Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Anesthesia Implications

Position: Supine, head turned away from field
Time: 1-2 hours (average)
Blood Loss: Low (10-50 ml)
Post-op Pain: Minimal (1-3)
Maintenance Paralytic: Yes
Lead: Yes

Pre-op Preparation – These patients will most likely have severe cirrhosis and coagulation issues. Check coag labs (PT, PTT, INR), have platelets and FFP available if needed. Coagulation abnormalities should be treated and resolved before the procedure.

Off-site – These procedures are typically done in Interventional Radiology (IR) or cath lab

Lines – Have an 18g IV in case you need to transfuse blood. an A-line should be strongly considered (and generally recommended) especially if hemodynamically unstable and/or anticipated high blood loss.

Approach – GETT is usually standard with TIPS, most surgeons want the patient to be paralyzed due to the high risk of bleeding if a vessel in the liver is perforated due to unexpected movement/bucking. MAC/Local could be used if necessary (eg. respiratory issues).

Circuit extension – If taking the GETT approach, the circuit will need to be out of the surgical field. Have an extension and drape it from the chest/abdomen up to the patient’s airway.

Fluoroscopy / Xray (general considerations): Have lead aprons and thyroid shields available. Alternatively, distancing yourself 3 to 6 feet will reduce scatter radiation to 0.1% to 0.025% respectively. Occupational maximum exposure to radiation should be limited to a maximum average of 20 Sv (joules per kilogram – otherwise known as the Sievert/Sv) per year over a 5 year period. Limits should never exceed 50 Sv in a single year.

Arterial line (general considerations): Preoperatively check pulses to gauge the best side to attempt the A-line. Perform an Allen test to ensure adequate blood flow. Have the A-line equipment set up and ready in the room.

Off-site (general considerations): Extra precaution should be taken preoperatively if the surgery is planned off-site (away from the OR or your normal work spaces). Depending on your facility setup, it’s wise to take emergency airway equipment and drugs with you that would be necessary to treat the gamut of anesthesia emergencies.

High blood loss RISK (general considerations): Though most of these cases don’t result in a high blood loss, there is a high blood loss RISK. Type and cross, CBC, and CMP should be done prior to the procedure. Consider having an A-line, blood tubing, and extra IV push-lines. Depending on the fragility of the patient, you may want to have blood in the room and available.

A transjugular intrahepatic portosystemic shunt (TIPS) is a percutaneous interventional radiological procedure that creates a connection within the liver between the portal and systemic circulations.

A TIPS procedure is typically done for patients with severe liver failure causing life threatening variceal bleeding. In most cases this is a last ditch effort to decrease portal pressure by bypassing the liver with a shunt passed through the liver to the systemic circulation.