Procedure Note

CVC insertion

Procedure: CVC___ Double lumen ___ placement
Indication: Hemodynamic monitoring ___ Intravenous access ___ Stem Cell Harvest ___

The patient was placed in a dependent position appropriate for central line placement based on the vein to be cannulated. The patient’s ___right/left neck was prepped and draped in sterile fashion. 1% Lidocaine was used to anesthetize the surrounding skin area. A triple lumen 9-French Cordis ___ catheter was introduced into the the internal jugular vein ___ common femoral vein ___ using the Seldinger technique and under ultrasound guidance. The catheter was threaded smoothly over the guide wire and appropriate blood return was obtained. Each lumen of the catheter was evacuated of air and flushed with sterile saline. The catheter was then sutured in place to the skin and a sterile dressing applied. Perfusion to the extremity distal to the point of catheter insertion was checked and found to be adequate.

Estimated Blood Loss: 3___ cc
The patient tolerated the procedure well and there were no complications.
Follow up CXR showed catheter in place

Thoracocentesis

Procedure: Thoraocentesis

Consent for operation or procedure: Risks and benefits discussed with patient and consent obtained

Anesthesia: 3 cc of Lidocaine

Patient positioned sitting. Pleural examined with ultrasound for appropriate site placement. 10th intercostal space was chosen. Site marked and prepared. Site draped with sterile dressing. Wheel of lidocaine placed. Lidocaine then introduced deep to the pleural space. Thoracocentesis needle was placed through the skin into the pleural cavity. The needle was withdrawn and the site cleaned and bandaged with gauze and tape. Samples were sent to the lab for analysis.

Amount: ___ cc

Estimated Blood Loss: minimal

Complications: The patient tolerated the procedure well without complications.

Paracentesis

Procedure: Abdominal Paracentesis
Consent for operation or procedure: Risks and benefits discussed with patient and consent obtained

Anesthesia: 3 cc of Lidocaine

Patient positioned supine. Abdomen examined with ultrasound for appropriate site placement. ___ was chosen. Site marked and prepared. Site draped with sterile dressing. Wheel of lidocaine placed. Lidocaine then introduced deep to the peritoneum. Paracentesis needle was placed through the skin into the abdominal cavity. The needle was withdrawn and the site cleaned and bandaged with gauze and tape. Samples were sent to the lab for analysis.

Amount: ___ cc

Estimated Blood Loss: minimal

Complications: The patient tolerated the procedure well without complications.

Intubation

Time: ___
Indication: Respiratory Distress
Resident: ___
Attending: Dr.___

A time-out was completed verifying correct patient, procedure, site, positioning, and special equipment if applicable. The patient was placed in a flat position. Sedation was obtained using Midazolam 15mg (0.2mg/kg, if CrCl<10, half dose___). Pre-oxygenation via ___ could maintain SpO2 around ___%.

The Glidescope___ MAC3___ blade was used and inserted into the oropharynx at which time there was a Grade 1 view of the vocal cords. A ___ 7.5-french endotracheal tube was inserted and visualized going through the vocal cords. The stylette was removed. End-tidal CO2 was above ___ 30mmHg. Breath sounds were heard in both lung fields equally. The endotracheal tube was placed at ___23 cm, measured at the lip.

A portable chest x-ray AP view showed endotrachealtube was in place above carina.

Ventilator Setting:
FiO2: ___%; Mode: ___; RR ___/min; PEEP ___mmHG.

The follow up ABG:

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Lumbar Puncture

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INDICATION: ___

PROCEDURE OPERATOR: ___

ATTENDING PHYSICIAN: ___

CONSENT:
Consent was obtained from patient prior to the procedure. Indications, risks, and benefits were explained at length.

PROCEDURE SUMMARY:
A time-out was performed. My hands were washed immediately prior to the procedure. I wore a surgical cap, sterile gown and sterile gloves throughout the procedure. The patient was placed in the right lateral position with help from the nursing staff. The area was cleansed and draped in usual sterile fashion using betadine scrub. Anesthesia was achieved with 1% lidocaine 3 cc. A 20-gauge 3.5-inch spinal needle was placed in the L___ lumbar interspace.

RESULT:
On the first attempt, clear colored cerebral spinal fluid was obtained. The opening pressure was ___cm H20. CSF was collected into ___ tubes. These were sent for the usual tests, including 1 tube to be held for further analysis if needed. The post procedure opening pressure was ___ cm H20. A sterile bandaid was placed over the puncture site. The patient had no immediate complications and tolerated the procedure well. Estimated blood loss was ___.

Death

Called by nurse to pronounce death. On exam, no heart sounds or breath sounds was noted after 1 minute of auscultation. Pupils were fixed and dilated without pupillary light reflex. Pt had no reaction to pain stimulus. Patient was pronounced dead on ___ / ___ / ___ at ___ : ___ , and surrounded by the beloved family. Attending Dr.___ was notified. Family was present and condolences were offered.