DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Traumatic brain injury, status post motor vehicle collision.
2. Anticipated prolonged need for mechanical ventilatory support.
POSTOPERATIVE DIAGNOSES:
1. Traumatic brain injury, status post motor vehicle collision.
2. Anticipated prolonged need for mechanical ventilatory support.
PROCEDURE PERFORMED: Percutaneous tracheostomy.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal anesthesia plus local infiltration with 0.5% lidocaine with epinephrine.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old male who was involved in a motor vehicle collision with subsequent traumatic brain injury. He has had prolonged ventilator support and likely will require future prolonged ventilatory support. Need for formal tracheostomy is indicated for this reason. The risks, benefits and alternatives were described to the patient’s family, and they were willing to proceed.
DESCRIPTION OF PROCEDURE: This procedure was performed at the bedside in the surgical intensive care unit. A surgical time-out was undertaken to verify the patient’s procedure and site. He was adequately sedated with vecuronium 10 mg as well as intermittent fentanyl and propofol, which he had already been receiving. The patient’s Miami-J collar was removed, and the patient’s neck was mildly extended as deemed safe by Neurosurgery.
The anterior neck was prepped with Betadine solution and draped in a sterile fashion. Attention was directed at the midline trachea, where a longitudinal skin incision was made in the midline, just inferior to the cricothyroid membrane. The cricothyroid membrane was palpated and the tracheal rings were noted. Approximately the third tracheal interspace was identified. This was then accessed with a needle and sheath and a Seldinger technique was employed. Identification of the location of the tracheostomy site was confirmed with fiberoptic bronchoscopy. Once endotracheal position of the sheath and guidewire were confirmed, the tracheostomy site was serially dilated. Next, a cuffed Shiley tracheostomy tube was inserted over a tracheal dilator, over the guidewire, into the trachea. The Shiley cuff was inflated and the dilator and guidewire were removed. The inner cannula was introduced and the ventilator was connected to the newly formed tracheostomy. The previous orotracheal tube was removed, and the patient was ventilated adequately through the percutaneous tracheostomy.
The tracheostomy itself was secured with 2-0 silk x4 at the skin. Also, a Velcro neck tie was also employed to help secure the tracheostomy tube. No air leak was noted. Tidal volumes were appropriate for the ventilator settings. The patient tolerated the procedure well. All instrument and needle counts were correct at the end of the case.
