Percutaneous Tracheostomy Procedure Note

Procedure: Percutaneous Dilatational Tracheostomy

Date/Time: [Start date/time — End date/time]

Location: [ICU bed/room]

Primary Operator: [Name, credentials/role]

Assistants: [Names and roles]

Additional Personnel: [Respiratory therapist, bronchoscopy operator if different, nursing — names and roles]

Indication

[Primary indication and supporting clinical context] (1–2 sentences. Include ventilator day, prior extubation attempts, secretion burden, or neurologic status as relevant. If urgent or emergent, state explicitly.)

Pre-Procedure Status

Airway: [Current airway device, size, depth at teeth/lip, cuff status]

Ventilator Settings: [Mode] [FiO2] [PEEP] [Set rate] [Tidal volume or pressure target]

Oxygenation: [SpO2] [Blood gas summary if relevant]

Procedural Risk Modifiers: [Coagulopathy/anticoagulation management / Anatomic concerns / Cervical spine precautions / High ventilator requirements / No significant procedural risk modifiers] (Include only those that applied; if none, state "No significant procedural risk modifiers.")

Consent and Preparation

• Informed Consent: [Obtained from patient / Obtained from surrogate (relationship) / Not obtained due to emergency — state rationale]
• Time-Out: [Performed with verification of correct patient, procedure, and site / Not performed due to emergency — state rationale]
• Positioning: [Supine, shoulder roll, neck extension / neutral with C-spine precautions]
• Skin Preparation: [Prep agent used]
• Local Anesthetic: [Agent, concentration, total volume]
• Sedation: [Moderate / Deep / General anesthesia], [Key medications with doses], [Neuromuscular blockade: Yes/No with agent and dose if yes]
• Monitoring: [SpO2, ECG, BP, capnography as applicable] (If anesthesia managed sedation separately, note this and reference their documentation.)

Procedure

Technique: [Technique and kit used, e.g., Seldinger technique with Ciaglia single-step dilator kit]

Bronchoscopy Guidance: [Yes / No]

• (If Yes) [Bronchoscope operator], [ETT repositioning method and depth], [Visualization findings including needle entry confirmation, airway assessment, suctioning performed]
• (If No) [Rationale or alternative adjuncts if relevant]

Ultrasound Guidance: [Yes / No]

• (If Yes) [Pre-scan findings: midline structures, thyroid position, vascular anatomy], [Target tracheal ring level]

Procedural Steps:

• [Landmark identification and target interspace]
• [Skin incision and blunt dissection to pretracheal fascia]
• [Needle entry and confirmation method: air aspiration / bronchoscopic visualization / ultrasound]
• [Guidewire placement]
• [Tract dilation: dilator type, sequence or single-step, ease/difficulty]
• [Tracheostomy tube insertion over guidewire]
• [Cuff inflation and initiation of ventilation via tracheostomy]
• [ETT deflation, withdrawal, and removal]

Confirmation of Placement: [End-tidal CO2 result], [Ventilator waveforms and delivered volumes], [Bilateral breath sounds], [Bronchoscopic confirmation if performed] (Include all methods used.)

Tracheostomy Tube

Tube: [Brand/model, size as ID or standard numbering]

Type: [Cuffed / Uncuffed], [Fenestrated / Non-fenestrated], [Standard / Extended length]

Inner Cannula: [Yes / No], [Disposable / Reusable]

Securement: [Sutures: number and type], [Ties/holder type]

Cuff Status: [Inflated / Deflated], [Cuff pressure in cm H2O or inflation volume in mL]

Findings and Complications

Estimated Blood Loss: [Volume in mL or "minimal"]

Specimens: [None / Description]

Complications: [No complications / Complications as listed below]

• (If complications occurred) [Complication, management steps, and patient response] (Add additional items as needed.)

Post-Procedure Status and Plan

Immediate Status: [Hemodynamic status], [SpO2], [ETCO2 if applicable], [Escalation required: Yes/No]

Post-Procedure Ventilator Settings: [Mode] [FiO2] [PEEP] [Set rate] [Tidal volume or pressure target] (Note any changes from pre-procedure settings.)

Airway Care Plan: [Suctioning frequency and indications], [Humidification: heated humidification / HME], [Cuff pressure target and recheck frequency], [Emergency equipment at bedside]

Stoma Care Plan: [Dressing type and change schedule], [Skin assessment plan], [Securement check frequency], [Escalation thresholds for bleeding]

Chest X-ray: [Ordered — indication / Not indicated — rationale]

Disposition: [Patient remains in ICU], [Monitoring level], [Analgesia/sedation plan]

Notifications: [Teams notified], [Family updated: Yes/No]

Follow-Up: [First trach change timing per protocol], [SLP referral if appropriate], [Weaning/decannulation considerations]

Attestation

[Operator attestation statement]

Electronic Signature: [Operator name, credentials]

Date/Time of Signature: [Date/time]

(Do not finalize without Primary Operator and Procedure Date/Time. Do not infer consent, time-out, tube details, confirmation methods, or complications — these must be explicitly documented.)