Informed Consent Discussion for Central Venous Catheter Placement in the PICU

Doctor, can you please explain why he needs this line? Is there another way?

Absolutely. I'm really glad you asked. So right now, Noah is needing an exceptional amount of medications as well as frequent blood draws. Whenever that's the case, as a team, we discuss whether or not it would be beneficial for the, a patient to have something called a central venous catheter.

Okay... a central venous catheter. What does that mean exactly? How is it different from the I V he already has in his arm?

Correct. It's different in two primary ways. The first of which is the length of the catheter. So it's longer than a typical I V, like the one he has in his arm. This provides added benefit in that it's stable and is less likely to come out with him moving around as a child who's five-year-old, uh, five years old typically does. The second way that it differs from, um, the I V that he has in his armis that it is in a much bigger vessel, in a bigger vein, and that allows it to actually deliver more medications at faster rates.

Okay... so it stays in better and can give him more medicine at once. ...

Yes. I'm sorry, I didn't quite hear you. What was that you said?

I said, okay... so it stays in better and can give him more of the medicine he needs. But... is it dangerous? Where does it actually go in his body?

Correct. Of course. So, I'm gonna answer those two questions separately. Let's first focus on the location. What we do before we start the procedure is our team will come in with an ultrasound. We will look at various locations, most likely in, um, his neck and in his legs, in his groin area, to determine which vessel would be the best vessel to uti-utilize, okay? The safest and, um, the most likely for us to succeed on a first attempt. So typic- just to, um, summarize there, these ve- uh, these catheters will either go in a neck vein or a vein that is in his groin. Okay?

Okay... his neck or his groin. And...

Yes. In terms of what complications are possible with this, as with any procedure where we're breaking the skin, there's always a risk of bleeding and infection. Okay? Um, to minimize the risk of infection, when we do the procedure, all the instruments we use are single-use, and they come from a sterile kit. We also are, um, fully, uh, the people who are doing the procedure all have sterile,uh, caps, gowns, and masks on, and no one without a sterile cap, gown, and mask is allowed in the room at the time of the procedure. To minimize the risk of, um, bleeding, what we do is, um, essentially, we make sure that he is not having any increased risk of bleeding, and right now, he's not. And then secondarily, we use an ultrasound as we're placing the IV to minimize how many times we would haveto attempt placing that IV, which then also reduces risk of bleeding. Okay? There are a couple other, um, complications that I want to make sure we discuss, but I want to see if you have any questions about those two risks before I proceed.

No... I understand that part. But... what about his lung? I've heard something before about lines like this and lungs. Could it hurt his lung?

Okay. Absolutely. I'm really glad you asked. So, injury to the lung is more common and exactly only common when the line is placed, uh, in the neck vein. Okay? Um, the particular injury that children can sometimes sustain is called a pneumothorax, which is essentially when part of the lung collapses on itself.Because of air that's introduced from the catheter, um, in a place that there wouldn't usually be g- uh, be air in the chest wall. Okay? Sometimes if that pneumothorax is big enough, it would require that he would get an additional chest tube to reinflate the lung, although that is, um, not frequently the case. Okay? So it is a known complication, but things like how we position the patient and using the ultrasound are...Tactics we use to minimize the risk of the pneumothorax.

Oh... a collapsed lung. That sounds really scary. So the groin would be safer for his lung then? Would you consider doing it there instead?

Mm-hmm. Mm-hmm. We certainly would. Um, yes. Essentially, if you, if we did the line in the groin, uh, the risk of the pneumothorax in the lung would be nothing. Okay? Um, the issue with, uh, line in the groin, uh, it has different risks. So the chances of it getting dirtier, because as you can imagine, there's pee and stool closein the vicinity, um, are a little bit higher than if, um, if we just did a line in the neck. And then secondarily, it's a little bit harder for children to move, uh, with a line in their leg versus their neck. So if it were the case where Noah still required a line and was awake enough to walk around, we wouldn't be able to allow him to do that because of the line in the vein. Or, um, excuse me, excuse me, the line in the leg vein. Okay? Um, I can say thatseldom is it the condition though, or is it the case that kids are improving enough to the point where they're walking around and they still require that central line. So I think if he's, you know, getting to the point where he's improved enough and mobile, we would also be able to remove that line, because we do, as a team, assess every day whether or not a child truly needs that line to minimize the risk of injury to the surrounding structure and infection.

Okay... that makes sense. So you'll pick the safest spot for him. ...

Absolutely.

...

I'm sorry. Okay. What was that?

Sorry... I was just thinking. Will he be awake for this? Will it hurt him?

