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Percutaneous Tracheostomy Tube Insertion Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Respiratory failure.

POSTOPERATIVE DIAGNOSIS:  Respiratory failure.

OPERATION PERFORMED:  Percutaneous tracheostomy tube insertion with bronchoscopy guidance.

SURGEON:  John Doe, MD

ANESTHESIA:  IV sedation with 1% lidocaine with epinephrine local anesthetic.

ESTIMATED BLOOD LOSS:  Minimal.

SPECIMENS:  None.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old woman being managed in the medical intensive care unit, had respiratory failure requiring mechanical ventilator support. General Surgery was consulted for planned percutaneous tracheostomy for prolonged mechanical ventilation requirements. After risks and benefits of the procedure were explained in detail to the patient and the patient's family, informed consent was obtained.

OPERATIVE FINDINGS:  Portable chest x-ray post tracheostomy tube insertion revealed good placement without pneumothorax or effusions.

DESCRIPTION OF OPERATION:  Following induction of general anesthesia, the patient was prepped and draped in the standard sterile surgical fashion. Local anesthetic was then applied to the area, approximately 2 fingerbreadths above the sternal notch. Gentle IV sedation with Versed and fentanyl was provided. A 1 cm incision was made transversely at the area of the local anesthetic placement. Using the hemostat, the subcutaneous tissues were bluntly dissected down to the trachea. A bronchoscope was then inserted from the ET tube and the ET tube was repositioned so that the bronchoscope revealed clear view of the trachea access. A needle catheter was then inserted via the neck incision and the bronchoscope confirmed placement of the needle and catheter. The needle was removed and the catheter advanced to short distance and the wire was passed easily under confirmation of the bronchoscopy. Sequential dilation was then performed using the percutaneous tracheostomy kit and a #8 Shiley trach was inserted without difficulty. The balloon was inflated and the ventilator hooked up to the tracheostomy tube. A bronchoscope was then reinserted through the tracheostomy and some secretions were removed and there was minimal blood suctioned as well. The tracheostomy was secured with 2-0 nylon. Portable chest x-ray was ordered stat., which revealed good placement of the tracheostomy tube. The patient tolerated the procedure well and there were no complications during the procedure.