Anesthetic Management Of Patient Research Articles

Neurogenic Pulmonary Edema Caused by Subarachnoid Hemorrhage: A Case Report

Neurogenic pulmonary edema is a serious and life-threatening complication caused by central nervous system diseases, excluding cardiogenic pulmonary edema, other causes of pulmonary edema, lung injury, etc. The lack of specific diagnostic criteria for NPE and the lack of awareness among clinicians often lead to underdiagnosis and misdiagnosis. The disease progresses rapidly with poor prognosis and high mortality [1]. In this paper, we report a patient with a ruptured right middle cerebral artery aneurysm causing subarachnoid hemorrhage, who developed neurogenic pulmonary edema and underwent elective aneurysm clamping under general anesthesia. The relevant perioperative management is reported as follows, and the anesthesia management of patients with neurogenic pulmonary edema is analyzed in the context of the relevant literature.

Rocuronium-induced respiratory paralysis refractory to sugammadex in Charcot-Marie-Tooth disease

PurposeProlonged postoperative neuromuscular respiratory paralysis after administration of a nondepolarizing neuromuscular blocking agent is a serious concern during anesthetic management of patients with Charcot-Marie-Tooth disease (CMTD). Some recent reports have described rocuronium use without respiratory paralysis in CMTD patients when sugammadex was used for its reversal. We report a case in which an induction dose of rocuronium caused a prolonged respiratory paralysis in a patient with undiagnosed type 1A CMTD (CMT1A).Clinical featuresA 63-yr-old-male with an American Society of Anesthesiologists Physical Status score of III underwent a left hip arthroplasty under general anesthesia for osteoarthritis. Preoperative pulmonary function testing indicated a restrictive impairment. Anesthesia was induced with fentanyl, remifentanil, propofol, and 0.73 mg·kg-1 of rocuronium. The train-of-four (TOF) count was 0 for the 273-min duration of surgery. After repeated doses of sugammadex failed to recover the TOF count and spontaneous respirations, a total of 1,200 mg (17.3 mg·kg-1) of sugammadex, which was assumed to be a sufficient amount for capturing the residual rocuronium, was administered. Although the patient expressed that he was awake via eye blinking, he could not breathe. Thus, he was placed on mechanical ventilation for 18 hr after surgery. A postoperative neurology consultation revealed a delayed nerve conduction velocity of 20 m·sec-1 and a mutated duplication of the PMP22 gene; a diagnosis of CMT1A was made.ConclusionsOur case shows that rocuronium can cause a prolonged neuromuscular respiratory paralysis refractory to sugammadex in patients with CMT1A and impaired respiratory function. Our case may also indicate that restrictive pulmonary impairment and low nerve conduction velocity of 20 m·sec-1 are predictive factors that cause prolonged neuromuscular respiratory paralysis refractory to sugammadex in CMT1A.

Overcoming Barriers to Implement Regional Anesthesia in Orthopedic Surgery of Upper Extremity with Lymphedema – A Case Report

Anesthetic management of patient with lymphedematous extremity undergoing orthopedic surgery is not well documented in the literature. Regional anesthesia may be the only viable option for upper limb orthopedic surgery in patients with multiple comorbid conditions. However, it may be technically challenging because of the altered nature of surrounding tissue. We report the perioperative challenges and management of an elderly female patient with multiple comorbidities scheduled for an emergency orthopedic surgery of the lymphedematous upper extremity.

Mechanical Cardiac Circulatory Support: an Overview of the Challenges for the Anesthetist.

