trinalankford
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I don't do many, so I'm a bit confused :/
The patient had a modified radical right mastectomy and simple left mastectomy. She also had a line placed. I have 19307 RT and 19303 LT 59 as the mastectomies, but my doc and I are "agreeing to disagree" over the cath:
After completing the mastectomies, the patient was placed in a 15-degree Trendelenburg position. I elected to approach the left subclavian vein which was entered with a 22-gauge 1.5-inch long needle. The large bore needle was then inserted. A guidewire was inserted but could not be advanced effectively, so it was withdrawn. This approach was made several times before I abandoned it.
I then went to a rather large visible external jugular vein that was entered through a short cutdown incision and circled by a right angle clamp, and then a 2-0 silk suture was utilized to tie off the vein distally. A vessel loop was placed to retract and compress the vein as it was then entered with a #11 scalpel blade. The guidewire was then introduced, but I was not successful in feeding it beyond what appeared to be a valvular system near the clavicle. After several attempts at this, I abandoned it, simply tied off the vein and closed the wound with subcuticular 4-0 Vicryl.
I then attempted to enter the left internal jugular system. The guidewire fed well, but whenever we utilized the portable x-ray unit to confirm placement, the guidewire was spiraling around in the vein and being deflected cephalad. Multiple attempts were made to withdraw the guidewire and deflect it inferiorly, and after several attempts I was able to deflect the guidewire down toward the right atrium.
The dilator and sheath were then placed over the guidewire, and we fed the catheter into the sheath. X-rays were taken, demonstrating that the soft pliable catheter did not follow the path of the guidewire, we injected the catheter with Hypaque, and we had entered a rather large vein but the catheter was coiled in the vein. I was unable to straighten out this catheter using the techniques I am aware of, so I simply removed the dilator and sheath and compressed the internal jugular vein perforation site. In fact, it should be noted that I asked Dr. S to place the guidewire initially, and he was kind enouigh to do so.
We then turned to the right side and Dr. S placed the guidewire which I then utilized to place the dilator sheath and ultimately the catheter tubing effectively. A pocket was started on the right pectoral region, but then I elected to abandon that site since there was the possibility of this patient receiving postop radiation.
I tunneled the catheter across the midline to a secondary site on the left pectoral region. The catheter system was connected to the porta-chamber. It irrigated and flushed and we could draw blood effectively to prove patency. The chamber was then sutured to the subcutaneous tissues with 4-0 Prolene. The wounds were then all closed with subcutaneous 3-0 Vicryl and running subcuticular 4-0 Vicryl. The smaller incisions were simply steri-stripped. OpSite dressing was applied to the port-a-catheter insertion site. A sterile dressing of Collodion and strips of Telfa were utilized, as stated, to cover the mastectomy sites. Total estimated blood loss was 300-350 mL. A c-arm was then utlized to scan the placement of the tubing, and it appears to be in good position at the end of this procedure.
**If you wouldn't mind helping me with the code for the PAC, I would be forever grateful!
The patient had a modified radical right mastectomy and simple left mastectomy. She also had a line placed. I have 19307 RT and 19303 LT 59 as the mastectomies, but my doc and I are "agreeing to disagree" over the cath:
After completing the mastectomies, the patient was placed in a 15-degree Trendelenburg position. I elected to approach the left subclavian vein which was entered with a 22-gauge 1.5-inch long needle. The large bore needle was then inserted. A guidewire was inserted but could not be advanced effectively, so it was withdrawn. This approach was made several times before I abandoned it.
I then went to a rather large visible external jugular vein that was entered through a short cutdown incision and circled by a right angle clamp, and then a 2-0 silk suture was utilized to tie off the vein distally. A vessel loop was placed to retract and compress the vein as it was then entered with a #11 scalpel blade. The guidewire was then introduced, but I was not successful in feeding it beyond what appeared to be a valvular system near the clavicle. After several attempts at this, I abandoned it, simply tied off the vein and closed the wound with subcuticular 4-0 Vicryl.
I then attempted to enter the left internal jugular system. The guidewire fed well, but whenever we utilized the portable x-ray unit to confirm placement, the guidewire was spiraling around in the vein and being deflected cephalad. Multiple attempts were made to withdraw the guidewire and deflect it inferiorly, and after several attempts I was able to deflect the guidewire down toward the right atrium.
The dilator and sheath were then placed over the guidewire, and we fed the catheter into the sheath. X-rays were taken, demonstrating that the soft pliable catheter did not follow the path of the guidewire, we injected the catheter with Hypaque, and we had entered a rather large vein but the catheter was coiled in the vein. I was unable to straighten out this catheter using the techniques I am aware of, so I simply removed the dilator and sheath and compressed the internal jugular vein perforation site. In fact, it should be noted that I asked Dr. S to place the guidewire initially, and he was kind enouigh to do so.
We then turned to the right side and Dr. S placed the guidewire which I then utilized to place the dilator sheath and ultimately the catheter tubing effectively. A pocket was started on the right pectoral region, but then I elected to abandon that site since there was the possibility of this patient receiving postop radiation.
I tunneled the catheter across the midline to a secondary site on the left pectoral region. The catheter system was connected to the porta-chamber. It irrigated and flushed and we could draw blood effectively to prove patency. The chamber was then sutured to the subcutaneous tissues with 4-0 Prolene. The wounds were then all closed with subcutaneous 3-0 Vicryl and running subcuticular 4-0 Vicryl. The smaller incisions were simply steri-stripped. OpSite dressing was applied to the port-a-catheter insertion site. A sterile dressing of Collodion and strips of Telfa were utilized, as stated, to cover the mastectomy sites. Total estimated blood loss was 300-350 mL. A c-arm was then utlized to scan the placement of the tubing, and it appears to be in good position at the end of this procedure.
**If you wouldn't mind helping me with the code for the PAC, I would be forever grateful!
Doc saw the total charges for this patient and flipped, and that was without the modifier for the extra degree of difficulty