Content area
Full Text
Keywords: Tricuspid valve, Tricuspid regurgitation, anesthesia, non-cardiac surgery, valve disease
The tricuspid valve is an atrioventricular valve located between the right atrium and the right ventricle of the heart that prevents the backward flow of blood from the right ventricle to the right atrium during systole.1 Tricuspid regurgitation (TR) occurs when the tricuspid valve is insufficient to prevent this backward flow of blood during systole.2 About 1.6 million people in the United States have moderate to severe TR.3 There are several anesthetic implications for the management of patients with this condition to prevent negative hemodynamic consequences that may occur.2
Case Report
A 55-year-old African American female presented for distal pancreatectomy splenectomy with a Roux-en-Y hepaticojejunostomy for chronic pancreatitis. History and physical assessment revealed a female 160 cm in height and 78 kg with a body mass index of 30.5 kg/m2. Co-existing conditions included essential hypertension, coronary artery disease, trace mitral regurgitation, mild TR, sarcoidosis, sleep apnea, peptic ulcer, gastroparesis, irritable bowel syndrome, gastritis, diverticulosis, pancreatic stricture, hepatitis C, arthritis, type 2 diabetes mellitus, depression, and alcohol use. Home medications included gabapentin, insulin aspart, insulin glargine, and losartan. Allergy profile: aspirin, hydrocodone, acetaminophen, tramadol, nalbuphine, metoclopramide, and ketorolac. Significant laboratory results included: red blood cells 3.56 M/uL, hemoglobin 9.8 g/dL, hematocrit 31.1%, BUN 5 mg/dL, BUN/creatinine mass ratio 8.3, AST 87 U/L, albumin 2.5 g/dL, total bilirubin 1.1 mg/dL, ALT 78 U/L, and glucose 90 mg/dL.
The patient was transferred to the operating room via stretcher and was assisted onto the operating room table. Standard monitors for noninvasive blood pressure, electrocardiogram, and pulse oximetry were applied. The patient was preoxygenated with O2 10 L/min via facemask. Upon achieving an end-tidal O2 of 90 mm Hg, smooth intravenous induction occurred with fentanyl 150 mcg, lidocaine 50 mg, propofol 200 mg, and vecuronium 8 mg. The trachea was intubated with a 7.5 mm cuffed endotracheal tube; placement was verified with direct visualization of the tube through the cords, tube fog, sustained EtCO2, and equal and bilateral breath sounds upon auscultation. Respiration was controlled by a mechanical ventilator and general anesthesia was maintained with isoflurane 1.4% inspired concentration in a mixture of O2 1 L/min and air 1 L/min.
Throughout the...