Purpose of ReviewOwing to increased utilization of Mechanical Circulatory Support (MCS) devices, patients with these devices frequently present for surgeries requiring anesthetic support. The current article provides basics of perioperative management of these devices.Recent FindingsUse of extracorporeal membrane oxygenation (ECMO) and left ventricular assist devices (LVADs) are on the rise with recently updated management guidelines. Veno-venous ECMO utilization has been widely utilized as a salvage therapy during the COVID-19 pandemic.SummaryIntra-Aortic Balloon Pumps continue to be one of the most frequently used devices after acute myocardial infarction. ECMO is utilized for pulmonary or cardiopulmonary support as salvage therapy. LVADs are used in patients with end-stage heart failure as a destination therapy or bridge to transplant. Each of these devices present with their own set of management challenges. Anesthetic management of patients with MCS devices requires a thorough understanding of underlying operating and hemodynamic principles.

Анестезіологічний менеджмент феохромоцитом в умовах спеціалізованого ендокринологічного центру

Мета роботи: упровадження сучасного анестезіологічного менеджменту пацієнтів із фео­хромоцитомою в умовах спеціалізованого ендокринологічного центру із застосуванням алгоритму етапного періопераційного гемодинамічного контролю.Матеріали й методи. Проведена імплементація анестезіологічного менеджменту в 33 жінок із фео­хромоцитомою надниркових залоз при її хірургічному видаленні шляхом відеоасистованої лапароскопічної адреналектомії. Усім пацієнткам застосовувався алгоритм етапного періопераційного гемодинамічного менедженту (ЕПОГМ): передопераційна таблетована гіпотензивна терапія до надходження в стаціонар, передопераційна інфузійна керована гіпотензивна терапія урапідилом та корекція гіповолемії збалансованими кристалоїдними розчинами та 10% розчином гідроксіетилкрохмалю (ГЕК) (200/0,5) на другому етапі, інтраопераційна інфузійна керована гіпотензивна терапія урапідилом на третьому етапі під контролем інвазивного та неінвазівного моніторингу гемодинаміки і профілактика надниркової недостатності та корекція гіповолемії на четвертому етапі.Результати та обговорення. У всіх хворих був відмічений вірогідно (p < 0,001) підвищений рівень метанефринів добової сечі до 1831,6 ± 337,9 мкг/24 год (контроль 169,3 ± 12,7 мкг/24 год). Згідно з розробленим алгоритмом ЕПОГМ на першому етапі застосовували доксазозин 10,0 ± 1,0 мг або урапідил 144,0 ± 11,2 мг у 2 прийоми. На другому етапі виконували гемодилюцію 10% розчином ГЕК (200/0,5) та інфузійну керовану гіпотензивну терапію урапідилом із середньою швидкістю 9,7 ± 1,9 мг/год. На третьому етапі інтраопераційно швидкість інфузії урапідилу становила 1,25 ± 0,08 мг/хв (додатково при хірургічному видаленні надниркової залози з феохромоцитомою болюсно вводився урапідил 25–50 мг в/в при виявленні навіть мінімального підвищення артеріального тиску). На четвертому етапі здійснювалась профілактика надниркової недостатності та гіповолемії.Висновки. Упровадження анестезіологічного менеджменту пацієнтів із феохромоцитомами в спеціалізованому ендокринологічному центрі забезпечило високу ефективність та безпеку при лапароскопічних адреналектоміях під час загальної анестезії та відсутність випадків із летальним кинцем. ЕПОГМ при підготовці до операції та під час хірургічного втручання є ефективним, легко керованим та безпечним методом стабілізації показників гемодинаміки у пацієнтів із феохромоцитомами під час адреналектомії.

Anaesthetic Management of Patient with Xeroderma Pigmentosum Posted for Basal Cell Carcinoma Excision

