Vickie Hyde Bodden
New Member
Hi my name is Vickie Hyde Bodden, I'm Cardiothoracic Coder for the last two years it's very challenging.
That's why I'm in need of some help for this Opt Report......
PREOPERATIVE DIAGNOSIS:
Status post coronary artery bypass grafting and aortic valve
replacement. Postoperative course complicated with respiratory
insufficiency and chronic renal insufficiency requiring hemodialysis.
The patient developed sternal dehiscence and required rewiring.
POSTOPERATIVE DIAGNOSIS:
Status post coronary artery bypass grafting and aortic valve
replacement. Postoperative course complicated with respiratory
insufficiency and chronic renal insufficiency requiring hemodialysis.
The patient developed sternal dehiscence and required rewiring.
PROCEDURE PERFORMED:
Sternal rewiring using Robicsek technique, insertion of irrigation
system catheters with mediastinal and right pleural chest tube,
bilateral myocutaneous pectoralis muscle flap advancements, and
insertion of a new right subclavian vein Quinton catheter for
hemodialysis.
SURGEON:
ASSISTANT:
ANESTHESIA: General endotracheal.
INDICATIONS:
The patient is a 66-year-old gentleman who is status post coronary
artery bypass grafting and aortic valve replacement about a couple of
weeks back. His postoperative course was complicated with respiratory
insufficiency and renal insufficiency requiring CVVH and hemodialysis.
The patient developed complete sternal dehiscence and was subsequently
scheduled for sternal rewiring.
DESCRIPTION OF PROCEDURE:
He was taken to the operating room on 03/13/2013. General anesthesia
was induced, intubated, and the area of the chest was prepped and
draped per routine fashion. The sternal incision was reopened. There
was a lot of fluid which was sent for culture and sensitivity. After
drainage of all fluid, the sternum was felt to be complete dehisced
with wires on both sides of the sternum and completely torn to either side of the sternum.
There was about a 2 to 3 cm
separation from both sternal edges. All wires were removed.
Dissection was carried out initially on the inferior plate of the
sternum on both sides in order to get a plane in order to be able to
place new wires in a Robicsek fashion. So, dissection was carried on
both sides of the posterior edges of the sternum. The right side pleura
was violated, and subsequently a right pleural chest tube was placed.
The left side was not violated. Once good dissection was carried out
to separate the mediastinum and pericardium from the posterior sternal
sides on both sides. Attention was then drawn to the myocutaneous
pectoralis area. Advancement flaps were performed on both sides in
order to be able to reapproximate the muscle and fascia, and the skin
without any tension. Good hemostasis was felt to be noted in both
flaps. Once exposure was felt to be appropriate on the top and bottom
of the sternum, the closure was undertaken in a Robicsek fashion after copious irrigation og the mediastinum was undertaken with warm antibiotic solution.
Sternal wires were
placed in a vertical manner on both sides of the sternum, and
subsequently a total of eight stainless steel horizontal wires were placed
horizontally to reapproximate the sternum. A couple of them were
closed in a figure-of-eight. Prior to doing that, copious irrigation
of the whole mediastinum was undertaken. Some tissues were also sent
from debridement of the bones of the sternum. Two mediastinal chest
tubes were placed, as well as a red rubber catheter for irrigation was
also placed in the mediastinum. Subsequently, the two edges of the
sternum were reapproximated with the help of the horizontal wires.
Subsequently, confirmation again of the myocutaneous flaps was
undertaken for good hemostasis. Two JP drains were placed one under
each muscle flap. Subsequently, using interrupted 0 Vicryl in a
figure-of-eight manner, the myocutaneous flaps were reapproximated.
After that, a single layer of 0 Vicryl fascial layer closure was
undertaken, and the skin was closed with staples. Also, using the
right subclavian approach, a Quinton catheter with two lumens for
hemodialysis was placed. Using an introducer needle, the right
subclavian vein was localized, through which a guide wire was passed. The
needle was taken off. Over the guide wire, dilators were passed to make a
tract using A seldinger_______ maneuver and subsequently, the dilators were
removed, and over the guidewire the Quinton catheter was passed into
the subclavian all the way to the right atrial- SVC junction. Good
blood return was noted. Chest x-ray was Then ordered to rule out
pneumothorax and confirm positioning of the catheter. Subsequently, the
catheter was sutured into place. Irrigation was also initiated
through the red rubber catheter with bacitracin at 50 mL an hour, and
the patient was transferred back to the intensive care unit intubated,
on some minor inotropic support in a stable condition.
