Transjugular intrahepatic portosystemic shunts - Revision history

Dsender87: Added volume mgmt section.

2023-10-16T17:03:57Z

Added volume mgmt section.

← Older revision		Revision as of 10:03, 16 October 2023
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	*Large bore PIV x2		*Large bore PIV x2
	*Arterial Line		*Arterial Line
	*CVP if indicated		*CVP if indicated, but will often be given from interventional team.

	===Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. -->===		===Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. -->===
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	*Potential ''intraprocedural'' complications 1) Portal vein rupture; intra-abdominal hemorrhage may be massive and require emergency surgery 2) Liver capsule perforation 3) Complete heart block, especially in patients with LBBB.		*Potential ''intraprocedural'' complications 1) Portal vein rupture; intra-abdominal hemorrhage may be massive and require emergency surgery 2) Liver capsule perforation 3) Complete heart block, especially in patients with LBBB.
	*Patient may have markedly reduced drug metabolism, anticipate prolonged medication effects. Low albumin levels may alter pharmacokinetics of heavily protein-bound medications.		*Patient may have markedly reduced drug metabolism, anticipate prolonged medication effects. Low albumin levels may alter pharmacokinetics of heavily protein-bound medications

			=== Volume Management ===

			* Post-paracentesis albumin is not necessary for removal of <5L.
			* For ≥5L removed, albumin replacement can be given.
			* The AASLD Class IIA recommendation is 6-8 grams of albumin for every liter removed (~1 bottle of 50cc of 25% OR ~1 bottle of 250cc of 5% IV albumin per 2 liters of ascites).<ref>{{Cite journal\|last=Runyon\|first=Bruce A.\|last2=AASLD\|date=2013-04\|title=Introduction to the revised American Association for the Study of Liver Diseases Practice Guideline management of adult patients with ascites due to cirrhosis 2012\|url=https://pubmed.ncbi.nlm.nih.gov/23463403\|journal=Hepatology (Baltimore, Md.)\|volume=57\|issue=4\|pages=1651–1653\|doi=10.1002/hep.26359\|issn=1527-3350\|pmid=23463403}}</ref><ref>{{Cite journal\|last=Ginès\|first=P.\|last2=Titó\|first2=L.\|last3=Arroyo\|first3=V.\|last4=Planas\|first4=R.\|last5=Panés\|first5=J.\|last6=Viver\|first6=J.\|last7=Torres\|first7=M.\|last8=Humbert\|first8=P.\|last9=Rimola\|first9=A.\|last10=Llach\|first10=J.\|date=1988-06\|title=Randomized comparative study of therapeutic paracentesis with and without intravenous albumin in cirrhosis\|url=https://pubmed.ncbi.nlm.nih.gov/3360270\|journal=Gastroenterology\|volume=94\|issue=6\|pages=1493–1502\|doi=10.1016/0016-5085(88)90691-9\|issn=0016-5085\|pmid=3360270}}</ref><ref>{{Cite journal\|last=Aithal\|first=Guruprasad P.\|last2=Palaniyappan\|first2=Naaventhan\|last3=China\|first3=Louise\|last4=Härmälä\|first4=Suvi\|last5=Macken\|first5=Lucia\|last6=Ryan\|first6=Jennifer M.\|last7=Wilkes\|first7=Emilie A.\|last8=Moore\|first8=Kevin\|last9=Leithead\|first9=Joanna A.\|last10=Hayes\|first10=Peter C.\|last11=O'Brien\|first11=Alastair J.\|date=2021-01\|title=Guidelines on the management of ascites in cirrhosis\|url=https://pubmed.ncbi.nlm.nih.gov/33067334\|journal=Gut\|volume=70\|issue=1\|pages=9–29\|doi=10.1136/gutjnl-2020-321790\|issn=1468-3288\|pmc=7788190\|pmid=33067334}}</ref><ref>{{Cite journal\|last=Arora\|first=Vinod\|last2=Vijayaraghavan\|first2=Rajan\|last3=Maiwall\|first3=Rakhi\|last4=Sahney\|first4=Amrish\|last5=Thomas\|first5=Sherin Sarah\|last6=Ali\|first6=Rehmat\|last7=Jain\|first7=Priyanka\|last8=Kumar\|first8=Guresh\|last9=Sarin\|first9=Shiv Kumar\|date=2020-09\|title=Paracentesis-Induced Circulatory Dysfunction With Modest-Volume Paracentesis Is Partly Ameliorated by Albumin Infusion in Acute-on-Chronic Liver Failure\|url=https://pubmed.ncbi.nlm.nih.gov/31849085\|journal=Hepatology (Baltimore, Md.)\|volume=72\|issue=3\|pages=1043–1055\|doi=10.1002/hep.31071\|issn=1527-3350\|pmid=31849085}}</ref>

