Transjugular intrahepatic portosystemic shunt (TIPS): the anesthesiological point of view after 150 procedures managed under total intravenous anesthesia

Abstract

TIPS is a percutaneous procedure which diverts blood from the portal to the systemic circulation preventing rebleeding from varices and stopping or reducing the formation of ascites. The choice of the anaesthetic technique is still a matter of debate. Since January 2003, 150 consecutive TIPS were performed using total intravenous anesthesia (TIVA), (propofol/fentanyl or remifentanil), endotracheal intubation and mechanical ventilation. Sixty-one patients were classified as ASA 2, 73 ASA 3, and 16 ASA 4. According to CHILD classification, 96 patients were in Class A, 48 in Class B, 6 in Class C. Mean duration f the procedure was 100+/-62 min. After TIPS placement Portal vein pressure decreased from 30+/-10 to 14+/-4 mmHg while RAP increased from 8+/-4 to 12+/-6 mmHg. Intraoperative fluid management included mainly crystalloids (750+/-200 ml, 5.4+/-1.5 ml/kg/h). Fresh frozen plasma (median 2 units, range 1-3) was given in 20 patients (13%) if PT INR was >2. Packed red cells (median 2 units, range 1-5) were transfused in 35 patients (23%) to keep haematocrit >25%; platelets were administered before the procedure if platelet count was <50,000x10(-9) (20 patients, 13%). Urine output was kept above 4 ml/kg/h with loops diuretics (mean diuresis 700+/-200 ml, 5+/-1.5 ml/kg/h). Ten patients (6.6%) required ICU after the procedure, because of intraoperative hemodynamic instability. Three patients (2%) died in the early postoperative period because of multiple organ failure associated with the acute deterioration of an already marginal hepatic function.

Consensus conference on TIPS management: Techniques, indications, contraindications

“…In the absence of randomized controlled trials, GA with endotracheal intubation represents the ideal option for critical patients who are at risk for aspiration during the procedure [46][47][48]. Chronic liver diseases are associated with variable and non-uniform reductions in drug-metabolizing activities.…”

Common procedures and strategies for anaesthesia in interventional radiology

“…Procedures to reduce portal hypertension and associated variceal bleeding and ascites are performed on patients critically ill with end-stage liver disease [27]. These include transjugular intrahepatic portosystemic shunt (TIPS) creation and balloon occluded retrograde transvenous obliteration (BRTO) of varices with sclerosant [28].…”

“…Coagulopathy is often marked and may require correction peri-procedure. Complications of TIPS include encephalopathy and shunt stenosis, as well as haemorrhage [27]. BRTO complications include most commonly transient haemoglobinuria, vessel thrombosis or reaction to sclerosant is rare.…”

Comprehensive Review of TIPS Technical Complications and How to Avoid Them

“…General anesthesia, monitored anesthesia care, and IV moderate sedation have all been used during TIPS procedures [10]. Although general anesthesia with endotracheal intubation is associated with some risk of anesthetic medication administration in patients with liver dysfunction, it is considered the best option for intraprocedural anesthesia during TIPS [10].…”