A Respiratory Dilemma During a Transjugular Intrahepatic Portosystemic Shunt Procedure
A 54-yr-old, 55kg man with a history of alcohol abuse and hepatitis is scheduled for a transjugular intrahepatic portosystemic shunt (TIPS). He has received sclerotherapy for variceal bleeding, but recurrent bleeding has ensued. He has no other major complaints. His international normalized ratio is 1.1. A radial arterial line is placed preoperatively together with a 16-gauge IV in his hand. Noninvasive monitors are placed, and general anesthesia is induced with etomidate, fentanyl, and vecuronium. After the endotracheal tube (ETT) is placed in the trachea, anesthesia is maintained with 50% nitrous oxide in oxygen with isoflurane 0.8%. Bilateral air entry is confirmed, the end-tidal CO2 is 32mmHg, and the end-tidal CO2 trace looks normal. The ETT is secured. The room is darkened, as is routine in these cases. The operator (radiologist) is in close proximity to the patient’s head, where he is placing an IV line in the internal jugular vein so that he can place the shunt in the portal venous system. With the x-ray machine on the other side of the head, you have no access to the airway and are unable to feel for pulses in the head or arms (the latter being tucked along side of the patient). Thirty minutes into the case, there is a sudden marked increase in the peak inspiratory pressure from 28 to 42cm H2O. All other parameters are within normal limits. You suspect right endobronchial intubation, but you are prevented from listening to the right side of the chest because it is made sterile and covered by sterile drapes. You are reluctant to pull the ETT back because you really do not know if there is right endobronchial intubation. Is there anything you can do to confirm your suspicions without making the surgical field on the right side of the chest unsterile?
KeywordsInternal Jugular Vein Transjugular Intrahepatic Portosystemic Shunt Disseminate Intravascular Coagulation Variceal Bleeding Peak Inspiratory Pressure