	===Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->===		===Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->===

Jashvin: Hepatic encephalopathy

2023-02-02T02:16:05Z

Hepatic encephalopathy

← Older revision		Revision as of 19:16, 1 February 2023
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	===Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->===		===Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->===
	Potential ''PACU'' complications include PV thrombosis (may mimic MI or PE), intraperitoneal bleed, hepatic infarction, new or worsening encephalopathy (20% of patients), stent migration, sepsis, fluid/electrolyte disturbance, biliary tree injury.		Potential ''PACU'' complications include PV thrombosis (may mimic MI or PE), intraperitoneal bleed, hepatic infarction, new or worsening encephalopathy (20% of patients), stent migration, sepsis, fluid/electrolyte disturbance, biliary tree injury.

			Hepatic encephalopathy: failure of liver to filter toxic metabolites such as ammonia, which leads to CNS toxicity. Most sedative-hypnotics and IV induction agents serve to decrease blood flow to the liver and may result in acute accumulation of toxic metabolites which can precipitate hepatic encephalopathy. Of note, propofol has minimal effect on hepatic blood flow and predictable pharmacokinetic profile even in the setting of severe hepatic dysfunction.

	==Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). -->==		==Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). -->==

Asdoyal: editing, editing, editing

2022-08-05T18:15:06Z

editing, editing, editing

← Older revision		Revision as of 11:15, 5 August 2022
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	\| lines_access = Two large PIV, consider central line		\| lines_access = Two large PIV, consider central line
	\| monitors = Standard Monitors, Arterial Line, possible Central Line		\| monitors = Standard Monitors, Arterial Line, possible Central Line
	\| considerations_preoperative = Coagulopathies from liver dysfunction		\| considerations_preoperative = Coagulopathies from liver dysfunction, possible full stomach,
	\| considerations_intraoperative = Possible large blood loss		\| considerations_intraoperative = Possible large blood loss, altered drug effect, complete heart block
	\| considerations_postoperative =		\| considerations_postoperative = Hepatic encephalopathy, PV thrombosis, hepatic infarction, hemorrhage, fluid/electrolyte imbalance.
	}}		}}

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	TIPS is a procedure for patients with portal hypertension (typically from cirrhosis) and associated large gastric/esophageal varices or ascites. A percutaneous shunt between the portal and systemic circulations is created. An esophageal variceal bleed has a high mortality (30-80%).<ref>{{Cite journal\|last=Wipassakornwarawuth\|first=Suchart\|last2=Opasoh\|first2=Manus\|last3=Ammaranun\|first3=Kasiri\|last4=Janthawanit\|first4=Pathomporn\|date=2002-06\|title=Rate and associated risk factors of rebleeding after endoscopic variceal band ligation\|url=https://pubmed.ncbi.nlm.nih.gov/12322843\|journal=Journal of the Medical Association of Thailand = Chotmaihet Thangphaet\|volume=85\|issue=6\|pages=698–702\|issn=0125-2208\|pmid=12322843}}</ref>		TIPS is a procedure for patients with portal hypertension (typically from cirrhosis) and associated large gastric/esophageal varices or ascites. A percutaneous shunt between the portal and systemic circulations is created. An esophageal variceal bleed has a high mortality (30-80%).<ref>{{Cite journal\|last=Wipassakornwarawuth\|first=Suchart\|last2=Opasoh\|first2=Manus\|last3=Ammaranun\|first3=Kasiri\|last4=Janthawanit\|first4=Pathomporn\|date=2002-06\|title=Rate and associated risk factors of rebleeding after endoscopic variceal band ligation\|url=https://pubmed.ncbi.nlm.nih.gov/12322843\|journal=Journal of the Medical Association of Thailand = Chotmaihet Thangphaet\|volume=85\|issue=6\|pages=698–702\|issn=0125-2208\|pmid=12322843}}</ref>

