DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Respiratory failure and pneumonia.
POSTOPERATIVE DIAGNOSIS: Respiratory failure and pneumonia.
PROCEDURES PERFORMED:
1. Tracheostomy.
2. Bronchoscopy assistance for tracheostomy.
SURGEON: John Doe, MD
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old female. She is status post a Whipple. The patient has subsequently developed respiratory failure and had been monitored in the ICU for a period of several days. Within the last 24 hours, the patient has had a bronchoscopy revealing a pneumonia. The patient has remained on high requirements of ventilatory support, including elevated positive end-expiratory pressure. A discussion was undertaken in the presence of the patient, who is alert, and the patient’s significant other. The benefits and risks of the procedure were explained. Both parties seemed to agree that they thought that this would be beneficial, and informed consent was signed by the patient’s significant other.
DESCRIPTION OF OPERATION: Prior to the procedure, informed consent was obtained as described above. The patient was placed in a supine position. Full ventilatory support with a rate of 16 and FiO2 of 100% was initiated, and subsequently, a roll was placed under the patient’s shoulders. This was done after the patient was given an initial 2 mg of Versed and 50 of fentanyl. Total medications for the procedure will be 4 mg of Versed, 100 mg of fentanyl, and 10 mg of vecuronium. After the initial medication was administered, the patient’s vital signs were monitored for a period of time as she was prepped and draped in a sterile fashion. At this point, we administered 5 mg of vecuronium. Again, the patient’s vital signs were monitored and felt to be satisfactory. At this point, an initial 5 mg of vecuronium was administered. Having been prepped and draped in a sterile fashion, we identified the anatomic landmarks, including the sternal notch, the thyroid cartilage, and the cricoid cartilage.
A small incision was made in the midline above the notch, and dissection was carried down slightly to the level of the trachea. We were able to feel the edge of the cricoid as well as the tracheal rings. The bronchoscope was inserted through the endotracheal tube, and the tube was withdrawn slightly to about 18 cm at the lip. At this point, we placed the needle through the trachea and advanced the wire. The wire could be readily observed with the bronchoscope. At this point, we passed the serial dilators in the standard fashion for the Blue Rhino tracheostomy kit, and then, subsequently, a #8 Shiley was placed within the patient’s trachea and the balloon inflated. We performed bronchoscopy through this, identified that the tracheostomy was in fact in the patient’s trachea and suitably above the carina. At this point, we withdrew the bronchoscope and reconnected the patient to the ventilator. The previous endotracheal tube was completely removed from the patient’s mouth, and the patient’s oropharynx was suctioned.
The tracheostomy tube was secured in a standard fashion with four corner ligation using a silk suture and trach strap was applied. The patient tolerated the procedure. There was one identified venous bleeder on the skin edge, which upon making our initial incision we did suture ligate with a figure-of-eight suture. At the conclusion of the procedure, the patient will be returned to a more upright position, and a stat portable chest x-ray will be ordered and reviewed.
