© The State of Queensland (Queensland Health), 2011

Permission to reproduce should be sought from ip_officer@health.qld.gov.au

(Affix identification label here)

URN:

Family name:

Central Vascular Access Device Given name(s):

Insertion Address:

Date of birth: Sex: M F I

Facility:

A. Interpreter / cultural needs  The device may become blocked and need
medications to unblock or may need to be
An Interpreter Service is required? Yes No removed.
If Yes, is a qualified Interpreter present? Yes No  (Tunnelled and Non-tunnelled catheters only) The
A Cultural Support Person is required? Yes No device may be accidentally removed if pulled or
If Yes, is a Cultural Support Person present? Yes No tugged on.
 Failure of local anaesthetic which may require a
B. Procedure
further injection of anaesthetic or a different
The following will be performed (Doctor/doctor method of anaesthesia may be used.
delegate to document – include site and/or side where  Nerve damage, is usually temporary, and should
relevant to the procedure) get better over a period of time. Permanent nerve
damage is rare.
...........................................................................................................................................................................
Less common risks and complications include:
...........................................................................................................................................................................
 Infection at the skin, requiring antibiotics and/or
A Central Vascular Access Device is used to give you further treatment.
medication directly into your blood stream without  Infection in the device, requiring the device to be
DO NOT WRITE IN THIS BINDING MARGIN

having to repeatedly insert a needle into your vein. removed.

There are many different types of devices. The  Pneumothorax, a collection of air around the
device that you have inserted is dependant on the lining of the lungs. This usually resolves by itself
type and length of treatment required. but sometimes may require a tube to be inserted
Non-Tunnelled Catheter such as Vascath® and into the chest.
central line;  Damage to surrounding structures such as blood
Tunnelled Catheter such as Hickman Catheter® vessels, organs and muscles, requiring further
and Permacath Dialysis Catheter®; treatment.

PROCEDURAL CONSENT FORM

Implantable Port such as Portacath® and  Failure to gain access to the vein. This may
Infusaport®. require a second attempt from a different location.
This procedure will require an injection of local  Blood clot blocking the vein, may require
anaesthetic and a sedation anaesthetic. medication to treat.
 An allergy to injected drugs, requiring further
C. Risks of the procedure treatment.
In recommending a Central Venous Access Device,  The procedure may not be possible due to
the doctor believes the benefits to you from having medical and/or technical reasons.
this procedure exceed the risks involved. Rare risks and complications include:
The risks and complications with this procedure and  Injected medications may leak outside of the vein
with having a device can include but are not limited to under the skin and into tissue, this may require
the following. treatment.
Common risks and complications include:  A fast or irregular heart beat. This usually
 Minor pain, bruising and/or infection from the IV resolves on it’s own but sometimes may need
cannula. This may require treatment with further treatment.
antibiotics.  The catheter tip may move from the original
v2.00 - 03/2011

 Pain or discomfort at the insertion site. This may placement. The device may need to be removed.
require medication.  An air bubble enters the blood stream. This can
 Bleeding or bruising may occur. This is usually travel to the heart causing a heart attack or to the
stopped by applying further pressure and/or ice to brain causing a stroke.
the puncture site. This is more common if you  An increased lifetime cancer risk due to the
take Aspirin, Warfarin, Clopidogrel (Plavix and exposure to x-rays.
Iscover) or Dipyridamole (Persantin and
 Seizures and/or cardiac arrest due to local
Asasantin).
anaesthetic toxicity.
SW9240

 The device may become kinked and need

 Death as a result of this procedure is very rare.
repositioning or removal.
If sedation is given extra risks include:
 faintness or dizziness, especially when you start
to move around

Page 1 of 2 Continues over page ►►►


Central Vascular Access Device
Insertion
Facility:
 fall in blood pressure
 nausea and vomiting
 weakness
 an existing medical condition getting worse
 heart and lung problems such as heart attack or
vomit in the lungs causing pneumonia. This may
require emergency treatment
 stroke resulting in brain damage.
D. Patient consent
I acknowledge that the doctor/doctor delegate has
explained the proposed procedure.
I understand;
 the risks and complications, including the risks
that are specific to me.
 the sedation/anaesthetic required for this
procedure. I understand the risks, including the
risks that are specific to me.
 that no guarantee has been made that the
procedure will improve my condition even though
it has been carried out with due professional care.
 if immediate life-threatening events happen
during the procedure, they will be treated based
on my discussions with the doctor/doctor delegate
or my Acute Resuscitation Plan.
 a doctor/doctor delegate undergoing further
training may conduct this procedure.
I have been given the following Patient
Information Sheet/s:
Central Vascular Access Device
Insertion
 I was able to ask questions and raise concerns
with the doctor/doctor delegate about the
proposed procedure and its risks. My questions
and concerns have been discussed and
answered to my satisfaction.
 I understand I have the right to change my mind
at any time including after I have signed this form
but, preferably following a discussion with my
doctor/doctor delegate.
 I understand that image/s or video footage may
be recorded as part of and during my procedure
and that these image/s or video/s will assist the
doctor to provide appropriate treatment.
 I understand that Queensland Health may release
my relevant de-identified information obtained
from this and related procedures for education
and training of health professionals.
On the basis of the above statements,
(Affix identification label here)
URN:
Family name:
Given name(s):
Address:
Date of birth: Sex: M F I
I request to have the procedure
Name of Patient: ..........................................................................................................................
Signature: ..........................................................................................................................................
Date: ......................................................................................................................................................
Patients who lack capacity to provide consent
Consent must be obtained from a substitute decision
maker/s in the order below.
Does the patient have an Advance Health Directive
(AHD)?
Yes Location of the original or certified copy of the AHD:
................................................................................................................................................................
No Name of Substitute
Decision Maker/s: ...............................................................................................................
DO NOT WRITE IN THIS BINDING MARGIN
Signature: .....................................................................................................................................
Relationship to patient: .................................................................................................
Date: ....................................................... PH No: ..................................................................
Source of decision making authority (tick one):
Tribunal-appointed Guardian
Attorney/s for health matters under Enduring Power
of Attorney or AHD
Statutory Health Attorney
If none of these, the Adult Guardian has provided
consent. Ph 1300 QLD OAG (753 624)
E. Doctor/delegate Statement
I have explained to the patient all the above points
under the Patient Consent section (D) and I am of
the opinion that the patient/substitute decision-
maker has understood the information.
Name of
Doctor/delegate: .......................................................................................................................
Designation:..................................................................................................................................
Signature:……………………………………………………….. Date……………………..………
F. Interpreter’s statement
I have given a sight translation in
.....................................................................................................................................................................
(state the patient’s language here) of the consent form
and assisted in the provision of any verbal and written
information given to the patient/parent or
guardian/substitute decision-maker by the doctor.
Name of
Interpreter: ......................................................................................................................................
Signature:……………………………………………………….. Date……………………..………
03/2011 - v2.00
Page 2 of 2
 © The State of Queensland (Queensland Health), 2011
Permission to reproduce should be sought from ip_officer@health.qld.gov.au
Consent Information - Patient Copy
Central Vascular Access Device Insertion

1. What is a Central Vascular Access
Device?
A Central Vascular Access Device is used to give you
medication directly into your blood stream without
having to repeatedly insert a needle into your vein.
There are many different types of devices. The device
that you have inserted is dependant on the type and
length of treatment required.
Types of devices include:
a) Non-Tunnelled Catheter such as Vascath® and
central line;
b) Tunnelled Catheter such as Hickman Catheter®
and Permacath Dialysis Catheter®;
c) Implantable Port such as Portacath® and
Infusaport®.
2. Will there be any discomfort, is any
anaesthetic needed?
This procedure will require the injection of a local
anaesthetic and a sedation anaesthetic.
may alter the affects of the sedation anaesthetic.
If you have a drug habit please tell your doctor.
5. During the procedure
For All Devices
A fine needle (IV cannula) will be inserted into a vein
in your arm.
Ultrasound will be used to look at the veins at the base
of your child’s neck (sometimes a vein in their groin is
used). A suitable vein for the catheter will be selected.
Local anaesthetic and sedation will be injected.
A small cut is made in the skin over the vein.
Using ultrasound as a guide the needle will be
inserted into your vein. You may be asked to hold
your breath for several seconds while the catheter is
inserted. The tip of the catheter will be positioned
using x-ray guidance in a major blood vessel next to
the heart. The catheter does not go into your heart.
When the catheter is in the correct place a chest x-ray
will be taken to confirm its placement.

