DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: End-stage renal disease.
POSTOPERATIVE DIAGNOSIS: End-stage renal disease.
OPERATION PERFORMED: Insertion of Vas-Cath in the left internal jugular vein.
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: Local.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old female with end-stage renal disease who had a left AV fistula placed. Attempts were made to use this; however, the nurses had difficulty. The patient now requires access for initiation of acute dialysis.
DESCRIPTION OF PROCEDURE: The patient was placed in a supine head-down position and the left neck and chest prepared and draped in a sterile fashion. Approximately 5 mL of 1% lidocaine was used for local anesthesia.
A 21 gauge needle was used to find the left internal jugular vein. In a similar fashion, an 18 gauge needle was passed down the left internal jugular vein. Guidewire was then passed through the needle into a central location. After dilatation of the tract, a dual lumen 11.5 French 19 cm Mahurkar catheter was threaded over the guidewire and was sutured in place with 2-0 silk. Good venous return was obtained in each port, after which each was flushed with saline followed by 2500 units of heparin.
A sterile dressing was then placed over this. The patient tolerated the procedure well, and the chest x-ray following this showed no pneumothorax and the line tip to be in the SVC-RA junction.
