DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Chronic congestive heart failure with inadequate venous access for medication.
POSTOPERATIVE DIAGNOSIS: Chronic congestive heart failure with inadequate venous access for medication.
PROCEDURE PERFORMED: Insertion of a MediPort through a percutaneous puncture of the left subclavian vein using C-arm control.
ANESTHESIA: Xylocaine 1% with epinephrine local infiltration augmented by intravenous sedation, which was administered and monitored by the department of anesthesia.
ESTIMATED BLOOD LOSS: 15 mL.
DRAINS: No drains were left in place.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room after the establishment of intravenous sedation. The patient was prepared with Betadine and sterile drapes. Because of his difficulty with breathing, he was kept pretty much in a 30-degree upright sitting position during the preparation and draping. The area beneath the left clavicle was then infiltrated with 1% Xylocaine with epinephrine local anesthesia.
The patient was flattened, and a percutaneous puncture of the subclavian vein was made after three passes. Once the vein was accessed, the guidewire easily passed inside the vein, position being confirmed using the C-arm. The wire was left in place, the needle was removed, and the patient was again sat up to a level of comfort.
A subcutaneous pocket was then made. A curvilinear incision was made and deepened through the skin and subcutaneous tissue to a position just anterior to the pectoral fascia. At this level, a pocket was made of sufficient size to tolerate the MediPort. The catheter was then cut to the appropriate length, using the C-arm to measure this, and the wire was delivered into the pocket wound. The vein dilator with peel-away sheath was passed over the guidewire into the central vein without difficulty, position again being confirmed using the C-arm. The guidewire and introducer were removed, and the catheter was passed through the peel-away sheath without difficulty, position again confirmed with the C-arm.
The peel-away sheath was then removed, and final picture again indicated the catheter was in good position. The port was fixed to the pectoral fascia with three 3-0 Vicryl sutures placed approximately 120 degrees apart from each other. The port was accessed with a Huber needle and easily aspirated blood and was flushed with Hep-Lock solution.
Meticulous hemostasis was achieved in the wound with cautery. The subcutaneous tissue was closed over the port using several interrupted sutures of 3-0 Vicryl and the skin closed using subcuticular suture of 4-0 Vicryl reinforced with Steri-Strips. A sterile dressing was applied, and the patient was sent to the recovery room in satisfactory condition. The patient remained somewhat awake throughout the procedure, indicated no significant pain or discomfort, tolerated the procedure well, and had no increasing shortness of breath.
Sample #2
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Follicular lymphoma.
POSTOPERATIVE DIAGNOSIS: Follicular lymphoma
PROCEDURE PERFORMED: Insertion of left subclavian MediPort catheter with C-arm fluoroscopy.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed in a supine position on the operating room table. Shoulder roll was placed, and the bed was placed in Trendelenburg. Head was turned to the right. The chest and shoulder area and neck were prepped and draped in the usual sterile fashion. Satisfactory intravenous sedation was given. Xylocaine 1% was used to infiltrate the skin beneath the left clavicle, and a standard venipuncture was easily accomplished. A J-wire was threaded. Subcutaneous pocket was then created, and the introducer placed over the J-wire. The center portion of the introducer and the wire were removed. The catheter was passed through the peel-away sheath and the sheath removed. The pocket did not seem to allow for comfortable positioning of the catheter at this point, so we extended it, undermining superiorly and laterally such that the catheter could fit without being coiled or kinked. This was checked by x-ray. It appeared to be in the superior vena cava. There was excellent blood return and ease of irrigation. We then closed the skin with 4-0 PDS as a subcuticular suture. Benzoin and Steri-Strips were applied after a reinforcing suture of 5-0 nylon. There was again excellent flow after the skin was closed. The probe was then flushed with heparin. The patient tolerated the procedure well and, after the dressing was in place, returned to the day surgery area where standard x-ray was ordered.
