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Procedural consent form

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Carotid Stenting

 

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"#$%&%'() **********************************************************************************************************************************************

 

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!B!!!!!

 

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  • A. Interpreter / cultural needs

 

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Less common risks!and complications include:

B. Procedure
B.
Procedure

O50!-3&&3Y%1D!Y%&&!40!/06-36;02!(Doctor/doctor

delegate!to document – include site and/or side where relevant to the procedure)

****************************************************************************************************************************************************************************!

****************************************************************************************************************************************************************************!

****************************************************************************************************************************************************************************!

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Rare Risks!and complications include:

  • C. Risks of the procedure

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Common risks!and complications include:

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+,--%.!/#'%01'!%201'%-%$#'%31!&#40&!50607! ! 89:)! "#;%&(!:#;0)! Carotid Stenting <%=01!:#;0>)! ,2260>>)! ! "#$%&%'() ********************************************************************************************************************************************** ?#'0!3-!@%6'5)! A0.)!! !B!!!!! !"! D.
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"#;%&(!:#;0)!
Carotid Stenting
<%=01!:#;0>)!
,2260>>)!
!
"#$%&%'() **********************************************************************************************************************************************
?#'0!3-!@%6'5)!
A0.)!! !B!!!!! !"!
D.
Risks of iodinated contrast for
patients with renal impairment
V1!'50!4#>%>!3-!'50!#43=0!>'#'0;01'>P!
!
I request to have the procedure
Specific Risks!3-!K32%1#'02!L31'6#>'!'3!/#'%01'M>!
%201'%-%02!#>!5#=%1D!Renal Impairment.
Name of Patient/
Substitute decision
maker and relationship: .......................................................................................................
! <%=%1D!'50!L31'6#>'!'3!/03/&0!N%'5!N0#O0102!
O%210(>!+601#&!%;/#%6;01'7P!$#1!$#Q>0!-Q6'506!
Signature: ............................................................................................................................................
O%210(!2#;#D0P!N5%$5!;#(!%1!'Q61!$#Q>0!'50!
O%210(>!'3!>'3/!N36O%1D!/63/06&(!+#$Q'0!601#&!
Date:
...................................................................
……………………………………………………………
...
-#%&Q607*!!
Substitute Decision-Maker:!!81206!'50!Powers of Attorney Act
1998 and/or the Guardianship and Administration Act 2000*!K-!'50!
!
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E.
Patient consent
!
!
!
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F.
Doctor / doctor delegate statement
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Name of
/63$02Q60*!K!Q1206>'#12!'50!6%>O>P!%1$&Q2%1D!'50!
Consenter:
..........................................................................................................................................
6%>O>!'5#'!#60!>/0$%-%$!'3!;0*!
!
Designation: .....................................................................................................................................
I have been given the following Patient
Information Sheet/s:
Signature: ............................................................................................................................................
Date:
……………………………………………………………
!
!
!!Carotid Stenting
!
Iodinated Contrast
G.
Interpreter’s statement
  • About your Anaesthetic +%-!#//&%$#4&07

!

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K!5#=0!D%=01!#!>%D5'!'6#1>&#'%31!%1!

***************************************************************************************************************************************************************************

(state the patient’s language here)!3-!'50!$31>01'!

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DQ#62%#1H>Q4>'%'Q'0!20$%>%31I;#O06!4(!'50!23$'36*!

Name of

Interpreter: .........................................................................................................................................

Signature: ...........................................................................................................................................

Date:

…………………………………………………………… ..

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>?G)>>?!H!I!)E>!

>?G)>>?!H!I!)E>! Consent Information - Patient Copy Carotid Stenting 1. What is a Carotid Stenting? J!*#1',-9!6,%+,!-/!#!21'A%9.1%!-+!K5-A5!#!/@#88!@%,#8! @%/5!,.B%!-/!28#A%9!-+,'!,5%!+#11'K%9!2#1,!'(!,5%!

Consent Information - Patient Copy Carotid Stenting

  • 1. What is a Carotid Stenting?

J!*#1',-9!6,%+,!-/!#!21'A%9.1%!-+!K5-A5!#!/@#88!@%,#8!

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-+0'80%9!-+!-,/!./%=!28%#/%!1%#9!,5%!Iodinated

Contrast Patient Information Sheet!(If you do not have this information sheet please ask for one).

!

  • 2. Will there be any discomfort, is any anaesthetic needed?

45-/!21'A%9.1%!K-88!1%F.-1%!#+!-+R%A,-'+!'(!8'A#8!

#+#%/,5%,-A!#+9!,5%!./%!'(!#!/%9#,-'+!'1!$%+%1#8!

#+#%/,5%,-AE!M(!L'.!#1%!B''Q%9!('1!#!$%+%1#8!

#+#%/,5%,-A!28%#/%!1%#9!,5%!About your Anaesthetic! 2#,-%+,!-+('1@#,-'+!/5%%,!(If you do not have this information sheet please ask for one).!!

  • 3. What is sedation?

