PEG Tube Placement Transcription Sample Report

DATE OF PROCEDURE:   MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Inability to eat.

POSTOPERATIVE DIAGNOSIS:  Inability to eat.

PROCEDURE PERFORMED:  Percutaneous endoscopic gastrostomy tube placement.

SURGEON:  John Doe, MD

ANESTHESIA:  IV sedation.

ESTIMATED BLOOD LOSS:  Zero.

TUBES:  20-French Ponsky PEG tube to gravity drainage.

COMPLICATIONS:  None.

 INDICATIONS FOR PROCEDURE:  The patient is a (XX)-year-old female who was recently hospitalized after sustaining a cerebrovascular accident secondary to dysfunction from this. She has been unable to take adequate nutrition by mouth. After a discussion between the family and the neurology service, it was felt that a G-tube would be appropriate to aid in her recovery and to maintain enteral access. She now presents for this procedure. Prior to beginning the procedure, we met with the family and discussed the procedure, complications, risks, benefits, and alternatives.

DESCRIPTION OF PROCEDURE:   On the day of the procedure, the patient was taken to the endoscopy suite. She was placed in 30 degrees head-up position. A time-out was held, and the patient and the planned procedure were confirmed with all those present. She was placed on pulse oximetry and a monitor as well as nasal cannula oxygen. She was sedated with divided doses of fentanyl and Versed. She received a total of 100 mcg of fentanyl and 3 mg of Versed throughout the procedure, which allowed for excellent sedation.

Once an adequate level of sedation was reached, a bite block was placed, and her esophagus was intubated. We then passed the GE junction and entered the stomach. We continued the endoscopy out to the first portion of the duodenum. There were no ulcers present. A retroflexed view of the GE junction revealed a small hiatal hernia. The light from the endoscope was readily visible through the patient's anterior abdominal wall, 2 cm inferior to the left costal margin. This transilluminated quite easily. A single finger impulse was seen briskly through the gastroscope as well. The patient's epigastrium was then prepped with Betadine and draped in a standard sterile fashion. We used a local needle to infiltrate the skin over the proposed PEG site first. This was infiltrated with a wheal of lidocaine. The local needle was then used to enter the stomach. Suction was held on this as it was used to enter the stomach, and we saw no air or succus or stool prior to entering the gastric lumen. Local was then infiltrated as we withdrew the needle along the path of this.

A small stab incision was then made, and the introducer needle was then placed while aspirating into the gastric lumen. Again, no air, succus or stool was noted prior to visualizing the tip of the needle in the gastric lumen. The guidewire was then placed through the introducer needle. This was grasped and was withdrawn through the patient's mouth. This was then attached to a #20 Ponsky PEG tube, which was then pulled in an antegrade manner into the stomach and out the anterior abdominal wall. The esophagus was reentered better with the gastroscope, and this was advanced into the stomach. The tube at 2.5 cm was noted to be not too tight or not too loose but to appear just right without any blanching of the gastric mucosa. It appeared it spun easily as well. It was secured at this depth, then cut to size, and placed to gravity drainage.

The stomach was then desufflated, and the endoscope was then withdrawn along the length of the esophagus. The patient tolerated the procedure well, and with supplemental oxygen, remained with saturations greater than 95% throughout the procedure. There were no complications. The patient was then taken to the recovery room in stable condition.

Sphenopalatine Artery Ligation Transcription Sample Report

DATE OF OPERATION:  MM/DD/YYYY

 PREOPERATIVE DIAGNOSIS:  Recurrent right-sided epistaxis.

POSTOPERATIVE DIAGNOSIS:  Recurrent right-sided epistaxis.

OPERATIONS PERFORMED:
1.  Right sphenopalatine artery ligation.
2.  Right anterior ethmoidectomy.
3.  Left sinus exploration.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General endotracheal anesthesia.

ESTIMATED BLOOD LOSS:  Approximately 150 mL.

SPECIMENS:  None.

OPERATIVE FINDINGS:  There were no remarkable findings in the nasal cavity. The patient did have synechia of the left middle turbinate to the septum. This was most likely due to her previous multiple packings of the sinus cavities.

