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Percutaneous Tracheostomy Medical Transcription Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Spinal cord injury with resultant central cord syndrome and pneumonia.

POSTOPERATIVE DIAGNOSIS:
Spinal cord injury with resultant central cord syndrome and pneumonia.

PROCEDURE PERFORMED:
Percutaneous tracheostomy.

SURGEON:  John Doe, MD

ANESTHESIA:  General anesthesia with local infiltration.

ESTIMATED BLOOD LOSS:  Minimal.

COMPLICATIONS:  None.

OPERATIVE FINDINGS:  Midline percutaneous tracheostomy was performed without complication. No evidence of air leak from the ventilator. Location was confirmed with flexible bronchoscopy.

INDICATIONS FOR PROCEDURE:  The patient is a (XX)-year-old male, status post motor vehicle collision, in which he sustained a cervical spine injury. He has been in the intensive care unit requiring ventilator support for approximately three weeks. He failed extubation and required reintubation. For this reason, it is felt that he will require prolonged ventilator support and therefore tracheostomy is indicated. The risks, benefits and alternatives were explained to the patient's family, and consent was obtained to proceed with the procedure.

DESCRIPTION OF PROCEDURE:  The procedure was initiated at the bed side. A time-out was performed, verifying the patient, surgical site and procedure. The patient received antibiotics prior to the procedure. His neck was positioned with a towel roll behind his shoulder blades. This allowed for mild extension of his cervical neck. The neck was then prepped with Betadine solution. The area was then draped in a sterile fashion.

Attention was directed at the midline trachea, where the cricothyroid membrane was palpated. Approximately two fingerbreadths above the sternal notch, a midline vertical incision was created with a scalpel after local infiltration with 0.5% lidocaine with epinephrine. Of note, the patient was adequately sedated and paralyzed with vecuronium, propofol and fentanyl.

Next, dissection was carried forth down to the subcutaneous tissue in a careful blunt manner with hemostats. The anterior trachea was visualized with the tracheal rings. Approximately the second tracheal ring was identified. Then, using Seldinger technique and a percutaneous tracheostomy set, the trachea was entered with a 14 gauge needle with an overlying sheath. This was all confirmed under direct visualization of a fiberoptic flexible bronchoscope. Entrance into the trachea was identified through the third tracheal ring interspace.

Following this, a guidewire was inserted. The needle was removed, leaving the sheath and the guidewire intact. Next, the sheath was removed and a small dilator was inserted. The tracheal rings were then serially dilated. A #8 Shiley was then opened. The balloon was checked. It was placed over a tracheal dilator, which was then advanced over the guidewire and through the previously dilated tract. The Shiley tracheostomy tube was noted to pass in the trachea with little resistance.

The guidewire and dilator tubes were removed from the trachea. An inner cannula was placed through the tracheostomy tube. The tracheostomy was then secured at the anterior neck with 2-0 silk x4. The oral endotracheal tube was removed and the ventilator was attached to the newly placed tracheostomy tube. Adequate tidal volumes were noted. The cuff was inflated and no evidence of air leak was noted. No evidence of bleeding was noted. At this point, the procedure was concluded and the patient tolerated the procedure well.