The passage of the catheter through the right atrium may cause irritation precipitating arrhythmias, and rarely damage to the myocardium. Technical difficulty can occur in puncture of the portal vein, which may result in liver capsule puncture and potentially fatal haemorrhage into the peritoneal cavity.

Portal venous rupture, inadvertent puncture of the hepatic arteries, biliary structures, and right kidney have also been reported.

Late complications such as stent occlusion, thrombosis, or dislodgement may also occur. Patients undergoing TIPS are medically complex as a result of chronic liver disease causing multisystem physiological disruption.

They should receive multidisciplinary input as part of comprehensive preoperative assessment and optimization before undergoing the procedure.

Patients who are potential or confirmed transplant candidates must be carefully considered as TIPS may rarely precipitate sudden decompensation to fulminant hepatic failure.

These cases should be discussed with a transplant centre and transferred if appropriate. A full evaluation of co-existing conditions should be undertaken in the usual manner before anaesthesia, although there are several particular areas to which attention must be directed in order to ensure optimal outcomes.

The urgency of the procedure will determine the extent of preoperative work-up that is feasible. Cardiovascular status must be assessed.

Patients with cirrhosis often exhibit a hyperdynamic circulation with low-normal arterial pressure due to persistent splanchnic vasodilatation.

Cardiac output will increase after TIPS insertion as pooled venous blood returns to the systemic circulation; hence, any degree of heart failure must be assessed before shunt insertion as this is likely to deteriorate with the effective fluid challenge post-procedure.

Symptomatic heart failure and tricuspid regurgitation should be assessed using transthoracic echocardiography and treatment optimized before TIPS is considered.

All patients should undergo echocardiography to determine left ventricular function and to exclude severe pulmonary hypertension; this would contraindicate the procedure due to the expected increase in right heart and pulmonary pressures with increased preload after shunting.

Reduced functional residual capacity due to ascites and hepatic hydrothorax impairs respiratory function.

This is exacerbated by the supine position required for the procedure. Baseline ventilatory observations may reveal respiratory dysfunction, while a chest radiograph will indicate the presence and extent of hydrothorax.

Consideration should be given to drainage of any intraperitoneal or intrathoracic fluid collection in patients with severe respiratory compromise.

This is normally performed on the day before the TIPS procedure and should involve the use of albumin for volume replacement 8 g per 2.

Thrombocytopenia and coagulopathy are common in cirrhotic patients and these abnormalities should be corrected before shunt insertion.

Cross-matched blood should be requested according to local policy, bearing in mind that patients have often had multiple transfusions in the past after repeated variceal haemorrhage and may therefore have atypical antibodies requiring extended cross-matching and import of blood products from regional centres.

Baseline renal impairment must be investigated further, as this may represent intrinsic renal damage or a degree of hepatorenal syndrome.

In either case, the receipt of a significant contrast load during TIPS insertion may adversely affect renal function. This may be attenuated by correction of hyponatraemia, volume expansion with human albumin solution, and the use of acetylcysteine for 48 h, although there is a lack of trial evidence to support this.

The presence and severity of hepatic encephalopathy should be assessed and graded, 2 as this may occur or worsen after shunt insertion due to entry of unprocessed portal blood into the systemic circulation.

The presence of overt hepatic encephalopathy may contraindicate TIPS in the elective situation. In the emergency situation, such a detailed work-up is not feasible and the results of historical investigations may need to be acquired.

Baseline laboratory testing should be performed—haemoglobin, platelet count, coagulation screen, and renal and hepatic function—as these will guide optimization and influence post-procedure destination.

Haemodynamic stability should be the aim, but may be unattainable with ongoing variceal bleeding, and temporizing measures such as a Sengstaken tube insertion may have a place.

Patients with acute variceal haemorrhage will usually receive vasopressors e. Complexities of remote site anaesthesia should be considered and include the delivery of care in an unfamiliar environment, often distant from theatres and their inherent safety due to staff and equipment availability , with staff not necessarily trained in anaesthetic practice.

For elective TIPS procedures, the choice between sedation or general anaesthesia will depend on patient factors and local practice. There is little literature comparing different methods and so the advantages and disadvantages of each must be considered for each individual case.

Conscious sedation can be used, using combinations of short-acting sedative agents that include midazolam, propofol, and remifentanil.

Although sedation may avoid the need for general anaesthesia, many patients experience significant discomfort in the supine position for a prolonged period of time.

Airway protection is not guaranteed, ventilation may be compromised, agitation caused by encephalopathy may hinder safe completion of the procedure, and discomfort during balloon dilatation of the intrahepatic tracts may be severe.

In cases managed under sedation, equipment and personnel should be immediately available for conversion to general anaesthesia, which may then present a significant challenge with a patient positioned on the imaging table.

General anaesthesia is recommended by many as the preferred technique on the grounds of safety, particularly when complications occur. Sedative premedication should be avoided, as this will have a prolonged effect, and may exacerbate encephalopathy.

An H 2 -receptor antagonist or proton pump inhibitor can be used. Set up of an interventional radiology suite for a TIPS procedure under general anaesthesia.

Central venous access may be required, in which case the femoral veins or the left internal jugular vein can be used after discussion with the radiologist.

Invasive arterial pressure monitoring should be used as haemodynamic instability is a frequent complication.

Insertion of lines on the side most accessible to the anaesthetist in the interventional suite is advisable, along with the use of multi-lumen extension devices.

A double pressure transducer is essential, as this will allow one port for connection of the arterial line and a second port for transduction of the venous pressure line inserted by the radiologist.

Urinary catheterization and patient warming are required as procedures may be prolonged. A broad-spectrum antibiotic e.

In most cases, tracheal intubation is the safest option, as patients with ascites have disrupted respiratory mechanics and a raised intra-abdominal pressure which will increase the risk of regurgitation of gastric contents.

Rapid sequence induction of anaesthesia with application of cricoid pressure is often warranted. Controlled ventilation is useful as a motionless patient and the ability to provide frequent breath holds will aid the radiologist in positioning the shunt.

Good communication between radiologist and anaesthetist is essential. Say you are concerned that a union could cause a loss of personal communication due to union members having to go through a union steward.

Examples of situations include: sharing YouTube videos that unions post showing outrageous behavior on the picket line, specifics of promises made during campaigns at other companies versus contracts that unions have negotiated, information about strikes and fines to employees who cross picket lines, and stories about union corruption.

Also share examples of positive actions that your worksite has experienced as a result of the employer and employees working directly with each other.

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Cancel Sign In. There are all sorts of legal issues involved. To assist you in this and to ensure that you will be able to keep your invaluable lines of employee communications open, two acronyms will prove useful to you:.

We will now review what they stand for and what they relate to. Following that, you will take a quiz to see how well you have grasped these important tools.

Es Foe Tipps auch, Foe Tipps es. - Forge of Empires – Guides, Tips und Tricks