Introduction: Xeroderma Pigmentosum (XP) is a hereditary autosomal recessive disorder due to defect in nucleotide repair genes. In this condition patient might require multiple surgeries for removal of skin and ocular lesion. Case report: A 17 year old male patient, weighing 43 kg presented with multiple lesions over face since 2 months. He had cutaneous lesions over full body with no major neurological deficit. General anaesthesia was planned. Patient’s body protection from artificial light and eye protection given in operating room. Patient Pre medicated with Inj glycopyrrolate, Inj Midazolam and Inj fentanyl. Preoxygenation done with 100% oxygen for 3 min. Induced with Inj Propofol. After elimination of reflexes and reaching enough depth of anaesthesia laryngeal mask airway(LMA) number 3 inserted and good lung ventilation confirmed by chest rise and ETCO2 then LMA fixed in place. Anaesthesia maintained with 50% nitrous oxide in oxygen, IV Propofol with intermittent positive pressure ventilation. Further analgesia supplemented by inj.Bupivacaine 0.25% infiltration locally around wound given. The procedure lasted for 40 min. Conclusion: Xeroderma pigmentosum patients have risk of worsening neurological disorder with genotoxic drugs and volatile anaesthesia and prolongation of recovery from muscle relaxants. In this case report demonstrated that patient with XP can safely be managed under general anaesthesia with IV propofol, without muscle relaxant and inhalational volatile anaesthetics.

Anaesthetic Management of Patient with Distal Radius Fracture with Ipsilateral Arteriovenous Fistula

Introduction: Patient with upper limb fracture with ipsilateral limb AV fistula, anaesthetic options are still challenging. Case Report: A 40 year old male patient who is an K/C/O CKD on maintenance hemodialysis and hypertensive on medication.Patient had AV fistula on the same side of the fracture, Detailed examination of the fistula was done, 1. Thrill over the fistula palpated. 2. Bruit was auscultated on the fistula side. 3. Radial pulse was palpated for volume and rhythm. 4. Fistula hand was compared with other hand for colour , any cyanosis or pallor, temperature, ulcer, edema , pigmentation or peeling of the skin and Nicoladoni Branham sign was negative Under USG, plexus was identified. Using 23G spinal needle , Bupivacaine 0.5(H) 15ml[75mg] plexus . Post supraclavicular block , both sensory and motor blockade was checked. Without tourniquet surgery was proceeded , face mask with 5L/min of O2 was given to the patient. Intraoperatively patient was hemodynamically stable, maintenance fluid of 0.5ml/kg/hr. Post procedure examination of AV fistula was repeated to check the patency. Conclusion: Use of regional anaesthesia over general anaesthesia in distal end fracture with ipsilateral AV fistula has advantage in both in management and patency of the AV fistula.

Hemodynamic collapse and severe metabolic acidosis following propofol in the setting of undiagnosed mitochondrial dysfunction: a case report

Anesthetic management of patients with mitochondrial disorders is challenging due to their rare nature, and difficulties to develop evidence–based protocols for general anesthesia. We report a case of a 52–year–old male with hypertension, congenital deafness, optic neuritis, hypogonadism and myotonia, who developed severe refractory hypotension and bradycardia, and intractable severe lactic acidosis during induction of general anesthesia with fentanyl, propofol, and succinylcholine. The surgery had to be postponed and supportive management started. After extensive work–up, the patient was diagnosed with probable mitochondrial dysfunction. Patient returned for surgery under a different anesthetic regimen consisting of ketamine, fentanyl, ephedrine and dexmedetomidine; yielding a successful perioperative course and highlighting potential alternative strategies to manage anesthesia in patients with such disorders. Key words: Mitochondrial Diseases; Propofol Infusion Syndrome; Lactic Acidosis Abbreviations: MD – Mitochondrial disorders; PRIS – Propofol related infusion syndrome; HIPAA – Health Insurance Portability Accountability Act; MAP Mean arterial pressure; NMBAs – Neuromuscular blocking agents. Citation: Kim DW, Hu A, Vaughn D, Rajan GRE. Hemodynamic collapse and severe metabolic acidosis following propofol in the setting of undiagnosed mitochondrial dysfunction: a case report. Anaesth. pain intensive care 2021;25(4):527–531. DOI: 10.35975/apic.v25i4.1587 Received: September 24, 2020. Reviewed: April 1, 2021, Accepted: May 31, 2021

Independent Predicting Factors for Subcutaneous Emphysema Associated with Robotic-Assisted Laparoscopic Radical Prostatectomy: A Retrospective Single-Center Study.

