity

Stop agent -> 100% oxygen -> airway + ventilation -> hemodynamic support -> treat malignant hyperthermia if suspected (dantrolene).

Recognition

  • Hypotension, arrhythmias, and profound CNS depression/coma can occur.
  • Always assess for malignant hyperthermia signs.

Immediate actions

  • 100% oxygen.
  • Support ventilation and blood pressure.
  • Initiate MH protocol and dantrolene if indicated.

Antidote

  • No specific antidote for sevoflurane itself; dantrolene for MH.

Decontamination

  • Not applicable.

Escalation

  • ICU escalation if hemodynamic instability, arrhythmia, or MH concern.

Clinical pearls

Common mistakes, resistance logic, and bedside traps

Recovery profile

  • Among the fastest-recovery volatile agents.

Day-case fit

  • Well-suited to ambulatory/day-case anesthesia pathways.

Analgesia gap

  • Provides hypnosis ONLY - NO analgesia (opioid required for pain control).

Pediatric standard

  • Pediatric mask induction remains a common standard use-case.

MH vigilance

  • Always keep malignant hyperthermia risk in mind and monitor temperature.

Concentration discipline

  • Avoid prolonged very high concentrations such as sustained 8% exposure.

QT risk control

  • Monitor QT risk carefully in vulnerable patients and interacting drug regimens.

Pharmacokinetics

  • Low blood-gas solubility enables rapid onset/offset.
  • About 95% exhaled unchanged.
  • About 3-5% hepatic metabolism (CYP2E1).
  • Minimal accumulation relative to older volatiles.

Mechanism of action

  • Enhances GABA-A and glycine receptor-mediated inhibition.
  • Suppresses NMDA and other excitatory pathways.
  • Produces hypnosis, amnesia, and immobility.

Common brand names

Saudi Arabia

Sevorane · Ultane · Sojourn

Global

Generic sevoflurane

Common trade names are curated examples only — formulations and availability vary. Verify the exact product name with your local pharmacy and national regulator before prescribing or dispensing.

Country practice notes

  • Widely used across GCC hospitals as a primary volatile anesthetic.
  • Common brands in the region include Sevorane, Ultane, and Sojourn.
  • Standard choice for pediatric mask induction in Gulf practice.
  • Available in MOH and private operating room settings.

Saudi Arabia — confirm with local formulary.