OPERATIVE REPORT PATIENT: Gordon Miller SURGEON: Robert C. Downey, MD PROCEDURE PERFORMED: Central venous access placement. INDICATION: Massive gastrointestinal bleed.

OPERATIVE REPORT PATIENT: Gordon Miller SURGEON: Robert C. Downey, MD PROCEDURE PERFORMED: Central venous access placement. INDICATION: Massive gastrointestinal bleed. The procedure was done emergently because of the patient’s critical condition. His right IJ area was prepped in the usual fashion. It was very difficult to visualize his right IJ vein, even though his habitus should have allowed us to do so, but the patient was, I believe, severely intravascularly volume depleted, and his vein was collapsing. I have attempted to access the right internal jugular vein multiple times, both under real-time ultrasound guidance and even later on blindly. I was able to get blood return and hit the vein; however, I was not able to advance the guidewire. I was able to advance it one time and put the catheter in, and it was nonfunctioning. I had to take the catheter out and tried multiple other times on the right IJ vein without success. That procedure was terminated. Pressure was applied. There was no cervical hematoma whatsoever. The patient was uncomfortable because of the length of the procedure but did well otherwise. Hemodynamically, he was unchanged, and his oxygen saturations remained stable. I prepped the IJ vein area in the usual fashion. One percent lidocaine was used for local anesthesia. Again, the left IJ vein was collapsing. With deep inspiration, the vein could be well visualized on the real-time and ultrasound guidance, after which I could get access to the left IJ vein. A wire was advanced without difficulty while the patient was holding his breath. A triple-lumen trauma line was advanced with a dilator over the guidewire without difficulty using the Seldinger technique. The three ports had good blood return, and the three of them were flushed with normal saline. The line was secured to the skin. The patient tolerated the procedure well without any immediate complications, and chest x-ray was ordered. ICD-10-CM Code: