DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Respiratory failure.
2. Possible pneumonia.
PROCEDURE PERFORMED: Bronchoscopy with bronchoalveolar lavage.
SURGEON: John Doe, MD
ANESTHESIA: IV sedation.
ESTIMATED BLOOD LOSS: Zero.
SPECIMENS: Left and right bronchoalveolar lavage for microbiology.
COMPLICATIONS: None.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old gentleman who has been admitted to the neurosurgical ICU with myasthenia gravis. Despite plasmapheresis and ongoing ICU care, he has continued with respiratory failure and his NIFs have remained low. The patient thus presents for tracheostomy. He has also been diagnosed with a possible pneumonia by the neurosurgical ICU team with the presence of left lower lobe infiltrate. Thus, he also presents for bronchoalveolar lavage at the same time.
DESCRIPTION OF PROCEDURE: On the date of the procedure, the patient remained in the neurosurgical intensive care unit. He underwent bronchoscopic-assisted percutaneous tracheostomy. Once this procedure had been successfully completed, the bronchoscope was inserted through the patient’s newly placed #8 Shiley tracheostomy tube. This was advanced to the carina. We surveyed the left side first. Then, the bronchoscope was advanced into the left lower lobe and was wedged in the left lower lobe segmental orifices, segment 9. An alveolar lavage specimen was taken. It was suctioned and collected in a Lukens trap and was then passed off the table and sent to Microbiology. We then advanced the bronchoscope into the right lower lobe segmental bronchi. The bronchoscope was wedged, and an additional alveolar lavage was taken. The specimen was suctioned and was collected in a Lukens trap and was passed off the table to send to Microbiology. We then surveyed the bronchi. There was a small amount of blood that was remaining from the tracheostomy. This was suctioned free and removed. It did not reaccumulate. We surveyed the right upper lobe, right middle lobe, and right lower lobe segmental orifices, and each of these was seen to be free of mucous plugs. We then surveyed the left upper lobe, left lower lobe, and lingula. There was a moderate amount of secretions present in the left lower lobe. These were suctioned free and removed. These did not recur. There was no significant mucous plugging seen in the left lower lobe. There was general, what appeared to be, edema of the airways, but there did not appear to be severe tracheobronchitis. We did not see any endobronchial lesions. The bronchoscope was then removed, and the procedure was terminated. The patient tolerated the procedure well and remained in critical condition in the neurosurgical intensive care unit at the termination of the case.
