Question

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?

Answer 1

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