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IVC Filter Removal - Queensland Health - ivc filter removal complications


IVC Filter Removal - Queensland Health-ivc filter removal complications

(Affix identification label here)
URN:
Family name:
IVC Filter Removal Given name(s):
Address:
Facility: Date of birth: Sex: M F I
A. Interpreter / cultural needs Less common risks and complications include:
An Interpreter Service is required? Yes No Infection, requiring antibiotics and further
If Yes, is a qualified Interpreter present? Yes No treatment.
A Cultural Support Person is required? Yes No A blood clot at the puncture site may form,
disrupting the blood flow from the legs, arms or
If Yes, is a Cultural Support Person present? Yes No head. This may require treatment with
B. Procedure medications.
Blood clots trapped in the IVC Filter may dislodge
The following will be performed (Doctor/doctor during removal and travel to the lungs or block
delegate to document - include site and/or side where other blood vessels in the body.
relevant to the procedure) Damage to surrounding structures such as blood
........................................................................................................................................................................... vessels, organs and muscles, requiring further
treatment.
........................................................................................................................................................................... An allergy to injected drugs, requiring further
...........................................................................................................................................................................
treatment.
The removal of an Inferior Vena Cava Filter is a The procedure may not be possible due to
procedure that removes the small metal device (filter) medical and/or technical reasons.
that is currently implanted in your Inferior Vena Cava Rare risks and complications include:
(IVC). An increased lifetime cancer risk due to the
This procedure will require an injection of a local exposure to x-rays.
anaesthetic. Sometimes it will require the use of a Seizures and/or cardiac arrest due to local
sedation anaesthetic. anaesthetic toxicity.
Death as a result of this procedure is possible
C. Risks of the procedure
In recommending the IVC Filter Removal, the doctor If sedation is given extra risks include:
believes the benefits to you from having this faintness or dizziness, especially when you start
procedure exceed the risks involved. to move around
The risks and complications with this procedure can fall in blood pressure
include but are not limited to the following. nausea and vomiting
Common risks and complications include: weakness
Minor pain, bruising and/or infection from the IV an existing medical condition getting worse
cannula. This may require treatment with heart and lung problems such as heart attack or
antibiotics. vomit in the lungs causing pneumonia. This may
Pain or discomfort at the puncture site. This may require emergency treatment
require medication. stroke resulting in brain damage.
Bleeding or bruising could occur. This is usually
stopped by applying pressure and/or ice to the
puncture site. This is more common if you take D. Risks of Iodinated Contrast for patients
Aspirin, Warfarin, Clopidogrel (Plavix and Iscover) with renal impairment
or Dipyridamole (Persantin and Asasantin). Specific Risks of Iodinated Contrast to patient's
The IVC Filter may not be able to be removed for identified as having Renal Impairment.
technical or medical reasons. Giving the Contrast to people with weakened
Failure of local anaesthetic which may require a kidneys (renal impairment), can cause further
further injection of anaesthetic or a different kidney damage, which may in turn cause the
method of anaesthesia may be used. kidneys to stop working properly (acute renal
Nerve damage, is usually temporary, and should failure).
get better over a period of time. Permanent nerve
damage is rare. ...........................................................................................................................................................................
...........................................................................................................................................................................
...........................................................................................................................................................................
Page 1 of 2 Continues over page
PROCEDURAL CONSENT FORM
v3.00 - 03/2011 DO NOT WRITE IN THIS BINDING MARGIN ? The State of Queensland (Queensland Health), 2011
Permission to reproduce should be sought from ip_officer@health.qld.gov.au
SW9256
(Affix identification label here)
URN:
Family name:
IVC Filter Removal Given name(s):
Address:
Facility: Date of birth: Sex: M F I
E. Patient consent I request to have the procedure
I acknowledge that the doctor/doctor delegate has Name of Patient:..........................................................................................................................
explained the proposed procedure. Signature: ..........................................................................................................................................
I understand; Date: ......................................................................................................................................................
the risks and complications, including the risks Patients who lack capacity to provide consent
that are specific to me. Consent must be obtained from a substitute decision
the sedation/anaesthetic required for this maker/s in the order below.
procedure. I understand the risks, including the Does the patient have an Advance Health Directive
risks that are specific to me. (AHD)?
that no guarantee has been made that the Yes Location of the original or certified copy of the AHD:
procedure will improve my condition even though
it has been carried out with due professional care. ................................................................................................................................................................
if immediate life-threatening events happen No Name of Substitute
during the procedure, they will be treated based Decision Maker/s: ...............................................................................................................
on my discussions with the doctor/doctor delegate
or my Acute Resuscitation Plan. Signature: .....................................................................................................................................
a doctor/doctor delegate undergoing further Relationship to patient:.................................................................................................
training may conduct this procedure. Date: ....................................................... PH No:..................................................................
I have been given the following Patient Source of decision making authority (tick one):
Information Sheet/s: Tribunal-appointed Guardian
IVC Filter Removal Attorney/s for health matters under Enduring Power
Iodinated Contrast of Attorney or AHD
Statutory Health Attorney