Objectives: Subcutaneous emphysema (SCE) is a complication associated with laparoscopic surgery. Severe SCE complicated by excessive hypercarbia may afford detrimental effects in surgical patients with cardiac dysfunction. Robotic-assisted laparoscopic radical prostatectomy (RALP) has several predisposing factors that contribute to SCE. The main purpose of our single-center retrospective study was to determine the preoperative and intraoperative predicting factors for SCE associated with RALP and to determine the actual incidence of SCE. Methods: In total, 229 adult male patients underwent standardized RALP for prostate cancer over the period of 1 May 2016 to 31 October 2018 at the Ehime University Hospital. We reviewed electronic clinical records for individual characteristics including age, body weight, height, coexisting disorders, preoperative ASA physical status, and the length of postoperative hospital stay. We also reviewed surgical and anesthetic records for the operation time, anesthetic method, and the partial pressure of end-tidal CO2 (PetCO2) during RALP. To determine the presence of SCE, we examined supine chest X-rays obtained after the completion of surgery. Results: We found 55 cases (24.0%) of SCE. Multiple logistic regression analysis showed that a BMI < 25 kg/m2 (OR: 3.0, 95% CI: 1.25–7.26) and a maximum value of PetCO2 of 46 mmHg or greater (OR: 23.3, 95% CI: 8.22–66.1) were independent predicting factors for SCE. Conclusion: These two predicting factors may be helpful to recognize the occurrence of SCE. Anesthesiologists should protect against SCE progression with the earlier detection of SCE for safe anesthetic management in patients undergoing RALP.

A case report on anaesthetic management of patient with bilateral retinitis pigmentosa with partial blindness for abdominal hysterectomy: Sequential combined spinal epidural anaesthesia in era of COVID19 pandemic

Retinitis pigmentosa is typically bilateral and symmetric. There is currently no treatment that can stop the process of retinitis pigmentosa, but gene therapy shows promise. Retinitis pigmentosa is typically a bilateral, progressive retinal degeneration that ultimately leads to death of both rod and the cone photoreceptors. Retinitis pigmentosa is generally symmetric, but can present asymmetrically. Other complications associated with retinitis pigmentosa include posterior subcapsular cataracts and cystoid macular edema, retinal detachment [1]. Forty-five separate gene loci have been identified that account for 50% of all bilateral retinitis pigmentosa cases. In addition, between 20-30% of patients with bilateral retinitis pigmentosa have an associated systemic disease, with more than 30 syndromes identified? The most widely known associated syndrome, Usher Syndrome, results in retinitis pigmentosa and hearing impairment. Other syndromes associated with retinitis pigmentosa are Laurence-Moon-Bardet-Biedl syndrome, Bardet-Biedl syndrome. We report the case of Retinitis pigmentosa with partially blind patient for Total abdominal hysterectomy managed by Sequential combined Spinal Epidural Anaesthesia (Sequential CSEA) in the era of COVID Pandemic inorder to avoid drastic changes in blood pressure thus preventing drastic change in intraocular pressure as intraocular pressure is a determining factor in partially blind patient with progressive retinitis pigmentosa. Sequential combined spinal epidural anaesthesia is a very safe regional anaesthesia technique to avoid General anaesthesia thus preventing abrupt increase in intraocular pressure and aerosol generation in era of COVID Pandemic. Sequential combined spinal epidural anaesthesia (Sequential CSEA) is probably the greatest advance in central neuraxial block. Sequential combined spinal epidural anaesthesia is a safe, effective, reliable technique with stable haemodynamic along with provision of prolonging analgesia compared to spinal anaesthesia alone for high risk patients.

