Preoperative diagnosis: Respiratory insufficiency
Postoperative diagnosis: Respiratory insufficiency
Operation: Tracheostomy with division of thyroid isthmus
Estimated blood loss: Less than 10 mL
Fluids: Crystalloid
Complications: None
Technique: The patient was brought to the operating room and placed in the supine position. He was given general anesthesia through his existing oral intubation tube. The anterior neck was prepped and draped in the usual sterile fashion. Lidocaine 1% with 1:100,000 epinephrine was infiltrated into the skin at the lower neck.
A transverse incision was made at the cricoid ring level through skin and subcutaneous fat. The platysmal layer was traversed, and then the strap muscles were separated in the midline. The thyroid isthmus was ligated and divided with #2-0 silk ligatures. An inferiorly based tracheostomy flap was created using the second and third tracheal rings and sewn into place with a #3-0 chromic stitch to the inferior dermis margin.
Hemostasis was achieved using suction cautery. At this point, the oral intubation tube was withdrawn, and a #8 Shiley low-pressure cuffed tube was passed into the newly created trach site. The trach ties were tied securely into place, and the cuff was inflated to a comfortable pressure. The patient then received further ventilation through the newly placed trach tube. The patient was then allowed to awaken from general anesthesia and was taken back to the ICU in stable condition.
Select the appropriate ICD-10-CM and CPT code(s):

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The Answer of Preoperative diagnosis: Respiratory insufficiency
Postoperative diagnosis: Respiratory insufficiency
Operation: Tracheostomy with division of thyroid isthmus
Estimated blood loss: Less than 10 mL
Fluids: Crystalloid
Complications: None
Technique: The patient was brought to the operating room and placed in the supine position. He was given general anesthesia through his existing oral intubation tube. The anterior neck was prepped and draped in the usual sterile fashion. Lidocaine 1% with 1:100,000 epinephrine was infiltrated into the skin at the lower neck.
A transverse incision was made at the cricoid ring level through skin and subcutaneous fat. The platysmal layer was traversed, and then the strap muscles were separated in the midline. The thyroid isthmus was ligated and divided with #2-0 silk ligatures. An inferiorly based tracheostomy flap was created using the second and third tracheal rings and sewn into place with a #3-0 chromic stitch to the inferior dermis margin.
Hemostasis was achieved using suction cautery. At this point, the oral intubation tube was withdrawn, and a #8 Shiley low-pressure cuffed tube was passed into the newly created trach site. The trach ties were tied securely into place, and the cuff was inflated to a comfortable pressure. The patient then received further ventilation through the newly placed trach tube. The patient was then allowed to awaken from general anesthesia and was taken back to the ICU in stable condition.
Select the appropriate ICD-10-CM and CPT code(s):

Preoperative Diagnosis: Respiratory Insufficiency