Procedure Notes

Discussed with the substitute decision-maker, the introduction of artificial feeding using a PEG tube. We discussed the risks, benefits, alternatives, including bleeding, infection, perforation. We discussed that we would not be doing the procedure ourselves as part of Orange team medicine, but it would be done by the proceduralist.

We also discussed that it would not change the overall outcome aside from providing nutrition, and in patients with dementia or any cognitive issues there is still ongoing risk of no major change in outcome. PEG tubes do not have a different risk of aspiration, and in fact there is risk of aspiration despite the fact that the tube is now placed in the stomach. However it is more comfortable for the patient, and there is no risk of causing ulceration in the nasopharynx, risk of sinusitis, is tolerated better -with less pulling out of the tube. There is in the context of agitation still a risk of the tube being pulled out by the patient and causing some injury.

All discussions occurred using clear language and plain terms, opportunity was provided for the substitute decision-maker to ask questions, questions were answered, and they were satisfied with the answers provided.

CENTRAL LINE INSERTION:
Indication: hemodynamic support, central venous gasses, IV access
Consent: obtained
Emergency consent/discussion with substitute decision-maker regarding placement of a central venous access catheter.
The indication was explained. Alternatives were briefly discussed. Specific risks, including common risks (scar, thrombus, CVL-associated infection) and rare but serious risks (carotid injury requiring surgery, stroke, bleeding, pneumothorax) were presented. Informed consent was obtained.
Anesthetic:
Approx. 5 cc of 2% lidocaine was infiltrated into the skin at the insertion site.
Procedure:
The procedure was performed with full sterile technique and a full-bed drape.
Using US guidance the vein was cannulated. The wire was advanced and position was confirmed using US. The skin and subcutaneous tissues were then dilated, and a previously flushed and capped line was inserted. The wire was withdrawn. The distal lumen was capped and flushed and venous backflow was confirmed on all three lumens. The CVL was stitched in place and a dressing was applied prior to breaking sterility.
Xray reviewed as applicable.