bda23054
Networker
NAME OF OPERATION
Percutaneous tracheostomy, fluoroscopically placed gastrostomy tube, gastroduodenogram, bronchoscopy.
ANESTHESIA
General.
WOUND CLASS
3 - contaminated.
BLOOD LOSS
5 mL.
SPECIMEN REMOVED
None.
INDICATIONS
This is a 69-year-old male who has been on a ventilator for over 2 weeks. He was extubated for a short time and then reintubated. He also had poor oral intake and was elected to have a "trach" percutaneous endoscopic gastrostomy (PEG) tube.
DESCRIPTION OF OPERATION
The patient was brought to the operative table and placed in the supine position. General anesthesia was induced. First the neck was prepped and draped in the usual sterile fashion. The patient was previously intubated and through this tube a bronchoscopy was performed, visualizing the carina. Just proximal to the carina the endotracheal (ET) tube was pulled back after the skin around the 3rd and 4th tracheal membranes and subcutaneous tissues was anesthetized with 0.5% Marcaine with epinephrine. Using an 18-gauge needle the trachea was cannulated under direct bronchoscopic vision. A guide wire was passed. A skin incision was made and the guide wire was left in place. The needle was then removed. Using the dilating catheters provided in the Blue Rhino kit, the tracheostomy was dilated to the size of an 8-Shiley. This was then all cannulated under direct vision and the tracheostomy was inserted. The balloon was blown, enlarged, and he was noted to have a good 02 saturation and C02 return. So the ET tube was removed. The tracheostomy was then placed and was sutured in 4 quadrants using a 2-0 Prolene and then an umbilical tape was used to secure around the neck.
Attention was then turned to the stomach which too was prepped and draped in the usual sterile fashion. Under fluoroscopic guidance an 18-gauge needle was placed within the stomach lumen and a guide wire was inserted, again under fluoroscopic guidance. There was noted to be direct cannulation of the gastric unit. The guide wire was removed. The incision was enlarged and there were multiple attempts to feed the guide wire and tube past the gastric unit into the duodenum. The 1st portion of the duodenum was cannulated without any difficulty, but then 2nd and beyond could not be cannulated and passed. A gastrogram was performed, a gastroduodenogram was performed showing contrast within the duodenum and peristalsing distally. Despite this, after multiple guide wire attempts beyond the 1st portion of the duodenum could not be cannulated. At this point it was decided to just leave a gastrostomy tube in. The guide wire was then cannulated up to a 14 French and then the gastrostomy was placed under direct vision. It was then pigtailed within the gastric unit and retracted. It was secured with 2-0 Prolene. A dressing was applied. A gastrogram at the conclusion of the procedure showed contrast within the fundus of the stomach. The patient was wheeled back to the ICU in stable condition.
Percutaneous tracheostomy, fluoroscopically placed gastrostomy tube, gastroduodenogram, bronchoscopy.
ANESTHESIA
General.
WOUND CLASS
3 - contaminated.
BLOOD LOSS
5 mL.
SPECIMEN REMOVED
None.
INDICATIONS
This is a 69-year-old male who has been on a ventilator for over 2 weeks. He was extubated for a short time and then reintubated. He also had poor oral intake and was elected to have a "trach" percutaneous endoscopic gastrostomy (PEG) tube.
DESCRIPTION OF OPERATION
The patient was brought to the operative table and placed in the supine position. General anesthesia was induced. First the neck was prepped and draped in the usual sterile fashion. The patient was previously intubated and through this tube a bronchoscopy was performed, visualizing the carina. Just proximal to the carina the endotracheal (ET) tube was pulled back after the skin around the 3rd and 4th tracheal membranes and subcutaneous tissues was anesthetized with 0.5% Marcaine with epinephrine. Using an 18-gauge needle the trachea was cannulated under direct bronchoscopic vision. A guide wire was passed. A skin incision was made and the guide wire was left in place. The needle was then removed. Using the dilating catheters provided in the Blue Rhino kit, the tracheostomy was dilated to the size of an 8-Shiley. This was then all cannulated under direct vision and the tracheostomy was inserted. The balloon was blown, enlarged, and he was noted to have a good 02 saturation and C02 return. So the ET tube was removed. The tracheostomy was then placed and was sutured in 4 quadrants using a 2-0 Prolene and then an umbilical tape was used to secure around the neck.
Attention was then turned to the stomach which too was prepped and draped in the usual sterile fashion. Under fluoroscopic guidance an 18-gauge needle was placed within the stomach lumen and a guide wire was inserted, again under fluoroscopic guidance. There was noted to be direct cannulation of the gastric unit. The guide wire was removed. The incision was enlarged and there were multiple attempts to feed the guide wire and tube past the gastric unit into the duodenum. The 1st portion of the duodenum was cannulated without any difficulty, but then 2nd and beyond could not be cannulated and passed. A gastrogram was performed, a gastroduodenogram was performed showing contrast within the duodenum and peristalsing distally. Despite this, after multiple guide wire attempts beyond the 1st portion of the duodenum could not be cannulated. At this point it was decided to just leave a gastrostomy tube in. The guide wire was then cannulated up to a 14 French and then the gastrostomy was placed under direct vision. It was then pigtailed within the gastric unit and retracted. It was secured with 2-0 Prolene. A dressing was applied. A gastrogram at the conclusion of the procedure showed contrast within the fundus of the stomach. The patient was wheeled back to the ICU in stable condition.