I was able to ask questions and raise concerns If none of these, the Adult Guardian has provided
with the doctor/doctor delegate about the consent. Ph 1300 QLD OAG (753 624)
proposed procedure and its risks. My questions
and concerns have been discussed and F. Doctor/delegate Statement
answered to my satisfaction.
I understand I have the right to change my mind I have explained to the patient all the above points
at any time including after I have signed this form under:
but, preferably following a discussion with my the Patient Consent section (E)
doctor/doctor delegate. Iodinated Contrast - Patients with Renal
I understand that image/s or video footage may Impairment Section (D) (for renal impaired
be recorded as part of and during my procedure patients only)
and that these image/s or video/s will assist the and I am of the opinion that the patient/substitute
doctor to provide appropriate treatment. decision-maker has understood the information.
I understand that Queensland Health may release Name of
my relevant de-identified information obtained Doctor/delegate:.......................................................................................................................
from this and related procedures for education Designation:..................................................................................................................................
and training of health professionals. Signature:................................................................. Date...................................
On the basis of the above statements, G. 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...................................
Page 2 of 2
DO NOT WRITE IN THIS BINDING MARGIN
03/2011 - v3.00
Consent Information - Patient Copy
IVC Filter Removal
1. What is an IVC Filter removal? Do not drink any alcohol and stop recreational
The removal of an Inferior Vena Cava Filter is a drugs 24 hours before the procedure as these
procedure that removes the small metal device (filter) may alter the affect of the sedation anaesthetic. If
that is currently implanted in your Inferior Vena Cava you have a drug habit please tell your doctor.
(IVC). The IVC is the main blood vessel in your 5. During the procedure
abdomen that carries blood from your legs back to A fine needle (IV cannula) will be put into a vein in
your heart. your arm.
Your doctors have decided that you no longer need The Radiologist (x-ray doctor) will inject local
this device and it can be removed. It is removed by anaesthetic into the skin. A needle and catheter are
placing a needle and thin plastic tube (catheter) into a inserted into the vein in your neck. Once the catheter
vein in your neck. is in place the needle is removed.
Iodinated `Contrast' is used to map your veins so the The catheter is guided through the main blood vessels
doctor can check the filter and your IVC before in your body until it reaches the IVC. You should not
removal. For more information on Iodinated Contrast be able to feel the catheter inside your body.
and the risks involved in its use, please read the X-ray pictures are taken while the Contrast is injected
Iodinated Contrast Patient Information Sheet. (If into your IVC.
you do not have this information sheet please ask for
one). A special removal catheter or `snare' is inserted and
attached to the implanted filter `capturing' it. The
2. Will there be any discomfort, is any
catheter and filter are removed from the vein.
anaesthetic needed? Once the filter has been removed, firm pressure will be
This procedure will require the injection of local
put over the area where the catheter went into your
anaesthetic. Sometimes it may a sedation anaesthetic.
skin (puncture site). This allows the veins to seal over
so you will not bleed.
3. What is sedation? 6. After the procedure
Sedation is the use of drugs that give you a `sleepy- The recovery time varies depending on the sedation
like' feeling. It makes you feel very relaxed during a given. It varies between 2 to 4 hours.
procedure that may be otherwise unpleasant or The IV cannula will be removed after you have
painful. You may remember some or little about what recovered.
has occurred during the procedure.
This procedure may only have a light sedation. You Staff will discuss with you what level of activity is
need to be able to fully co-operate at times by holding suitable after your procedure.
your breath when instructed by the doctor.
Sedation is generally very safe but has a risk with side 7. What are the risks of this specific
effects and complications. Whilst these are usually procedure?
temporary, some of them may cause long-term The risks and complications with this procedure can
problems. include but are not limited to the following.
The risk to you will depend on: Common risks and complications include:
- whether you have any other illness Minor pain, bruising and/or infection from the IV
- personal factors, such as whether you smoke or are cannula. This may require treatment with
overweight. antibiotics.
Pain or discomfort at the puncture site. This may
require medication.
4. Preparation for the procedure Bleeding or bruising could occur. This is usually
The medical imaging department will give you stopped by applying pressure and/or ice to the
instructions on how to prepare for your procedure. puncture site. This is more common if you take
You will be told when to have your last meal and Aspirin, Warfarin, Clopidogrel (Plavix and Iscover)
drink. This is to make sure your stomach is empty or Dipyridamole (Persantin and Asasantin).
so that if you vomit during the procedure there will The IVC Filter may not be able to be removed for
be nothing to go into your lungs. technical or medical reasons.
Please tell the staff if you are or suspect you might Failure of local anaesthetic which may require a
be pregnant or are breastfeeding. further injection of anaesthetic or a different
List or bring all your prescribed drugs, those drugs method of anaesthesia may be used.
you buy over the counter, herbal remedies and Nerve damage, is usually temporary, and should
supplements. get better over a period of time. Permanent nerve
damage is rare.
Page 1 of 2 Continues over page
? The State of Queensland (Queensland Health), 2011
03/2011 - v3.00 Permission to reproduce should be sought from ip_officer@health.qld.gov.au

Should I Have my IVC filter removed?Retrievable IVC filters should be removed as soon as it is reasonable to do so (in many patients, this can be 2-3 weeks after anticoagulation is begun). Prophylactic placement of IVC filters in patients at risk of DVT is common, though controversial; these patients in particular should have their IVC filters removed as soon as possible, to avoid preventable complications.

Pdf INFO

Title: IVC Filter Removal
Subject: IVC Filter Removal
Keywords: Informed, consent, Medical Imaging, IVC, Filter, Removal, xray, x-ray, radiology
Author: Patient Safety Centre - Informed Consent
Creator: PScript5.dll Version 5.2.2
Producer: Acrobat Distiller 9.2.0 (Windows)
CreationDate: Tue Apr 5 14:22:35 2011
ModDate: Tue Jun 7 10:26:19 2011
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Form: AcroForm
Pages: 5
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Page size: 595.22 x 842 pts (A4) (rotated 0 degrees)
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