Case 8 – History


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Case 8

TIPS procedure


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Brief Past Medical History

The patient was a middle-aged man with prior alcohol use disorder with cirrhosis; and chronic renal disease of unknown etiology on peritoneal dialysis.

The patient was evaluated for kidney vs. kidney-liver transplant.

Transplant was deferred to due elevated transhepatic pressure.

The patient was first scheduled for a transjugular intrahepatic portosystemic shunt (TIPS) procedure.


Pre-operative labs



Hospital course

The patient underwent the TIPS procedure.


TIPS Fluoroscopy



Intraoperative events

The procedure was complicated intraoperatively by a duration of hypotension during repositioning to a transplenic approach.


Selected Anesthesia Data

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Portion of Anesthesia Graph

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Postoperative course

Careful review of the medical records showed no documentation that any members of the post-operative care team were aware of the intraoperative hypotension.


Postoperative Labs – POD 1


POD 1 0225

POD 1 0708

POD 1 0815

POD 1 2233


Postoperative Abdominopelvic CT – POD 1


(switch to coronal view)

(Start at 02:18 for rapid view.)

(switch to axial view)

(Start at 03:52 for rapid view.)


Postoperative Labs – POD 2


POD 2 0805

POD 2 1201


Postoperative course, continued

The post-operative course was complicated by progressive elevation in liver function test, hepatic failure and then multi-organ failure in the immediate postoperative period.

The patient underwent cardiopulmonary arrest and died.


Next: External exam

Discussion Questions

1. Summarize the patient history.

2. Summarize the available anesthesia data.

3. Summarize the postoperative laboratory studies.

4. Summarize the radiographic studies.

5. What main ethical issues define this case?

6. What scenario might have allowed for a different outcome postoperatively and what might that have looked like? What specific choices might the post-operative care team have made?

7. Patients move from one unit or care floor to another in hospitals. How, as a provider, would you ensure continuity of care? What provider issues may affect continuity? What system issues may affect continuity? What is the role of charting in ensuring continuity? What other factors facilitate patient care continuity inside a hospital?