A right para-tracheal mass extending into the anterior mediastinum

The anesthetic management of patients with a mediastinal mass represent a challenge due to the potential for difficult ventilation and intubation, as well as the risk of cardiovascular collapse upon induction of general anesthesia. Different strategies and alternatives have been described. We present the case of a 70-year-old man with a right para-tracheal mass extending into the anterior mediastinum with 90% mid-tracheal lumen obstruction who was successfully managed with venous-venous extra-corporeal membrane oxygenation (ECMO) during mass debulking and tracheal stent placement.

A Randomized Comparative Trial to Study the effect of Preoperative single shot Epidural with Ropivacaine in Lumbar Laminectomy

Background: laminectomy surgeries are usually performed in cases of spinal canal stenosis, disc prolapse etc. It has been reported that the use of regional anesthesia techniques in combination to general anaesthesia has shown better heamodynamic stability intraoperatively, better pain scores and reduced intraoperative blood loss. The present study was conducted to evaluate the efficacy of fusion technique of combining epidural and general anaesthesia in patients undergoing lumbar laminectomies. Aim: To evaluate the efficacy of combined epidural general anesthesia for lumbar laminectomy surgeries with epidural ropivacaine. Materials and Methods: A prospective randomised study was conducted in 100 patients who are scheduled for lumbar laminectomy surgeries belonging to ASA Class I and II age between 40-60 years were randomly allocated into two groups (Group E and Group F) of 50 each. Group E: 12ml of 0.5% Ropivacaine and 50µg fentanyl epidurally. Group F:12ml of Normal Saline and 50µg fentanyl epidurally. The parameters recorded were intraoperative analgesia by heart rate and blood pressure, Rescue analgesia, Blood loss. Results: Intraoperatively requirement of general anesthetics, Heart rate, MBP, Blood loss, is lesser in Group E when compared with Group F. It was observed that longer time to rescue analgesia in group E than in group F. Conclusion: combined epidural general anesthesia with local anesthetic (ropivacaine) with narcotic (fentanyl) is a better technique for anesthetic management of patients posted for lumbar laminectomy. Thus from our study we conclude that combined epidural general anesthesia technique with epidural ropivacaine is a better alternative to general anesthesia providing stable hemodynamics, reducing dose of general anesthetics, less blood loss.

General anesthesia with remimazolam in a patient with mitochondrial encephalomyopathy: a case report

BackgroundSystemic anesthetic management of patients with mitochondrial disease requires careful preoperative preparation to administer adequate anesthesia and address potential disease-related complications. The appropriate general anesthetic agents to use in these patients remain controversial.Case presentationA 54-year-old woman (height, 145 cm; weight, 43 kg) diagnosed with mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes underwent elective cochlear implantation. Infusions of intravenous remimazolam and remifentanil guided by patient state index monitoring were used for anesthesia induction and maintenance. Neither lactic acidosis nor prolonged muscle relaxation occurred in the perioperative period. At the end of surgery, flumazenil was administered to antagonize sedation, which rapidly resulted in consciousness.ConclusionsRemimazolam administration and reversal with flumazenil were successfully used for general anesthesia in a patient with mitochondrial disease.

Rocuronium reversed with sugammadex for thymectomy in myasthenia gravis: A retrospective analysis of complications from Japan.

