PREOPERATIVE DIAGNOSIS: Respiratory failure, intracranial hemorrhage.
POSTOPERATIVE DIAGNOSIS: Respiratory failure, intracranial hemorrhage.
PROCEDURE PERFORMED: Tracheostomy.
ANESTHESIA TYPE: General.
ESTIMATED BLOOD LOSS: 10 mL
HISTORY: This is a 58-year-old female who presented to the trauma center several days ago
with isolated head trauma. She has been on the ventilator and unable to support her ventilation
without a mechanical ventilator. She is thus unable to be weaned from a ventilator and thus in
need of a tracheostomy. She also is unable to swallow and thus will need a PEG placement.
Due to the fact that there is no endoscope functioning at this time we have decided to do the
PEG at a later time. The risks and benefits were explained to the family and they consented to
the procedure.
PROCEDURE: The patient was brought to the operating room and had SCDs placed prior to
induction of anesthesia. She had preoperative antibiotics given prior to any incision. She had
come down with the ET-tube and this was hooked up to the ventilator by the anesthesia staff.
She was prepped and draped in normal sterile fashion and the anatomic landmarks of the
thyroid cartilage and sternal notch were identified, as well as the cricothyroid membrane. About
1 fingerbreadth below the cricothyroid membrane, incision was made down to the level of the
subcu tissue. Bovie electrocautery was used to dissect down through the platysma. Any venous
bleeders were identified and tied off with silk suture. Right angles were used and a suture
ligature was placed with silk suture around the end of the isthmus and this was transected in the
midline. We then had good exposure of the trachea. We identified the third tracheal ring. We
had the ICU staff deflate the balloon and we placed stay sutures laterally on both sides of the
third tracheal ring. This was carried down from skin to the tracheal ring back up to the skin. We
then reinflated the balloon and then when we were ready we deflate the balloon again and made
a square incision around the third tracheal ring and removed this portion in a square fashion. We
brought our ET-tube out proximally just proximal to this and used a tracheal spreader to dilate
the trachea. We then placed a #8 Shiley tracheostomy tube without any difficulty and the balloon
was inflated. We then hooked our tracheostomy to the ventilator and received good end tidal
C02. The patient was oxygenating at 100% and her tidal volumes were equivalent to what they
were pre-op with the ET-tube. There were no signs of bleeding and good, hemostasis was,
achieved. The skin around the tracheostomy incision was closed in running fashion and the
tracheostomy was secured in four places with nylon suture. The Vicryl stay sutures were
secured to the chest wall with Steri-Strips. The patient tolerated the procedure well and was
taken to ICU in stable condition.
What is the ICD-10-PCS code assigned?
ICD-10-PCS code - OB113F4
O - Medical and Surgical
B - Respiratory System
1- Bypass
1- Trachea
3 - Percutaneous
F - Tracheostomy device
4 - Cutaneous
OB113F4 - Bypass Trachea to Cutaneous with Tracheostomy Device, Percutaneous Approach
PREOPERATIVE DIAGNOSIS: Respiratory failure, intracranial hemorrhage. POSTOPERATIVE DIAGNOSIS: Respiratory failure, intracranial hemorrhage. PROCEDURE PERFORMED: Tracheostomy. ANESTHESIA...
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