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Foe Tipps Background VideoFoETipps: Azteken Teil 2: Der Markt (Minispiel) in Forge of Empires (deutsch)
In any patient with established cirrhosis, endoscopic surveillance for varices should be performed at diagnosis and repeated every 2—3 yr.
When medical or endoscopic therapy fails and portal pressure remains persistently high, shunt procedures such as TIPS may be beneficial.
TIPS provides symptomatic benefit and improves survival in patients with diuretic-resistant ascites which requires frequent paracentesis.
Clinical outcomes, including mortality, after TIPS can be predicted using liver disease severity scores such as the model for end-stage liver disease or Child—Pugh scores.
Where possible, clinical assessment by a hepatologist, echocardiography, and triple-phase computed tomography CT should be performed in all patients.
Contraindications to TIPS insertion 6. TIPS insertion requires expertise in interventional radiology and is usually performed in the angiography suite.
Internal jugular vein cannulation allows passage of a catheter into the hepatic vein where wedge pressure is measured and HVPG calculated.
Hepatic venography using contrast or carbon dioxide , often ultrasound-assisted by a second operator, is used to delineate the vascular anatomy of the liver and a communication between a branch of the hepatic venous and portal venous circulation is created by the cutting tip of the catheter under fluoroscopic control.
After balloon dilatation of this communicating track, a polytetrafluoroethane-covered nitinol e. Internal jugular vein access can be complicated by carotid or tracheal puncture, pneumothorax or haemothorax, thoracic duct, or brachial plexus injury.
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.
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