 INDICATION FOR OPERATION:  The patient is a (XX)-year-old female who has had a history of recurrent right-sided epistaxis requiring multiple packings. The decision was made to take the patient to the operating room for an elective right sphenopalatine artery ligation and anterior ethmoidectomy. The risks and benefits of the procedure were explained to the patient, and the decision was made to proceed.

 DESCRIPTION OF OPERATION:  The patient was taken to the operating room and was placed in the supine position on the operating room table. General face-mask anesthesia was given until a deep plane of anesthesia was obtained. At that point, an endotracheal tube was placed by the anesthesiology service without difficulty. The table was then turned. Afrin-soaked pledgets were placed in the areas bilaterally allowing for decongestion. After approximately 5 minutes, the nasal pledgets were removed, and 4 mL of 1% lidocaine with 1:100,000 epinephrine was injected in the left and right nasal cavities. Injection sites included the septum, middle turbinate, and the superior uncinate. The Afrin-soaked nasal pledgets were placed back into the nares for approximately another five minutes. The patient was then draped. The nasal pledgets were removed. Left nasal cavity exploration was performed. Of note, there was synechia of the septum to the middle turbinate. No other lesions or masses were noted in the inferior, middle, and superior meatus. There was no evidence of superficial vasculature, which may be responsible for bleeding. The septum appeared clean of any local trauma. The nasopharynx was clear, and the left eustachian tube was open.

Attention was then turned towards the right nasal cavity. A 0-degree endoscope was used to visualize the right nasal cavity. Again, there was some mild scarring of the middle turbinate to the lateral nasal wall. A Straightshot microdebrider was used to resect the inferior half of the middle turbinate to allow access to the uncinate, maxillary sinus, the grand lamella and the sphenopalatine artery canal. The uncinate was removed with backbiting forceps. The Straightshot microdebrider was used to complete the uncinectomy.

A large maxillary antrostomy was then performed with the microdebrider. This was begun at the natural os of the maxillary sinus and carried posteriorly to the posterior antral wall. The opening of the antrostomy went to the superior border of the inferior turbinate. The superior border went to the lamina papyracea. A caudal elevator was then used to elevate the mucosa over the region of the sphenopalatine artery. The artery was then identified. A 2 mm Kerrison rongeur was then used to open up the canal of the sphenopalatine artery. This was carried laterally to the posterior antral wall. The bony encasing of the artery was opened to allow a 270-degree view around the artery. The branch point of the posterior nasal artery was identified. A Freer was then used to loosen the superior and inferior tissues from around the artery to allow placement of hemoclips. Approximately three hemoclips were then placed laterally to the branch point of the sphenopalatine artery. The clips were well secured to the artery. Suction Bovie cautery was then used medially to the clips for local cauterization.

Attention was then turned towards the anterior ethmoidectomy. The ethmoid bulla was removed with the microdebrider. The microdebrider was carried superiorly into the anterior ethmoids. The nasofrontal recess was identified. The skull base was identified. There was no evidence of injury to the skull base. There was an area of thin bone. The anterior ethmoid artery was not directly identified, and thus, there was no cautery performed at this location.

The nose was then thoroughly irrigated with copious amounts of warm normal saline. Approximately 5 mL of FloSeal was then injected into the maxillary sinus and the anterior ethmoids for hemostasis and healing. One Doyle splint was used on the right nasal cavity to prevent further synechia. This was sewn in place with #3 Prolene. The nasal cavities were again thoroughly irrigated with warm normal saline and suctioned. There was no evidence of bleeding at the end of the case. The patient was then awoken from general anesthesia, extubated, and sent to the postanesthesia care unit in stable condition.

Tonsillectomy Samples       ENT Operative Samples #1       ENT Operative Samples #2

Implantable Cardioverter Defibrillator Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PROCEDURES PERFORMED:
1.  Implantation of implantable cardioverter defibrillator.
2.  Intraoperative testing of ICD function.
3.  Unsuccessful attempt at placement of left ventricular pacing lead.

INDICATIONS FOR PROCEDURE:
1.  Congestive heart failure, NYHA class II.
2.  Dilated nonischemic cardiomyopathy.
3.  Left bundle branch block.