3. What is sedation? Non-Tunnelled Catheter

Sedation is the use of drugs that give you a ‘sleepy- The catheter is inserted directly into the vein and is
like’ feeling. It makes you feel very relaxed during a held in place with sutures and a dressing. This type of
procedure that may be otherwise unpleasant or catheter can stay in for about a week.
painful. You may remember some or little about what
has occurred during the procedure. Tunnelled Catheter
This procedure may only have a light sedation. You A small cut is made in the skin on your chest and the
need to be able to fully co-operate at times by holding catheter is pushed (tunnelled) under your skin until it
your breath when instructed by the doctor. reaches the vein to be entered.
Sedation is generally very safe but has a risk with side Tunnelled Catheters are held in place with sutures.
effects and complications. Whilst these are usually One or two sutures are also required to close the small
temporary, some of them may cause long-term cut over the vein at the base of the neck. Dressings
problems. will be applied. This type of catheter can stay in for
months.
4. Preparation for the procedure
The medical imaging department will give you
instructions on how to prepare for your procedure.
 You will be told when to have your last meal and
drink. This is to make sure your stomach is empty
so that if you vomit during the procedure there will
be nothing to go into your lungs.
 Please tell the staff if you are or suspect you
might be pregnant or are breastfeeding.
 If you take Aspirin, Warfarin, Clopidogrel (Plavix
and Iscover) or Dipyridamole (Persantin and
Asasantin) or any other drug that is used to thin
your blood ask your doctor/health practitioner if
you should stop taking it before the procedure as
it may affect your blood clotting.
 List or bring all your prescribed drugs, those drugs
Taken from CancerHelp UK, the patient information website of Cancer research UK:
you buy over the counter, herbal remedies and www.cancerhelp.org.uk
03/2011 - v2.00

supplements.
 Do not drink any alcohol and stop recreational
drugs 24 hours before the procedure as these

Page 1 of 3 Continues over page ►►►

 Consent Information - Patient Copy
Central Vascular Access Device Insertion

Implantable Port  The device may become blocked and need

A port is inserted entirely under your skin and has a medications to unblock or may need to be
catheter attached. The catheter is pushed (tunnelled) removed.
under your skin until it reaches the vein to be entered.  (Tunnelled and Non-tunnelled catheters only) The
All cuts are closed with sutures and dressings applied. device may be accidentally removed if pulled or
Totally implantable devices can stay in for months or tugged on.
even years.  Failure of local anaesthetic which may require a
further injection of anaesthetic or a different
method of anaesthesia may be used.
 Nerve damage, is usually temporary, and should
get better over a period of time. Permanent nerve
damage is rare.
Less common risks and complications include:
 Infection at the skin, requiring antibiotics and/or
further treatment.
 Infection in the device, requiring the device to be
removed.
 Pneumothorax, a collection of air around the lining
of the lungs. This usually resolves by itself but
sometimes may require a tube to be inserted into
the chest.
 Damage to surrounding structures such as blood
vessels, organs and muscles, requiring further
Taken from CancerHelp UK, the patient information website of Cancer research UK:
6.www.cancerhelp.org.uk
After the procedure treatment.
 Failure to gain access to the vein. This may
The recovery time varies depending on the device
inserted and the sedation given. It can be anywhere require a second attempt from a different location.
between 2 to 4 hours.  Blood clot blocking the vein may require
The IV cannula will be removed after you have medication to treat.
recovered.  An allergy to injected drugs, requiring further
Following the insertion of your device it is normal to treatment.
experience some tenderness and bruising for about 24 Rare risks and complications include:
to 48 hours. Panadol and ice packs may help this.  Injected medications may leak outside of the vein
You will be educated about your Central Vascular under the skin and into tissue, this may require
Access Device, how to take care of it and the treatment.
recommended level of activity advised while it is in  A fast or irregular heart beat. This usually resolves
place. on its own or may need further treatment.
 The catheter tip may move from the original
7. What are the risks of this specific placement. The device may need to be removed.
procedure?  An air bubble enters the blood stream. This can
The risks and complications with this procedure and travel to the heart causing a heart attack or to the
with having a device inserted can include but are not brain causing a stroke.
limited to the following.  An increased lifetime cancer risk due to the
Common risks and complications include: exposure to x-rays.
 Minor pain, bruising and/or infection from the IV  Seizures and/or cardiac arrest due to local
cannula. This may require treatment with anaesthetic toxicity.
antibiotics.  Death as a result of this procedure is very rare.
 Pain or discomfort at the insertion site. This may
require medication. If sedation is given extra risks include:
 Bleeding or bruising may occur. This is usually  faintness or dizziness, especially when you start
stopped by applying further pressure and/or ice to to move around
the puncture site. This is more common if you
 fall in blood pressure
take Aspirin, Warfarin, Clopidogrel (Plavix and
Iscover) or Dipyridamole (Persantin and  nausea and vomiting
03/2011 - v2.00

