Tracheostomy and Bronchoscopy Operative Reports

Jan 13, 2021 | Uncategorized

Tracheostomy and Bronchoscopy Operative ReportsThe reports below describe a patient undergoing a tracheostomy operation and a bronchoscopy operation. Both procedures have been documented in detail, describing the step-by-step process used by doctors to carry out each surgery. Keep reading for more on how each procedure was performed.nnDo you have a complicated surgery case that needs help with coding? Welter Healthcare Partners would love to help! Please upload the operative note by clicking on the link below. Remember to remove ALL patient protected health information and organization identifiers. Welter Healthcare Partners will not use any medical records submitted in which PHI is not removed and protected. nn– Click Here to Submit Redacted Surgery Case Study –nn nnOPERATIVE REPORT (1 of 2)nn12/XX/20nnPREOPERATIVE DIAGNOSIS: Ventilator Dependence, Metabolic EncephalopathynPOSTOPERATIVE DIAGNOSES: SamenPROCEDURES: Tracheostomy with 8-French Shiley tracheostomy under moderate sedation.nSURGEON: M. K., D.O.nASSISTANT: W. F., DO.nANESTHESIA: General. (the patient is already intubated and sedated on precedex with fentanyl. 5mg of versed was administered)nBLOOD LOSS: Less than 1 mL.nBLOOD REPLACEMENT: None.nPOSTOPERATIVE CONDITION: Stable.nnDESCRIPTION OF PROCEDURE:nAfter all risks and benefits were explained and discussed with the patient’s husband including but not limited to blood loss, infection, as well as injury to the tracheal structures and intraabdominal perforation. All questions were answered. Written informed consent was obtained and is in the chart for review. The patient is already intubated in the ICU, she is on precedex and fentanyl. 5mg of versed is given. A time-out was completed. Neck was prepped and draped in a sterile fashion. Sterile technique was utilized throughout the procedure with gown, gloves, face mask, and hat. The abdomen was also prepped in a similar fashion. Local anesthetic was provided. 2 cm cephalad to the suprasternal notch, a transverse incision was created, and the trachea was palpated. The assistant is doing the bronchoscopy and the endotracheal tube is full back by the assistant until the finder needle was fully visualized by bronchoscopy. The wires passed into the trachea, the needle is removed, the dilator is placed over the wire and then removed, the larger dilators placed over the wire and then removed. Finally, the final dilator inside of the tracheostomy tube is passed until the balloon is within the trachea, the dilator is removed and the tracheostomy tube is left in place. It is attached to the ventilator and bronchoscopy confirms is physician above the level of the carina. The endotracheal tube was removednfrom the mouth. The tracheostomy is sutured in place. She tolerated the procedure well.nn nn nnTracheostomy and Bronchoscopy Operative ReportsOPERATIVE REPORT (2 of 2)nnPREOPERATIVE DIAGNOSIS: Respiratory FailurenPOSTOPERATIVE DIAGNOSES: SamenPROCEDURES: BronchoscopynSURGEON: William Fulton, DO, FACOSnASSISTANT: Majid Kianmajd, DOnFINDINGS: Intact trachea with minimal mucous secretionsnSPECIMEN(S) REMOVED: NonenBLOOD LOSS: NonenANESTHESIA:  General Endotracheal nANESTHESIOLOGIST(S): NonenCULTURES: NonenDRAINS: NonenBLOOD REPLACEMENT: NonenPOSTOPERATIVE CONDITION: StablenCOMPLICATIONS: Nonenn nnDESCRIPTION OF PROCEDURE:nnPatient was prepared for procedure of bedside bronchoscopy to use concurrently with placement of a tracheostomy. The bronchoscope was advanced into the ET and the trachea was directly visualized. Minimal saline irrigation was utilized to assist with visualization. The carina was visualized and the tracheobronchial tree grossly appeared intact with polyps or lesions or bleeding noted. During the bronchoscopy placement of the needle and guidewire were visualized for the procedure of percutaneous tracheostomy. Ventilation and O2 saturation were monitored through the procedure and patient remained stable throughout. The tracheostomy was visualized in placed with the bronchoscope also advanced directly into the tracheostomy as well. The bronchoscope was withdrawn without difficulty. Patient tolerated procedure well.n