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Tesio Catheter Insertion Sample Transcription Medical Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Renal failure with need for long-term dialysis access.

POSTOPERATIVE DIAGNOSIS:
Renal failure with need for long-term dialysis access.

OPERATION PERFORMED:
Placement of Tesio permanent catheter via right internal jugular vein.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:
Local with monitored anesthesia care.

COMPLICATIONS:
None.

INDICATIONS FOR OPERATION:
The patient is a (XX)-year-old patient who has renal insufficiency. This may be secondary to drug overdose. The patient will need to have a dialysis catheter placed. The patient does not yet know whether her need for dialysis will be permanent. I have recommended to her that she have a Tesio catheter placed. The risks of bleeding, infection, vascular injury, pneumothorax, and thrombosis were all carefully discussed and the patient's questions were answered.  The patient appeared to understand and agreed to proceed with the aforementioned procedure.

DESCRIPTION OF PROCEDURE AND FINDINGS:
The patient had a previous right internal jugular vein catheter, which was removed about 3 days ago. The area appeared clean. There were good jugular venous pulses noted both on the left and right side. We prepped both the right and left sides, neck, and chest and draped with sterile towels and drapes. The head was turned left, and then the patient was placed in Trendelenburg.

Using a 22 gauge needle, the skin posterior to the sternocleidomastoid muscle at the base of the neck was infiltrated. The needle was advanced towards the internal jugular vein. The intermediate soft tissues were anesthetized, and the position of the vein was noted. Successful venipuncture was then accomplished with 2 single Cook needles and 2 guidewires were passed into it. The catheter exit sites were then selected on the chest wall. The tunnels were anesthetized, and the catheter was passed through the tunnels, flushed with heparinized saline and then locked. The vein dilator peel-away sheath was then passed over each of the guidewires into the central circulation.

The dilators and wires were removed. The sheath was then immediately clamped to prevent bleeding aspiration and each catheter was then passed through its respective sheath into the central circulation while the sheath was peeled away.

Using C-arm fluoroscopy, the position of the catheters was adjusted so that the venous catheter was approximately 3 cm distal to the arterial catheter tip in the mid atrium to supine from Trendelenburg position. It was easy to aspirate and infuse both catheters. Both catheters were then fully flushed with heparinized saline and locked. The venipuncture site was closed with 4-0 Vicryl suture, and the catheter exit site closed with 4-0 Vicryl suture. Sterile bandages were applied.

The patient tolerated the procedure without complications. The final sponge, needle, and instrument counts were correct. The patient left the operating room in satisfactory condition.