Patient Name: ,
DOB: SEX:
Ordering Physician: ,
PROCEDURE:
- Cholangiogram through existing catheter
- Biliary catheter replacement
INDICATION:
DATE:
OPERATORS: John Doe, MD (Attending)/Jane Doe, MD (Fellow)
MEDICATIONS: Versed mg IV, fentanyl mcg IV, Zosyn 3.375 gm IV
CONTRAST: ml non-ionic contrast
FLUOROSCOPY TIME: minutes
CATHETER: French biliary drain
COMPLICATIONS: None
TECHNIQUE: The risks, benefits, and alternatives to the procedure and sedation were explained to the patient. The specific risk of sepsis was detailed and accepted. Written informed consent was obtained.
The existing catheter and surrounding soft tissues were prepped and draped in sterile fashion. Local anesthetic was injected at the catheter entry site.
Contrast was injected through the existing tube and cholangiographic images obtained.
A wire was negotiated through the catheter and into the small bowel. The catheter was removed over the wire, and a new catheter was placed. The pigtail was formed and locked in the _____. The tube was _____ . The catheter was secured to the skin with 2-0 Ethilon. The patient tolerated the procedure well without immediate complications.
FINDINGS: Comparison is made to a prior study dated _____ .
- Cholangiogram through the catheter demonstrates
- The new catheter is appropriately positioned with the distal tip in the ____and the proximal side hole in a peripheral bile duct.
IMPRESSION: Uneventful image guided replacement of a biliary catheter as described.
PLAN:
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