	As the name suggests, the right IJ is accessed and a guidewire/catheter is inserted in the right hepatic vein. Carbon dioxide is wedged in the hepatic veins, through the sinusoids, and into the portal vein, creating a map. A stiff wire then guides the metallic introducer (needle) through the hepatic vein into the portal vein. This tract is ~~then~~ dilated with an angioplasty balloon and a self-expanding stent is deployed~~, creating~~ a shunt from the high pressure portal system into the low ~~pressured~~ central venous system<ref>{{Cite book\|url=https://www.worldcat.org/oclc/1117874404\|title=Anesthesiologist's manual of surgical procedures\|date=2020\|others=Richard A. Jaffe, Clifford A. Schmiesing, Brenda Golianu\|isbn=978-1-4698-2916-6\|edition=Sixth edition\|location=Philadelphia\|oclc=1117874404}}</ref>. This ~~decrease~~ in portal pressure ~~decreases~~ the risk of esophageal variceal bleeding and decreases ascites. <ref>{{Cite journal\|last=Chana\|first=A.\|last2=James\|first2=M.\|last3=Veale\|first3=P.\|date=2016-12-01\|title=Anaesthesia for transjugular intrahepatic portosystemic shunt insertion\|url=https://www.bjaed.org/article/S2058-5349(17)30002-1/abstract\|journal=BJA Education\|language=English\|volume=16\|issue=12\|pages=405–409\|doi=10.1093/bjaed/mkw022\|issn=2058-5349}}</ref> TIPS provides a survival benefit in patients with large volume, diuretic resistant ascites<ref>{{Cite journal\|last=Narahara\|first=Yoshiyuki\|last2=Kanazawa\|first2=Hidenori\|last3=Fukuda\|first3=Takeshi\|last4=Matsushita\|first4=Yoko\|last5=Harimoto\|first5=Hirotomo\|last6=Kidokoro\|first6=Hideko\|last7=Katakura\|first7=Tamaki\|last8=Atsukawa\|first8=Masanori\|last9=Taki\|first9=Yasuhiko\|last10=Kimura\|first10=Yuu\|last11=Nakatsuka\|first11=Katsuhisa\|date=2011-01\|title=Transjugular intrahepatic portosystemic shunt versus paracentesis plus albumin in patients with refractory ascites who have good hepatic and renal function: a prospective randomized trial\|url=https://pubmed.ncbi.nlm.nih.gov/20632194\|journal=Journal of Gastroenterology\|volume=46\|issue=1\|pages=78–85\|doi=10.1007/s00535-010-0282-9\|issn=1435-5922\|pmid=20632194}}</ref> as well as when used to control variceal bleeding. <ref>{{Cite journal\|last=García-Pagán\|first=Juan Carlos\|last2=Caca\|first2=Karel\|last3=Bureau\|first3=Christophe\|last4=Laleman\|first4=Wim\|last5=Appenrodt\|first5=Beate\|last6=Luca\|first6=Angelo\|last7=Abraldes\|first7=Juan G.