Case 24: A Respiratory Dilemma During a Transjugular Intrahepatic Porto-Systemic Shunt (TIPSS) Procedure
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A 54-year-old man (55 kg) with a history of alcohol abuse and hepatitis is scheduled for a transjugular intrahepatic porto-systemic shunt (TIPSS) in the x-ray suite. He has received sclerotherapy for variceal bleeding but recurrent bleeding has ensued. He has no other major complaints. His INR is 1.1. A radial arterial line is placed preoperatively together with a 16 G. 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 and the end tidal CO2 is 32 mmHG. 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 a central 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 or feel for pulses in the head or arms (the latter being tucked along the side of the patient). Thirty minutes into the case, there is a sudden marked increase in the peak inspiratory pressure from 28 to 42 cm 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 since you really do not know if there is right endobronchial intubation.
KeywordsTransjugular intrahepatic porto-systemic shunt General anesthesia Variceal bleeding Right endobronchial intubation TIPS TIPSS X-ray
- 3.Freedman AM, Sanyel AJ, Tisnado J, Shiffman ML, Luketic V, Posner MR. Complications of TIPS: a comprehensive review. Radiology. 1992;185:359.Google Scholar