Indwelling Pleural Catheter (IPC) Procedure Note

Procedure Type: [IPC Insertion / IPC Removal / Attempted-Aborted]

Date/Time: [Start date and time] – [End date and time]

Location: [Procedure location]

Side: [Right / Left] (Required; never infer)

Primary Operator: [Name, credentials]

Device/Brand: [PleurX / Aspira / Other: specify / Unknown]

Reason for Abortion: [Reason] (Only include if Procedure Type is Attempted-Aborted)

Indication and Clinical Context

[Indication for procedure] (1–3 sentences. For insertion, state rationale for IPC selection such as recurrent symptomatic pleural effusion, non-expandable lung, preference for outpatient management, or failed pleurodesis. For removal, state indication such as spontaneous pleurodesis with minimal drainage, infection, dysfunction, or patient preference. Reference prior procedures or imaging that informed the decision.)

Pre-procedure Assessment

• Allergies: [Relevant allergies including chlorhexidine, latex, local anesthetics / NKDA]
• Anticoagulation status: [Held / Continued / Not applicable]; [Peri-procedural plan and restart timing if applicable]
• Labs: [Pertinent labs (e.g., platelets, INR, PTT) with values and dates / Not checked—reason]
• Baseline vitals and oxygen: [Vitals]; [Room air / Supplemental O2: device and flow]
• Positioning tolerance: [Able to tolerate planned positioning / Limitations noted]

Consent

[Consent obtained: Written / Verbal] per institutional policy. Risks (bleeding, infection, pneumothorax, pain, catheter malfunction, re-expansion pulmonary edema), benefits (symptom relief, outpatient drainage capability), and alternatives (repeat thoracentesis, chest tube with pleurodesis, no intervention) were discussed. [Patient demonstrated understanding and agreed to proceed / Surrogate consent obtained: name and relationship].

Time-out

[Time-out completed verifying correct patient, procedure, and laterality / Not performed—reason].

Anesthesia

Local anesthesia: [Agent] [Concentration] [Total dose in mL and mg]. Infiltration from skin through pleura at planned entry site.

[Procedural sedation: medications with doses and times; monitoring (pulse oximetry, blood pressure, capnography if used); patient tolerance; recovery status] (Only include if sedation beyond local anesthesia was used; otherwise omit this paragraph entirely.)

Ultrasound

Ultrasound performed: [Yes / No—reason if not performed]

• Effusion characteristics: [Size estimate, free-flowing vs loculated]
• Target site: [Intercostal space and anatomical line]
• Depth to fluid: [Measurement in cm / Not measured]
• Safety structures visualized: [Diaphragm position, lung, other]
• Guidance method: [Static marking / Real-time guidance]

(If ultrasound not performed, omit bulleted details and document reason only.)

Procedure

(Include only the variant matching the Procedure Type. If Attempted-Aborted, briefly summarize steps attempted and reason for aborting, then proceed to Complications and Disposition.)

IPC Insertion

(Include only if Procedure Type is IPC Insertion)

• Positioning: [Supine / Semi-recumbent / Lateral decubitus] with [arm position].
• Skin prep and draping: [Chlorhexidine / Povidone-iodine] prep; sterile draping applied.
• Pleural entry: Entry at [intercostal space and line]; pleural fluid aspirated confirming intrapleural location.
• Guidewire: Guidewire advanced without resistance. [Note difficulties if encountered]
• Dilation and sheath: Tract dilated; peel-away sheath placed.
• Catheter placement: IPC advanced through sheath; all fenestrations confirmed intrapleural; sheath removed.
• Tunnel and cuff: Subcutaneous tunnel created; cuff positioned appropriately beneath skin at exit site.
• Securement: [Sutures / Adhesive anchoring device]; [Dressing type] applied.
• Initial drainage: [Yes—volume drained in mL, fluid appearance, patient tolerance / No—reason].

IPC Removal

(Include only if Procedure Type is IPC Removal)

• Positioning: [Supine / Semi-recumbent / Lateral decubitus].
• Skin prep: [Chlorhexidine / Povidone-iodine] prep at cuff and exit site.
• Local anesthesia: Infiltrated around cuff and exit site.
• Dissection: [Blunt / Sharp] dissection to free cuff from subcutaneous tissue.
• Catheter removal: Catheter removed intact [Yes / No—if not intact, describe retained portion and immediate plan].
• Wound closure: [Steri-strips / Suture / Tissue adhesive]; [Dressing type] applied.

Specimens

Pleural fluid sent for [cytology / cell count and differential / chemistries (protein, LDH, glucose, pH) / Gram stain and culture / AFB culture / fungal culture]; specimen labels verified.

(Only include this section if specimens were sent; otherwise omit entirely.)

Complications

[No immediate complications / Complications: pneumothorax, bleeding, significant pain requiring escalation, hypotension/vasovagal, catheter malposition or dysfunction, concern for re-expansion pulmonary edema, other]. [For suspected but unconfirmed issues, document as "Concern for..." with evaluation performed and plan.]

Post-procedure Assessment and Disposition

• Patient condition: [Stable, tolerated procedure well / Other]
• Vital signs: [Stable / Abnormalities noted]
• Dressing: [Clean, dry, intact / Other]
• Post-procedure imaging: [CXR ordered/performed—results if available / Not performed—reason]
• Estimated blood loss: [Minimal / Volume in mL]
• Analgesia: [Medications and dosing / None required]
• Anticoagulation restart: [Agent and timing / Not applicable]
• Disposition: [Home same day / Admitted / Other]
• Follow-up: [Timing and responsible service]

Drainage Plan and Home Instructions

For IPC Insertion

(Include only if Procedure Type is IPC Insertion)

• Maximum drainage per session: [Volume in mL, typically up to 1000–1500 mL]
• Stop drainage if: [Pain / Persistent cough / Worsening dyspnea / Lightheadedness]
• Drainage schedule: [Symptom-guided / Fixed frequency] with rationale
• Drainage performed by: [Patient/caregiver / Home health / Clinic]
• Supplies provided: [Vacuum bottles, dressing supplies, drainage log, other]
• Escalation pathway: For signs of infection (fever, exit site erythema or drainage, cloudy or malodorous fluid), catheter dysfunction, or worsening symptoms: contact [clinic number] during business hours; [after-hours number or emergency instructions] for urgent concerns.

For IPC Removal

(Include only if Procedure Type is IPC Removal)

• Wound care: Keep dressing clean and dry; change as instructed; avoid soaking or submerging for [timeframe].
• Symptom monitoring: Watch for fever, increasing redness, wound drainage, increasing pain, or new dyspnea; contact [clinic number] or [after-hours number] as appropriate.

Patient Counseling Documented

(Tailor to procedure type)

• Exit site/wound care and dressing changes reviewed.
• Drainage stop rules discussed. (For insertion only)
• Infection warning signs explained (fever, increasing redness, purulent drainage, cloudy or malodorous pleural fluid).
• When and how to contact the care team provided (business hours and after-hours).
• Activity restrictions reviewed. (Include if sedation was used)

(Meta-instructions: Do not infer laterality, imaging findings, complications, or consent—these must come from dictation. For safety-critical items—Consent, Time-out, Ultrasound, Complications—document explicitly as completed or not performed with reason, or "None" as appropriate. Omit optional sections entirely when not applicable. If procedure was attempted but aborted, document the reason and disposition in place of detailed procedural steps.)