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A#./%!8'+$H,%1@!21'B8%@/E!

  • 4. Preparation for the procedure

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-+/,1.A,-'+/!'+!5'K!,'!21%2#1%!('1!L'.1!21'A%9.1%E!!!

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@-$5,!B%!21%$+#+,!'1!#1%!B1%#/,(%%9-+$E!

! 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 #/Q!L'.1!9'A,'1G5%#8,5!21#A,-,-'+%1!-(!

L'.!/5'.89!/,'2!,#Q-+$!-,!B%('1%!,5%!21'A%9.1%!#/!

-,!@#L!#((%A,!L'.1!B8''9!A8',,-+$E!!

! List or bring all your prescribed drugs, those drugs you buy over the counter, herbal remedies and supplements.

! Do not drink any alcohol!#+9!stop recreational

drugs!)V!5'.1/!B%('1%!,5%!21'A%9.1%E!M(!L'.!5#0%!

#!91.$!5#B-,!28%#/%!,%88!L'.1!9'A,'1E!

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!
!
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  • 5. During the procedure

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L'.1!#1@E!!!

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B'9LE!

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Health), 2009

(Qu fficer eens @health.qld.gov.au land

from ip_o

Queensland

State be of sought

should

© The

Permission to reproduce

09/2009 - V 1.0

09/2009 - V 1.0 Patient Information Sheet Iodinated Contrast 1. What is Iodinated Contrast? The

Patient Information Sheet Iodinated Contrast

  • 1. What is Iodinated Contrast?

The medical imaging procedure your doctor has asked you to have uses Iodinated ‘Contrast’ (once called X- ray dye). Contrast is a colourless liquid which includes iodine. Contrast is injected into your blood stream to allow your organs to be seen more clearly on x-rays. Contrast is not a dye. It does not stain the inside of your body. Your doctor needs to use Contrast to be able to get all the information needed to assist with your diagnosis.

This information sheet must be read together with the information sheet of the procedure you are

booked for (if you do not have this information sheet please ask for one).

  • 2. During the procedure

When the Contrast is injected you may feel:

  • - A very warm or ‘flushed’ feeling over your body,

this may also make you think you have passed urine. You will not pass urine – it is only a feeling.

  • - A ‘metallic’ taste or smell may also happen. This usually lasts less than a minute.

  • 3. After the procedure

It is recommended that you drink 2 to 4 glasses of water after your procedure to help flush the Contrast from your body.

Contrast does not affect your ability to carry out normal activities; you should be able to continue with your day as normal.

  • 4. Precautions

Contrast is not suitable for some people; you will be asked a series of questions before it is given to you. Your answers allow staff to identify any risk factors that you may have.

Please tell the staff if you are or suspect you might be pregnant or are breastfeeding.

Kidney function

Contrast is removed from your blood by your kidneys through your urine. It is easily removed from the body of people who have normal kidney function.

Giving Contrast to people with weakened kidneys (renal impairment), can cause further kidney damage, which may in turn cause the kidneys to stop working properly (acute renal failure).

You may be asked to have a simple blood test to find out the level of their kidney function.

Diabetic Drug interactions - Metformin

(Other Drug names: Avandamet, Diabex, Diaformin, Formet, Glucohexal, Glucomet, Glucophage, Glucovance, Metforbell)

If kidneys suffer damage from the Contrast then the kidneys may not be able to remove Metformin from the body. It is safer to briefly stop taking Metformin when having Contrast. Staff will inform you when to stop and when it is safe to take Metformin again.

Contact your GP to monitor your diabetes if you are told to stop your Metformin.

5.

What are the risks of Iodinated Contrast?

The risks and complications with this injection can include but are not limited to the following.

Common risks and complications include:

No known common risks.

Less common risks and complications include:

Injected Contrast may leak outside of the blood vessel, under the skin and into the tissue. This may require treatment. In very rare cases, further surgery could be required if the skin breaks down.

Acute Renal Failure occurs when one or both of your kidneys suddenly stop working. Failure can last for days or weeks. It may take the kidneys a long time to regain their previous level of function and you may require dialysis to filter your blood during this time. There is a risk your kidneys could be permanently damaged. To reduce this risk the smallest possible dose of Contrast will be given.

The injection may not be possible due to medical and/or technical reasons.

Rare risks and complications include:

Allergic reactions occur within the first hour with most happening in the first 5 minutes. Late reactions have been known to occur up to a week after the injection.

Note: Allergy to topical iodine and/or seafood does not imply an allergy to Iodinated Contrast.

The reactions vary from:

 

Mild – hives, sweating, sneezing, coughing, nausea. Moderate – wide spread hives, headaches, facial swelling, vomiting, shortness of breath.

Severe – Severe reactions are rare but include: life- threatening heart palpitations, very low blood pressure, throat swelling, fits and/or cardiac arrest.

Death as a result of Iodinated Contrast is very rare.

6.

What are the safety issues when you leave the hospital?

Go to your nearest A&E (Accident and Emergency) department or GP if you become unwell.

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