Can some one please help me with the Operative Report I'm confuse with this one, thanks in advance for any help.......
That's why I'm in need of some help for this Opt Report......
PREOPERATIVE DIAGNOSIS:
Status post coronary artery bypass grafting and aortic valve
replacement. Postoperative course complicated with respiratory
insufficiency and chronic renal insufficiency requiring hemodialysis.
The patient developed sternal dehiscence and required rewiring.
POSTOPERATIVE DIAGNOSIS:
Status post coronary artery bypass grafting and aortic valve
replacement. Postoperative course complicated with respiratory
insufficiency and chronic renal insufficiency requiring hemodialysis.
The patient developed sternal dehiscence and required rewiring.
PROCEDURE PERFORMED:
Sternal rewiring using Robicsek technique, insertion of irrigation
system catheters with mediastinal and right pleural chest tube,
bilateral myocutaneous pectoralis muscle flap advancements, and
insertion of a new right subclavian vein Quinton catheter for
hemodialysis.
SURGEON:
ASSISTANT:
ANESTHESIA: General endotracheal.
INDICATIONS:
The patient is a 66-year-old gentleman who is status post coronary
artery bypass grafting and aortic valve replacement about a couple of
weeks back. His postoperative course was complicated with respiratory
insufficiency and renal insufficiency requiring CVVH and hemodialysis.
The patient developed complete sternal dehiscence and was subsequently
scheduled for sternal rewiring.
DESCRIPTION OF PROCEDURE:
He was taken to the operating room on 03/13/2013. General anesthesia
was induced, intubated, and the area of the chest was prepped and
draped per routine fashion. The sternal incision was reopened. There
was a lot of fluid which was sent for culture and sensitivity. After
drainage of all fluid, the sternum was felt to be complete dehisced
with wires on both sides of the sternum and completely torn to either side of the sternum.
There was about a 2 to 3 cm
separation from both sternal edges. All wires were removed.
Dissection was carried out initially on the inferior plate of the
sternum on both sides in order to get a plane in order to be able to
place new wires in a Robicsek fashion. So, dissection was carried on
both sides of the posterior edges of the sternum. The right side pleura
was violated, and subsequently a right pleural chest tube was placed.
The left side was not violated. Once good dissection was carried out
to separate the mediastinum and pericardium from the posterior sternal
sides on both sides. Attention was then drawn to the myocutaneous
pectoralis area. Advancement flaps were performed on both sides in
order to be able to reapproximate the muscle and fascia, and the skin
without any tension. Good hemostasis was felt to be noted in both
flaps. Once exposure was felt to be appropriate on the top and bottom
of the sternum, the closure was undertaken in a Robicsek fashion after copious irrigation og the mediastinum was undertaken with warm antibiotic solution.
Sternal wires were
placed in a vertical manner on both sides of the sternum, and
subsequently a total of eight stainless steel horizontal wires were placed
horizontally to reapproximate the sternum. A couple of them were
closed in a figure-of-eight. Prior to doing that, copious irrigation
of the whole mediastinum was undertaken. Some tissues were also sent
from debridement of the bones of the sternum. Two mediastinal chest
tubes were placed, as well as a red rubber catheter for irrigation was
also placed in the mediastinum. Subsequently, the two edges of the
sternum were reapproximated with the help of the horizontal wires.
Subsequently, confirmation again of the myocutaneous flaps was
undertaken for good hemostasis. Two JP drains were placed one under
each muscle flap. Subsequently, using interrupted 0 Vicryl in a
figure-of-eight manner, the myocutaneous flaps were reapproximated.
After that, a single layer of 0 Vicryl fascial layer closure was
undertaken, and the skin was closed with staples. Also, using the
right subclavian approach, a Quinton catheter with two lumens for
hemodialysis was placed. Using an introducer needle, the right
subclavian vein was localized, through which a guide wire was passed. The
needle was taken off. Over the guide wire, dilators were passed to make a
tract using A seldinger_______ maneuver and subsequently, the dilators were
removed, and over the guidewire the Quinton catheter was passed into
the subclavian all the way to the right atrial- SVC junction. Good
blood return was noted. Chest x-ray was Then ordered to rule out
pneumothorax and confirm positioning of the catheter. Subsequently, the
catheter was sutured into place. Irrigation was also initiated
through the red rubber catheter with bacitracin at 50 mL an hour, and
the patient was transferred back to the intensive care unit intubated,
on some minor inotropic support in a stable condition.
Can some one please help me with the Operative Report I'm confuse with this one, thanks in advance for any help.......