Procedural Note template and example

Procedure Details

• Procedure name: Ultrasound-guided internal jugular central venous catheter insertion
• Date and time: 24/10/2023 - 14:15
• Indication: Lack of peripheral venous access in septic shock requiring inotropic support (required)
• Consent: Written informed consent obtained from patient after discussing risks including bleeding, infection, pneumothorax, and accidental arterial puncture.

Personnel

• Primary operator: Dr A. Smith, Specialty Registrar in Emergency Medicine
• Assistant(s): Nurse J. Taylor, ED Staff Nurse
• Anaesthetist / Sedationist: N/A

Anaesthesia & Monitoring

• Anaesthesia type: Local
• Anaesthetic agents: Lidocaine 1% 5 mL subcutaneously
• Monitoring used: Continuous pulse oximetry, 3-lead ECG, non-invasive blood pressure (NIBP)

Description of Procedure

• Patient position: Trendelenburg position of approximately 15 degrees, head turned slightly to the left.
• Preparation and draping: Skin prepared with 2% chlorhexidine gluconate in 70% isopropyl alcohol and allowed to dry completely. Sterile full-body drape applied.
• Local anaesthetic: Lidocaine 1% 5 mL infiltrated subcutaneously and into deeper tissues overlying the right internal jugular vein.
• Technique: 1. Right internal jugular vein identified in short-axis using a linear ultrasound probe.

2. Under real-time ultrasound guidance, the vein was punctured using an 18-gauge introducer needle attached to a 10 mL syringe.
3. Venous blood return confirmed.
4. The syringe was removed, and a J-tip guidewire was advanced smoothly through the needle without resistance.
5. The needle was removed over the guidewire.
6. A small skin nick was made with a scalpel at the wire entry site.
7. A dilator was passed over the wire into the vein, then removed.
8. A triple-lumen central venous catheter was advanced over the wire to a depth of 15 cm.
9. The guidewire was removed, and all three lumens were aspirated, flushed with 0.9% sodium chloride, and capped.
10. The catheter was secured to the skin with 2-0 silk sutures and a sterile transparent occlusive dressing applied.

• Complications: None (required)

Findings & Specimens

• Intra-procedural findings: Right internal jugular vein patent and easily compressible with ultrasound. Guidewire visualized in the vein during advancement. Free venous return from all three lumens post-insertion.
• Specimens collected: N/A

Post-Procedure Plan

• Estimated blood loss: < 10 mL
• Patient condition: Stable, tolerated the procedure well without acute distress
• Post-procedure instructions: Chest radiograph ordered to confirm catheter tip position and rule out pneumothorax. Continue standard ICU monitoring. Maintain sterile dressing. (required)