Asasantin).  weakness
 The device may become kinked and need  an existing medical condition getting worse
repositioning or removal.

Page 2 of 3 Continues over page ►►►

 © The State of Queensland (Queensland Health), 2011
Permission to reproduce should be sought from ip_officer@health.qld.gov.au
Consent Information - Patient Copy
Central Vascular Access Device Insertion

 heart and lung problems such as heart attack or

...........................................................................................................................................................................
vomit in the lungs causing pneumonia, emergency
treatment may be necessary ...........................................................................................................................................................................

 stroke resulting in brain damage.

...........................................................................................................................................................................

...........................................................................................................................................................................
8. What are the safety issues when you leave
the hospital? ...........................................................................................................................................................................

If you were sedated, this will affect your judgment for

...........................................................................................................................................................................
about 24 hours. For your own safety:
 Do NOT drive any type of car, bike or other ...........................................................................................................................................................................

vehicle.
...........................................................................................................................................................................
 Do NOT operate machinery including cooking
implements. ...........................................................................................................................................................................

 Do NOT make important decisions or sign a legal ...........................................................................................................................................................................

document.
 Do NOT drink alcohol, take other mind-altering ...........................................................................................................................................................................

substances, or smoke. They may react with the ...........................................................................................................................................................................

anaesthetic drugs.
 Have an adult with you on the first night after your ...........................................................................................................................................................................

procedure. ...........................................................................................................................................................................

...........................................................................................................................................................................
Take care not to pull on the device. Notify your nurse
or clinic immediately if your device has been tugged or ...........................................................................................................................................................................

has fallen out.

...........................................................................................................................................................................

Go to your nearest Emergency Department or GP if ...........................................................................................................................................................................

you become unwell or have;
 pain, unrelieved by simple pain killers ...........................................................................................................................................................................

 continuous bleeding or swelling at the skin around ...........................................................................................................................................................................

the catheter
...........................................................................................................................................................................
 redness or inflammation on the skin around the
catheter ...........................................................................................................................................................................

 a fever
...........................................................................................................................................................................
 swelling in the arm on the side the device is
inserted in ...........................................................................................................................................................................

 other warning signs you may have been asked to ...........................................................................................................................................................................

be aware of.
...........................................................................................................................................................................

Notes to talk to my doctor/ health practitioner ...........................................................................................................................................................................

about: ...........................................................................................................................................................................

............................................................................................................................................................................
...........................................................................................................................................................................

............................................................................................................................................................................
...........................................................................................................................................................................

............................................................................................................................................................................
...........................................................................................................................................................................

............................................................................................................................................................................ ...........................................................................................................................................................................

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03/2011 - v2.00

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Page 3 of 3