Salvage TIPSS service provision during the COVID-19 outbreak
Salvage TIPSS in patients with variceal haemorrhage refractory to endoscopic/drug therapy is associated with a 60% 1-year survival (>70% in Child’s Pugh A/B) and is recommended in Child’s Pugh Score ≤13 (1,2). During the COVID-19 outbreak it is anticipated that there will be a shortage of ITU capacity meaning that referral pathways may need to be modified to continue to provide this life-saving treatment. Here we propose the framework for two salvage TIPSS referral pathways for the COVID-19 pandemic: the first when there is reduced ITU capacity but it is still possible to admit to the TIPSS centre ITU; the second where there is no ITU capacity. Please note, the pathways are only applicable to salvage or rescue TIPSS, and do not cover early or pre-emptive TIPSS.
Common to both referral pathways
- Transfer for salvage TIPSS will only be considered if:
- Sufficient clinical information is provided by the referring hospital via an SPR/Consultant (Gastroenterologist/Hepatologist where possible) for scenario 1 or Gastroenterology/Hepatology senior SPR/Consultant for scenario 2.
- There has been at least one endoscopy and attempt to control bleeding.
- An up to date triple phase CT has been reviewed in the TIPSS centre to ensure technical feasibility of TIPSS.
- A Standard Operating Procedure (SOP) is important with buy in from all stakeholders. It is anticipated that the operational logistics of the SOP will vary between centres. The SOP must cover any indemnity arrangements for the referring hospital and TIPSS centre.
Scenario 1 – reduced ITU capacity in TIPSS centre
- Inter-hospital transfer to TIPSS centre ITU for salvage TIPSS and specialist organ support peri-procedure, with a view to early transfer back to the referring hospital.
- Cirrhotic patients with organ failure may not be candidates because of the lower chance of survival, and impact on ITU resources.
Scenario 2 – no ITU capacity in TIPSS centre
- Salvage TIPSS for highly select patients without admission to a TIPSS centre bed. The patient will come directly to the Interventional Radiology Dept. (or equivalent) for a predetermined time slot during normal working hours or between 9am and 5pm at weekends, and return to the referring hospital the same day.
- For stable Child’s Pugh A-B patients with haemostasis only as specified in flow diagram 1. Those with significant inotrope or oxygen requirements will not be suitable.
- Anaesthetic Consultant to Anaesthetic Consultant discussion to facilitate transfer.
- Patients will be accompanied by an Anaesthetist in the ambulance who will stay for the duration of the TIPSS procedure and accompany the patient back to their referring hospital.
- See flow diagram 2 for details.
- There is a risk of unexpected deterioration during transfer or peri-TIPSS requiring admission to the TIPSS centre bed or death; or TIPSS complication manifesting after return to the referring centre. A monitoring committee is recommended.
- Responsibilities of the referring hospital will include provision of accurate information to the TIPSS centre to allow determination of risk-benefit ratio of TIPSS; stability of patients; risk assessment of the likelihood of deterioration during transfer/peri-TIPSS; safety during transfer both to and from TIPSS centre; and ensuring the ITU bed in the referring hospital remains unfilled to enable transfer back the same day. Effective communication of the risk-benefit ratio to the next of kin before the transfer is important.
- Maimone S, Saffioti F, Filomia R, et al. Predictors of re-bleeding and mortality among patients with refractory variceal bleeding undergoing salvage transjugular intrahepatic portosystemic shunt (TIPS). Dig Dis Sci 2019; 64(5):1335-45.
- Tripathi D, Stanley AJ, Hayes PC, Travis S, Armstrong MJ, Tsochatzis EA, Rowe IA, Roslund N, Ireland H, Lomax M, Leithead JA, Mehrzad H, Aspinall RJ, McDonagh J, Patch D. Transjugular intrahepatic portosystemic stent-shunt in the management of portal hypertension. Gut. 2020 Feb 29.
Varices management during COVID-19 outbreak
In light of BSG advice to suspend varices surveillance : HERE, interim guidance on the management of patients with the greatest risk of varices needing treatment (grade I varices and red signs or grade 2–3 varices) is proposed. Surrogate non-invasive markers and clinical stage of liver disease are used to select such patients for commencement of non-selective beta-blockers.
These guidelines are temporary and will be reviewed once BSG revises advice on variceal surveillance during the COVID-19 outbreak. Their validity will depend on the local impact of COVID-19 on endoscopy resource, in particular variceal surveillance and elective band ligation. Where these services have resumed we would advise referring to the BSG guidelines on management of variceal bleeding: HERE
Drafted on behalf of British Society of Gastroenterology and the British Association for the Study of the Liver