\|last8=Nevens\|first8=Frederik\|last9=Vinel\|first9=Jean Pierre\|last10=Mössner\|first10=Joachim\|last11=Bosch\|first11=Jaime\|date=2010-06-24\|title=Early use of TIPS in patients with cirrhosis and variceal bleeding\|url=https://pubmed.ncbi.nlm.nih.gov/20573925\|journal=The New England Journal of Medicine\|volume=362\|issue=25\|pages=2370–2379\|doi=10.1056/NEJMoa0910102\|issn=1533-4406\|pmid=20573925}}</ref>		As the name suggests, the right IJ is accessed and a guidewire/catheter is inserted in the right hepatic vein. Carbon dioxide is wedged in the hepatic veins, through the sinusoids, and into the portal vein, thus creating a map. A stiff wire then guides the metallic introducer (needle) through the hepatic vein into the portal vein. This tract is dilated with an angioplasty balloon and a self-expanding stent is deployed. This creates a shunt from the high pressure portal system into the low pressure central venous system.<ref>{{Cite book\|url=https://www.worldcat.org/oclc/1117874404\|title=Anesthesiologist's manual of surgical procedures\|date=2020\|others=Richard A. Jaffe, Clifford A. Schmiesing, Brenda Golianu\|isbn=978-1-4698-2916-6\|edition=Sixth edition\|location=Philadelphia\|oclc=1117874404}}</ref> This drop in portal pressure lowers the risk of esophageal variceal bleeding and decreases ascites. <ref>{{Cite journal\|last=Chana\|first=A.\|last2=James\|first2=M.\|last3=Veale\|first3=P.\|date=2016-12-01\|title=Anaesthesia for transjugular intrahepatic portosystemic shunt insertion\|url=https://www.bjaed.org/article/S2058-5349(17)30002-1/abstract\|journal=BJA Education\|language=English\|volume=16\|issue=12\|pages=405–409\|doi=10.1093/bjaed/mkw022\|issn=2058-5349}}</ref> TIPS provides a survival benefit in patients with large volume, diuretic resistant ascites that necessitates paracentesis<ref>{{Cite journal\|last=Narahara\|first=Yoshiyuki\|last2=Kanazawa\|first2=Hidenori\|last3=Fukuda\|first3=Takeshi\|last4=Matsushita\|first4=Yoko\|last5=Harimoto\|first5=Hirotomo\|last6=Kidokoro\|first6=Hideko\|last7=Katakura\|first7=Tamaki\|last8=Atsukawa\|first8=Masanori\|last9=Taki\|first9=Yasuhiko\|last10=Kimura\|first10=Yuu\|last11=Nakatsuka\|first11=Katsuhisa\|date=2011-01\|title=Transjugular intrahepatic portosystemic shunt versus paracentesis plus albumin in patients with refractory ascites who have good hepatic and renal function: a prospective randomized trial\|url=https://pubmed.ncbi.nlm.nih.gov/20632194\|journal=Journal of Gastroenterology\|volume=46\|issue=1\|pages=78–85\|doi=10.1007/s00535-010-0282-9\|issn=1435-5922\|pmid=20632194}}</ref> as well as when used to control variceal bleeding. <ref>{{Cite journal\|last=García-Pagán\|first=Juan Carlos\|last2=Caca\|first2=Karel\|last3=Bureau\|first3=Christophe\|last4=Laleman\|first4=Wim\|last5=Appenrodt\|first5=Beate\|last6=Luca\|first6=Angelo\|last7=Abraldes\|first7=Juan G.\|last8=Nevens\|first8=Frederik\|last9=Vinel\|first9=Jean Pierre\|last10=Mössner\|first10=Joachim\|last11=Bosch\|first11=Jaime\|date=2010-06-24\|title=Early use of TIPS in patients with cirrhosis and variceal bleeding\|url=https://pubmed.ncbi.nlm.nih.gov/20573925\|journal=The New England Journal of Medicine\|volume=362\|issue=25\|pages=2370–2379\|doi=10.1056/NEJMoa0910102\|issn=1533-4406\|pmid=20573925}}</ref>

