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HOSPITAL-RECORD OF OPERATION
INDICATION: Septic shock due to severe sepsis and the need to initiate mechanical ventilation.
PROCEDURE PERFORMED: Elective intubation.
ANESTHESIA: Versed and fentanyl.
PROCEDURE: After the procedure was explained to and consent was obtained from the patient's family, the patient was premedicated with Versed and fentanyl. After adequate anesthesia and analgesia was achieved, the patient's vocal cords were directly visualized with the aid of a laryngoscope using a Miller 3 blade. A size 8.5 endotracheal tube was then inserted and passed through the vocal cords atraumatically and without any difficulty. The CO2 monitor did confirm correct placement of the tube. The cuff was then inflated and the tube secured around 22 cm at the lips.
The patient tolerated the procedure well. There were no acute complications. A chest x-ray had been ordered to confirm correct placement of the endotracheal tube.
ICD-10-CM Code(s): ____________________
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