bda23054
Networker
Could use some help coding this procedure...
DESCRIPTION OF PROCEDURE
The patient was brought to the CT Suite and placed in the prone position, and was noted to be posterior to the bladder, anterior to the rectum. A radiopaque marker was placed over the right butt cheek and it was marked as the planned trajectory into the collection. This area was then anesthetized with 1% Lidocaine as deeply as the spinal needle would go. The spinal needle ---------- was intact after anesthetic was given. Films were taken showing proper trajectory of the planned route for drainage. This was then removed and exchanged for a 7-French pigtail catheter which was then slowly advanced under CT guidance into the peritoneal fluid collection. It was aspirated and noted to have serosanguineous fluid with slight turbidity, but cultures were taken and sent off the table. The abscess was greater than 95% drained with multiple aspirations taken. The catheter was then slowly removed aspirating throughout removal and the patient was allowed to lay on the table for approximately 5 minutes. CT scan was done again and it showed re-accumulation of the fluid and after review with Dr. Vierra, appeared to be somewhat of a darker or lucent Hounsfield unit suggesting that there was some venous bleeding within the wound. The patient was instructed to place pressure by sitting, otherwise tolerated the procedure well and was sent back to his room in stable condition.
DESCRIPTION OF PROCEDURE
The patient was brought to the CT Suite and placed in the prone position, and was noted to be posterior to the bladder, anterior to the rectum. A radiopaque marker was placed over the right butt cheek and it was marked as the planned trajectory into the collection. This area was then anesthetized with 1% Lidocaine as deeply as the spinal needle would go. The spinal needle ---------- was intact after anesthetic was given. Films were taken showing proper trajectory of the planned route for drainage. This was then removed and exchanged for a 7-French pigtail catheter which was then slowly advanced under CT guidance into the peritoneal fluid collection. It was aspirated and noted to have serosanguineous fluid with slight turbidity, but cultures were taken and sent off the table. The abscess was greater than 95% drained with multiple aspirations taken. The catheter was then slowly removed aspirating throughout removal and the patient was allowed to lay on the table for approximately 5 minutes. CT scan was done again and it showed re-accumulation of the fluid and after review with Dr. Vierra, appeared to be somewhat of a darker or lucent Hounsfield unit suggesting that there was some venous bleeding within the wound. The patient was instructed to place pressure by sitting, otherwise tolerated the procedure well and was sent back to his room in stable condition.