	==Preoperative management==		==Preoperative management==
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	===Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->===		===Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->===
	Potential ''PACU'' complications include PV thrombosis (may mimic MI or PE), intraperitoneal bleed, hepatic infarction, new or worsening encephalopathy (20% of patients)~~, hepatic infarction~~, stent migration, sepsis, fluid/electrolyte disturbance.		Potential ''PACU'' complications include PV thrombosis (may mimic MI or PE), intraperitoneal bleed, hepatic infarction, new or worsening encephalopathy (20% of patients), stent migration, sepsis, fluid/electrolyte disturbance, biliary tree injury.

	==Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). -->==		==Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). -->==
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	\|-		\|-
	\|Pain management		\|Pain management
	\|		\|Multimodal analgesics
	\|		\|Multimodal analgesics
	\|-		\|-
	\|Potential complications		\|Potential complications

Asdoyal: starting work on this topic.

2022-08-04T20:06:02Z

starting work on this topic.

Show changes

Asdoyal: starting work on this topic.

2022-08-04T14:38:34Z

starting work on this topic.

← Older revision		Revision as of 07:38, 4 August 2022
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	{{Infobox surgical case reference		{{Infobox surgical case reference
	\| anesthesia_type =		\| anesthesia_type = General
	\| airway =		\| airway = ETT
	\| lines_access =		\| lines_access = Two large PIV, consider central line
	\| monitors =		\| monitors = Standard Monitors, Arterial Line
	\| considerations_preoperative =		\| considerations_preoperative =
	\| considerations_intraoperative =		\| considerations_intraoperative =

Chris.Rishel: Text replacement - "|Respiratory" to "|Pulmonary"

2022-02-22T05:46:01Z

Text replacement - "|Respiratory" to "|Pulmonary"

← Older revision		Revision as of 22:46, 21 February 2022
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	\|		\|
	\|-		\|-
	\|~~Respiratory~~		\|Pulmonary
	\|		\|
	\|-		\|-

Tony.Wang: Added brief overview

2021-05-10T17:39:38Z

Added brief overview

← Older revision		Revision as of 10:39, 10 May 2021
Line 1:		Line 1:
	.		{{Infobox surgical case reference
			\| anesthesia_type =
			\| airway =
			\| lines_access =
			\| monitors =
			\| considerations_preoperative =
			\| considerations_intraoperative =
			\| considerations_postoperative =
			}}

			Insertion of low-resistance percutaneous shunt between the portal and systemic circulations.

			== Preoperative management ==

			=== Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> ===
			{\| class="wikitable"
			\|+
			!System
			!Considerations
			\|-
			\|Neurologic
			\|
			\|-
			\|Cardiovascular
			\|
			\|-
			\|Respiratory
			\|
			\|-
			\|Gastrointestinal
			\|
			\|-
			\|Hematologic
			\|
			\|-
			\|Renal
			\|
			\|-
			\|Endocrine
			\|
			\|-
			\|Other
			\|
			\|}

			=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===

			=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===

			=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===

			=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===

			== Intraoperative management ==

			=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===

			=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===

			=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===

			=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===

			=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===

			== Postoperative management ==

			=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===

			=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===

			=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===

			== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==

			{\| class="wikitable"
			\|+
			!
			!Variant 1
			!Variant 2
			\|-
			\|Unique considerations
			\|
			\|
			\|-
			\|Position
			\|
			\|
			\|-
			\|Surgical time
			\|
			\|
			\|-
			\|EBL
			\|
			\|
			\|-
			\|Postoperative disposition
			\|
			\|
			\|-
			\|Pain management
			\|
			\|
			\|-
			\|Potential complications
			\|
			\|
			\|}

			== References ==

			[[Category:Surgical procedures]]

Tony.Wang: Page creation

2021-05-10T17:38:08Z

Page creation

New page