Central Venous Catheter or Port Placement Operative Note

Date: [Date]

Procedure(s) Performed: [Procedure name(s) and laterality]

Indication: [Clinical indication]

Urgency: [elective / urgent / emergent]

Operator(s): [Primary operator and role; assistants]

Anesthesia: [local only / moderate sedation / general anesthesia] (Include agents and doses only if explicitly documented.)

Consent and Safety Verification

[Consent status and risks discussed] (Document that informed consent was obtained with discussion of risks, benefits, and alternatives. Note key risks discussed including bleeding, infection, arterial puncture, pneumothorax/hemothorax, malposition, arrhythmia, air embolism, and thrombosis. If emergent and consent was modified, document why and who provided consent or note emergency exception.)

[Pre-procedure time-out] (Document time-out confirming patient identity, procedure, and planned access site. Note site marking if performed.)

Procedure Details

[Patient positioning and clinical considerations] (Describe positioning and any relevant constraints affecting technique such as coagulopathy, prior central venous access issues, or existing devices.)

[Sterile preparation and CLABSI bundle compliance] (Explicitly state: hand hygiene performed; skin antisepsis with [agent] applied and allowed to dry; maximal sterile barrier precautions used including cap, mask, sterile gown, sterile gloves, and full-body drape. If any element was omitted, document the reason and mitigation.)

[Vascular access approach] (Specify target vessel and laterality; technique used [ultrasound-guided Seldinger / landmark / micropuncture / cutdown]; venous confirmation method [nonpulsatile dark blood return / ultrasound visualization / manometry]. If ultrasound was used, document pre-access vessel evaluation and real-time needle visualization. Note number of attempts if more than one.)

[Wire, dilation, and catheter placement] (Describe guidewire advancement, any resistance or ectopy encountered and actions taken, dilation method, catheter or sheath introduction, and insertion depth. Note any suspected malposition and how it was addressed.)

[Tunneled catheter details] (Include only for tunneled catheters: describe tunnel creation, exit site location, cuff positioning, and hemostasis.)

[Implanted port details] (Include only for implanted ports: describe pocket location, plane of dissection, port fixation method, catheter-to-port connection confirmation, and layered closure.)

[Hemostasis and dressing] (State how hemostasis was achieved and the dressing applied. Note if CHG-impregnated dressing was used.)

Device Specifications

• Catheter type: [non-tunneled CVC / tunneled catheter / implanted port]
• Lumens, size, length: [number] lumen, [French size] Fr, [length] cm
• Antimicrobial/antibiotic impregnation: [none / specify agent]
• Insertion depth at skin: [depth] cm (Include for CVCs only.)
• Securement method: [sutures / sutureless device]
• Port location: [site and side] (Include for ports only.)
• Port manufacturer/model: [manufacturer, model] (Include for ports only.)
• Port lot/serial/UDI: [identifier or reference to implant log] (Include for ports only.)

Imaging and Tip Position Confirmation

[Imaging modalities and findings] (For ultrasound: document what was confirmed during access. For fluoroscopy: describe catheter course and observed tip location. For ECG-guided placement: describe the waveform change indicating cavoatrial junction. Note whether images were saved.)

[Final tip position] (State final tip position using standardized language: lower SVC, cavoatrial junction, or high right atrium for upper body lines; IVC above diaphragm for femoral lines. If chest radiograph was obtained, state whether reviewed and summarize findings. If tip confirmation is pending, state this and specify use restrictions until confirmation is complete.)

Function Check

[Lumen function and lock] (Document blood return from each lumen and ability to flush without resistance. State lock solution used. For ports: note whether left accessed or de-accessed, and needle type/size if accessed.)

Complications

[Complications] (If none, state "None." If any occurred, describe the event, immediate clinical impact, management performed, patient condition after management, and follow-up plan. If a complication is suspected but not yet ruled out, document the evaluation plan and interim restrictions.)

Findings

[Clinically meaningful anatomic findings] (Include only if relevant observations such as vessel thrombosis, anatomic variants, stenosis, or unusual anatomy affected the procedure. Omit this section entirely if anatomy was unremarkable.)

Post-Procedure

• Line/port usability status: [Acceptable for immediate use / Do not use until imaging confirms position and rules out pneumothorax]
• Permitted therapies: [power injection / dialysis / vasopressors / standard infusions] (Include only therapies the device is rated for.)
• Flush and lock protocol: [Per institutional standard / specify]
• Dressing care: [Dressing type and timeline for first change]
• Escalation triggers: [Inability to aspirate or flush, swelling, new dyspnea, bleeding, signs of infection]

EBL: [Estimated blood loss]

Disposition: [Immediate post-procedure disposition and monitoring plan]