INDICATION FOR PROCEDURE:  This is a (XX)-year-old woman with a history of nonischemic dilated cardiomyopathy. The patient has class II congestive heart failure, on medical therapy, with persistent left ventricular dysfunction, most recently 30% by echocardiography. She was enrolled in the REVERSE trial, which involved placement of a biventricular ICD and then randomization to either back VVI pacing or active cardiac resynchronization pacing. She presented today for anticipated placement of a biventricular ICD.

DESCRIPTION OF PROCEDURE:  The patient was brought to the electrophysiology laboratory in the fasting state after signing informed consent. The left subclavian area was prepped and draped in the usual sterile fashion. Local anesthesia was achieved along the left deltopectoral groove using a combination of 1% lidocaine and 0.5% Marcaine. An incision was extended along the groove, and using a combination of blunt and Bovie dissection, the incision was extended to the level of the prepectoral fascia. Pulse generator pocket was fashioned inferomedial to the incision using blunt dissection in the prepectoral space. A left axillary vein was visualized with a Site-Rite II ultrasound device, and under direct ultrasonic visualization, the vein was punctured with a Cook needle, and a guidewire was placed. Using similar ultrasound guided technique, two additional guidewires were placed in the left axillary vein using separate needle sticks. Over one guidewire, a 9 French introducer sheath was advanced, and through the sheath, an active fixation ICD lead was advanced with the aid of straight and curved stylets. The lead was initially positioned in the distal right ventricular apex where sensing characteristics were less than optimal. The lead was drawn back slightly to a more proximal location of the right ventricular apex where acceptable sensing and pacing characteristics were found, and the lead was actively fixed in the location of this site. The lead was securely sutured to underlying pectoral muscles. Final lead measurements were favorable, and there was no diaphragmatic stimulation at high output pacing.

Over the second guidewire, a 7 French introducer sheath was advanced, and through this sheath, an active fixation pacing lead was advanced into the right atrium. The lead was initially fixed in an anterior location but dislodged during attempted cannulation of the coronary sinus and ultimately was positioned in a posterior position in the right atrium where sensing and pacing characteristics were favorable. The lead was securely sutured to the underlying pectoral muscle. Final lead measurements were favorable, and there was no diaphragmatic stimulation at high output pacing.

Over the third guidewire, a Medtronic extended hook coronary sinus guiding sheath was advanced, and attempts were then made to cannulate the coronary sinus. The coronary sinus proved to be extremely difficult to cannulate due to a very large right atrium and the position of the coronary sinus well off the floor of the atrium. In addition, there was a proximal valve impeding progress of any of our larger and stiffer catheters. It was possible with some effort to cannulate the coronary sinus with a guidewire and MPA-2 catheter, but insufficient support was afforded by the right atrium to allow passage of the sheath, which would dislodge the catheter and guidewire from the vessel.

Other attempts to place a stiffer catheter, including two different steerable EP catheters and a Medtronic Prevail Steerable catheter, were unsuccessful as we could not cannulate beyond the proximal portion of the coronary sinus and thereby also not allow sufficient support to advance the sheath. Extensive efforts were expended in the effort to place the sheath within the coronary sinus, including empiric efforts to cannulate via the middle cardiac vein or a posterolateral vein with guidewire sheath. When it was unable to advance beyond the coronary sinus ostium, ultimately elected to abandon efforts at placement of a left ventricular lead and thereby exit the patient from the research trial.

The guidewire and sheath were removed, and good hemostasis was obtained with digital pressure. The pulse generator pocket was thoroughly irrigated with antibiotic solution. The right atrium and right ventricular leads were attached to a dual chamber ICD, which was placed into the preformed pocket. The patient was sedated with intravenous Brevital, and ventricular fibrillation was induced with a synchronous countershock. The device properly detected arrhythmia and delivered a 15 joule countershock, which resulted in conversion to sinus rhythm. After 5 minutes, the patient remained sedated, and ventricular fibrillation again was induced in a similar fashion. On this occasion, a 10 joule countershock resulted in conversion to sinus rhythm. The patient emerged from anesthesia without difficulty and remained hemodynamically stable throughout the procedure during defibrillator testing.

 The wound was closed using two layers of deep Vicryl suture. The skin was closed using running 4-0 Monocryl suture. The wound was dressed with Steri-Strips and sterile gauze. The patient left the electrophysiology laboratory in stable condition with proper device function observed on monitor.


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