Postoperative respiratory failure is a serious problem in the anaesthetic management of patients with myasthenia gravis who undergo thymectomy. Although the classical recommendation is to avoid neuromuscular blockers, there is no strong evidence to support it. To evaluate the postoperative outcomes in patients with myasthenia gravis after thymectomy when anaesthetic management included rocuronium reversed with sugammadex. A retrospective cohort study. Nationwide acute in-patient care database. A total of 1143 patients with myasthenia gravis who underwent thymectomy were included. Data were collected from the medical insurance claims data of acute care in-patient hospitals. The postoperative complications when rocuronium reversed with sugammadex was compared against no muscle relaxant use using propensity score matching. The primary outcomes were the rates of in-hospital mortality, plasma exchange following thymectomy and the use of immunoglobulins. The secondary outcomes were the length of stay in the high dependency/ICUs, the total length of hospital stay and the duration and type of respiratory support following thymectomy. There were no significant differences between the propensity score matched groups in terms of plasma exchange [relative risk, 0.96; 95% confidence interval (CI), 0.64 to 1.43] and use of immunoglobulins (relative risk, 1.09; 95% CI, 0.60 to 1.97). The length of hospital stay was significantly shorter in patients in whom rocuronium and sugammadex were used: 29.0 vs. 35.4 days, P = 0.035. Anaesthetic management with rocuronium reversed by sugammadex was not associated with increased risk of respiratory complications. These findings could help in the anaesthetic management of patients with myasthenia gravis.

Anesthesia and Ullrich Congenital Muscular Dystrophy: Comment.

I read with great interest the short report published in the Images in Anesthesiology section about difficult intubation in a 2-yr-old patient with Ullrich congenital muscular dystrophy.1 This disease is well known to carry a risk of difficult intubation.2–6 The authors nicely described how they used a nasopharyngeal airway to administer a volatile anesthetic and oxygen through one nostril while performing nasotracheal fiberoptic intubation via the other. I am however surprised that the choice of the anesthetic agent(s) used was not discussed. Ullrich congenital muscular dystrophy indeed belongs to the subgroup of the collagen type 6–related myopathies occurring after a mutation of the COL6A1, COL6A2, or COL6A3 gene. Collagen type 6 is part of the large complex that anchors the basal lamina and the interstitium in muscle cells. The myopathy is probably caused by the muscle membrane fragility and an associated mitochondrial dysfunction, which can be decreased with cyclosporine A. As collagen 6 is close to the dystrophin-glycoprotein complex, this muscle disease could be at risk of anesthesia-induced rhabdomyolysis in the presence of halogenated agents or succinylcholine, as are children with Duchenne or Becker progressive muscular dystrophy. Very few reports on the anesthetic management of patients with this type of myopathy have been published so far and all except two5,6 report using total intravenous anesthesia.2–4 Carefully titrated intravenous anesthesia to maintain spontaneous ventilation and using either dexmedetomidine, propofol, and/or ketamine could therefore be a safe alternative.Dr. Veyckemans reports a financial relationship with European Journal of Anaesthesiology’s Editorial Board and Pediatric Anesthesia’s Editorial Board.

Anesthesia management for ENT surgery in a child with X‐linked pyruvate kinase deficiency

Pyruvate dehydrogenase complex deficiency (PDCD) is a rare X-linked disorder that affects glucose metabolism. There are several case reports describing the anesthetic management of patients with PDCD. This is the first case report to describe the anesthetic management of a PDCD patient requiring spontaneous ventilation using dexmedetomidine and ketamine.

COVID-19 and pregnancy: Challenges for an anesthesiologist

The anesthetic management of a pregnant patient with coronavirus disease 2019 (COVID-19) presents various unique challenges in terms of patient preparation, intraoperative management, and postoperative concerns, all while taking concurrent measures to prevent the spread of the virus from the patient to the healthcare workers. Anesthetic management of parturient in the era of the COVID-19 pandemic is further complicated by the fact that intubation and extubation are highly aerosol-generating procedures, and are generally advised to be avoided. While various organizations have come up with guidelines on the management of pregnant patients with COVID-19, definitive evidence-based guidelines for the same are lacking. This article aims to consolidate the available literature on the management of pregnant patients with COVID-19, with special impetus on the anesthetic management of these patients.