No. Um, we take patient comfort exceptionally seriously.In the pediatric ICU. Okay? So this is a sedated procedure. It's not full anesthesia like a child has when they undergo, um, when they undergo surgery and need a breathing tube. But, um, we do essentially use some medicines to make sure that he does not feel or remember the procedure.

Okay... that's...

Okay. Mm-hmm. If it's okay with you, I do wanna, um, talk about one other risk, in full transparency, of a central venous catheter.

Yes... please. I want to know everything.

Okay. Excellent. The other risk I wanna mention is sometimes the catheters can develop a clot, like a blood clot, around the catheter site. Okay? Our bodies are very good at detecting, um, injury to blood vessels and foreign bodies, which essentially this type of IV is. So occasionally, and especially so when children are sick, a clot can form around thecentral venous catheter site.

A...

What that would look... Yes. Um, what that would look like for Noah if it bec- if that happened and he, and became symptomatic, is we might to see s- um, see some discoloration at the site of the IV, um, or some leg swelling if we used the leg. Okay? We, on a regular basis, um, are looking at the site. It's, it's part of both the nurses' and the doc- the doctor's job multiple times through a shift to assess how anIV line or a central venous line is working. And so, as soon as there's any sign of a potential clot, um, lip smack we take action to get an ultrasound to see if it's, um, if there is evidence of a clot. And then if there is, we remove the catheter, and if needed, um, start medication to break up that clot.

Okay... a clot. So you watch for it closely. ...

Yes.

What... what happens if we don't do this? Is there any other choice?

There is. Um, in everything we do in medicine, and, uh, especially everything we do in a pediatric ICU, has a risk and benefit. Um, seldom is there only one right way to proceed. We could, for the time being, attempt to, if you will, just get by with the IVs that Noah has in his arms. Okay? Um, this would allow us to give medications, and there is one IV currently working that allows usto obtain blood. Although, um, the reliability of that IV is uncertain. So, if that IV stops being able to allow us to draw back blood from it, then what that would mean for Noah is that whenever we needed blood, we would have to poke him, um, in a vein as a blood draw to obtain the blood we need for testing.

Oh... so he'd get poked over and over again. ...

Mm-hmm. Key what?

I said... he'd get poked over and over. That's... that's a lot for a little boy...

It really is.

Okay... and you would be the one placing this line? Who actually does the procedure?

Mm-hmm. I would be the one placing the line, and then, uh, with me in the room, there would also be an ICU attending who was responsible solely for supervising me and providing direction. And then there would be another ICU attending in the room who is responsible solely for providing the sedation Noah needs to keep him calm, comfortable, and to make sure he doesn't remember the procedure. That doctor is also making sure that Noah's vitals stay normal and acceptable throughout the procedure.

Okay... so there's a whole team, and someone just watching him the entire time. That... that helps. How long will the line stay in? Will he need surgery to take it out?

Mm-hmm. The length of the line needed is uncertain. It really depends on his clinical course and how we are able to wean him off some of the medications that he currently requires for treatment. So that, I wish I had a better, more direct answer, but I, I don't really know right now. In terms of surgery for removal, he will not need surgery for removal. It's actually quite a simple procedure, and, um, lip smacks all it entailsis removal of the special bandage overneath, or over the insertion site for that IV. And then because it is sutured in to make sure that it stays still and in, uh, the bedside nurse is typically the one to remove it. He or she will cut the sutures, place a gauze over the site of insertion, and then pull the line out. We typically hold pressure a little bit, and then honestly, it's covered with a Band-Aid.

Oh... okay. Just a...

Mm-hmm. Yeah. Mm-hmm. And children, um, another important part to mention is that children don't require ongoing sedation for that. It typically happens within three to five minutes. Sometimes younger children are very anxious about that, especially depending where the line is placed, and so we may give them a one-time dose of medication to keep them calm. Um, but it's not ongoing sedation the way we do for the placement of the line.

Okay. That's... that's a relief. I think... I think I understand now. Can you just... make sure I've got it right? He needs this because the I V he has might not last, and he needs a lot of medicine and blood draws. You'll pick the safest spot, either his neck or his groin, using an ultrasound. He'll be sedated so it won't hurt. And the main risks are bleeding, infection, a clot, or... a collapsed lung if it's in the neck. Did I get that right?

Mm-hmm. You absolutely did. What else can I answer for you,though?

No... I think you've answered everything. Thank you for being so honest with me and taking the time...

Of course. I'm happy to do that. Would it be okay if I go over the true, uh, the actual paperwork with you right now? Ma'am? Okay.