Trans-jugular Intrahepatic PortoSystemic Shunt
aka "TIPSS"

Updated April 5, 2014
Author: Rob Hubbs

Description: Anesthetic Management of Trans-Jugular PortoSystemic Shunts aka "TIPSS" (sometimes called "TIPS") in Interventional Radiology

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Introduction:

A surprisingly good synopsis of the procedure is detailed on the Wikipedia site, found by clicking here .

Management

Preop Considerations

  • Altered mental status from encephalopathy
  • Full stomach considerations due to ascites or GI bleeding
  • Poor drug clearance due to hepatic failure
  • Coexisting diseases: coagulopathy, renal insufficiency, anemia

Physical Findings: Jaundice, ascites, easy bruising, asterixis

Labs:

  • hematocrit, platelet count, INR/PTT, liver function tests, electrolytes (BUN/Cr)
  • Documentation of portal hypertension

 

These patients have liver failure, cirrhosis, and high portal vein pressures resulting in esophageal varices and caput medusa, commonly with ascites.

Most cases are managed with a light endotracheal general anesthetic; sedation is an alternative, but airway obstruction and facial draping can make this approach more difficult.

The operator will get vascular access via the right internal jugular vein.

The procedure can last 4 hours or longer.

Blood Products

Fom Rob Hubbs:

"It is a good idea to type and cross blood (or at the very least type and screen) for TIPSS procedures far in advance of the procedure. These patients are by definition coagulopathic, have multiple medical problems, are invariably anemic, and usually have received blood in the past. The interventional radiologists may or may not appreciate the full extent of the issues with these patients.

Today's patient had a starting HCT of 27.9 and no type and screen/cross despite being admitted last night for her "work up." I sent a specimen just after induction for 2 units. I called the blood bank about 45 min later to see if they received the specimen and were doing the cross match. They asked how soon I needed the blood because it would take "a few hours or a day" since the patient had multiple blood antibodies (from prior transfusions). Soon after that the IR guy said, "how's she doing?" with a worried look on his face. I said fine, and why do you ask. He said, well I think I just punctured her liver capsule... In the end the patient did OK but it would have been ugly if she bled significantly. He said they "usually" don't bleed much but if they puncture the capsule it "can be catastrophic." The patient was not a Jehovah's Witness."

References

Review Article 2004 (pdf)