Anaesthetic Management of Patient with Atrial Septal Defect Posted for Abdominal Hysterectomy

Incidence of Atrial Septal Defect (ASD) in acyanotic congenital heart disease is about 10%. This condition is commonly diagnosed in childhood, although in some cases it is detected in later stages of life. Patients with ASD and Pulmonary Hypertension (PHT) pose a great challenge to anaesthetic management. Authors are presenting a case of general anaesthetic management of 39-year-old lady having ASD with mild to moderate PHT undergoing abdominal hysterectomy, a noncardiac surgery. The patient was induced with Inj. Propofol slow Intravenous (IV) and intubation was achieved with succinylcholine and maintenance was done with atracurium and isoflurane. The primary goal of general anaesthesia was to avoid increase in PHT and to maintain systemic vascular resistance.

Anesthetic Management for Patients With Pheochromocytoma : Series of Three Cases

1.1. Background. This study describes a case series that addresses the complex anesthetic management of adrenalectomy for patients with pheochromocytoma. It is a rare tumor, originating in the chromaffin cells of the adrenal medulla and a catecholamine-secreting agent, whose most common triad of symptoms is headache, sweating and tachycardia. 1.2. Cases: The first case corresponds to a 47-year-old woman with a history of three acute myocardial infarctions with a lesion located unilaterally in the left adrenal gland. After adrenal removal and due to persistence of hypertension, it was necessary to perform a left nephrectomy. The second case describes the conduction of a multimodal and opioid-free anesthesia of a 26-year-old female patient with dilated cardiomyopathy who underwent video laparoscopic right adrenalectomy The first report involves the case of a 14-year-old male patient with von Hippel-Lindau Syndrome, who underwent bilateral open adrenalectomy. All three cases were successfully preoperatively prepared and operated on and were discharged home between the 5th and 6th day compensated and without physiological changes. No genetic study of the three patients was performed. Continuous epidural anesthesia was performed in two patients, without hypotension and need for vasopressor. 1.3. Conclusion: In this pathology, it is essential to emphasize the extreme importance of the multidisciplinary approaches carried out in the three cases. We can affirm affirm that the favorable outcomes were only possible thanks to a great joint effort and judicious for monitoring the Endocrinology and Pediatrics services and for the coordinated relationship between the anesthetic and surgical teams, which were essential for obtaining hospital discharge in the first six days after surgery

Effect of large volume paracentesis performed just prior to transjugular intrahepatic portosystemic shunt on the anesthetic management during the procedure.

Background and Aims:Patients often undergo paracentesis prior to a transjugular intrahepatic portosystemic shunt (TIPS) procedure to improve respiratory mechanics. However, the effect of large volume paracentesis (LVP) on intraoperative hemodynamics and anesthetic management when it is performed immediately before the TIPS procedure is not well documented.Material and Methods:This is a retrospective study in patients undergoing the TIPS procedure between 2004 and 2017. Patients were divided into two groups based on the volume of preoperative paracentesis, namely, small volume paracentesis (SVP), defined as paracentesis volume less than 5 L and LVP, defined as paracentesis volume of at least 5 L. Patients' demographics and perioperative information were collected through chart review. The Wilcoxon signed-rank test, student's t-test, and Fisher's exact test were used when appropriate. Uni- and multivariate linear regression analyses were used to determine the predictive value of paracentesis volume in relation to intraoperative hemodynamics and management of hypotension.Results:Of 49 patients, 19 (39%) received LVP and the remainder received SVP. Baseline demographics were comparable between groups as were intraoperative hypotension and volume of infused crystalloid and colloid. However, vasopressor use (P = 0.02) and packed red blood cell transfusion (P = 0.01) were significantly higher in the large volume group. Paracentesis volume was an independent predictor of the phenylephrine dose (P = 0.0004), and of crystalloid (P = 0.05) and colloid (P = 0.009) volume administered after adjusting for age, sex, body mass index, alcohol use, hemoglobin, and model for end-stage liver disease score.Conclusion:The anesthetic management of patients who undergo LVP just prior to a TIPS procedure may require larger doses of vasopressors and colloids to prevent intraoperative hemodynamic instability during the TIPS placement but may be as well tolerated as SVP.