Robert C Wright, MD, PS – Puyallup, Washington
Informed Consent – Central Venous Catheter
Placement
We are considering the placement of a special intravenous line into you. This line may be used for
a number of reasons, depending upon your condition. The purpose for placement of the line will be
indicated below.
____ 1. Close hemodynamic monitoring.
____ 2. Administration of special medications.
____ 3. Administration of hyper-alimentation (feeding by vein).
Description of the Procedure
A central venous catheter may be placed on either the right or left side. It may be placed into the
subclavian vein, in which a needle will be inserted under your clavicle (collar bone). It may also be
placed into your internal jugular vein, with the needle entering into the neck. You are placed on
your bed with your head slightly down and a roll between your shoulders. You will be given local
anesthesia, and a needle will be inserted into the appropriate vein. This needle is used to guide a
catheter into the vein down to a level just above your heart. The catheter is secured to the skin and
a dressing is placed. A chest X-ray is always obtained after this procedure to confirm that the line
was placed properly.
Risks/Complications of Treatment
Treatment risks fall into two categories; those that could happen during any procedure, and those
that are specific for the central venous catheter placement. In any medical treatment, it is
impossible to predict all the things that could go wrong. Fortunately, complications are the
exception rather than the rule. Every reasonable effort is made to avoid complications. The most
common possible complications are as follows:
Possible complications of procedure
1. Bleeding – this is a problem that could happen any time the skin is cut.
2. Infection – we take special care to prevent an infection, but it is always a possibility.
3. Reactions to medications – this could be many things, from a minor rash to possible death.
Possible complications of placement of a central venous catheter
1. Pneumothorax – this is where your lung collapses from air let into the pleural space from the
needle.
2. Arrythmias – because the catheter is placed close to your heart, it may occasionally cause
rhythm problems. We will determine the appropriate monitoring for you while placing the
catheter.
3. Injury to a major blood vessel – rare occasions, the catheter may injure a large blood vessel,
requiring you to go to the operating room to have it repaired.
4. Inability to pass the catheter – there are a number of reasons why we may occasionally not
be able to get the catheter into the correct vein. Should this be the case, we will terminate
the procedure and discuss other options.
(see other side)
Consent for Treatment
I understand my need for a central venous catheter. I have read and understand the above
explanation of the procedure being proposed. My surgeon has answered my questions, and I
choose to proceed with surgery.
I understand that every operation may yield unexpected finding. I give the surgeon
permission to act on his best judgment in deciding to remove or biopsy tissues that appear to
be diseased, understanding that complications may arise from that action.
I understand that while most people who need a central venous catheter will benefit from the
same, I may not. My condition may not improve, and it may worsen. No absolute guarantee
can be made.
HIPPA: Before and after surgery, unless otherwise requested in writing by you, visitors whom
you invite to attend the surgery will be informed of the surgical finding, your surgical status,
and anticipated recovery issues for effectiveness of communications. Because of the anesthetic,
you may or may not remember these important details.
PRINT NAME OF PATIENT __________________________________________________________________
SIGNATURE __________________________________________________________ DATE _________________
WITNESS ____________________________________________________________ DATE _________________
SURGEON ____________________________________________________________ DATE _________________
RELATIONSHIP TO PATIENT IF SIGNATURE OF LEGAL GUARDIAN ___________________________________
____ I waive the right to read this form, and do not want to be educated and informed of
treatment risks; nonetheless, I understand the need for this surgery and grant permission to
the surgeon to proceed on my behalf.
SIGNATURE _____________________________________________________ DATE _________________
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