En 胸腔闭式引流术知情同意书

Modern Hospital Guangzhou

Informed Consent of Closed-Chest Drainage

Patient name：Sex：Age：Case No：

Brief description of disease and treatment recommendations

Closed-chest drainage is a procedure that a drainage tube is placed in the chest wall and a water-sealed drainage bottle is linked to the other end of the tube, which relieves intrathoacic pneumatosis and fluid and helps lung recruitment and recovery. The major indications are pneumothorax, hemothorax, hemopneumothorax, empyema, and other conditions after lung surgery and thoracic surgery. After surgery, patients should cough and deeply breathe more and do proper physical exercise to help the drainage of intrathoacic pneumatosis and fluid. At the meantime, the drainage tube should be kept unobstructed and not twisted, and also away from compression. The nurse should record the volume and nature of drainage as well as the fluctuation of water column. After the surgery, if there is no more gas relieved from the drainage tube, volume of drainage in 24 hours is less than 100ml (empyema is less than 30ml), and chest X-ray indicates satisfactory condition of lung recruitment, the chest tube can be removed.

Other

Potential risks and handling:

I have been informed that this procedure carries potential risks. However, certain uncommon risks are not included hereinto. The method of surgery should be individualized based on medical condition. I have been informed that I am entitled to discuss with my physician regarding the surgery and any associated special questions.

1．I understand that all anesthetic procedures carry potential risks.

2．I understand that all drugs might cause unwanted side effects, including mild symptoms such as nausea and rashes, serious anaphylactic shock, and even life-threatening events.

3．I understand the risks associated with this procedure and corresponding measures taken:

1)Allergic reactions to local anesthetic medications and drug toxic reactions or other

anesthetic accidents;

2)Cerebro-cardiovascular complications: cerebrovascular accident, arrhythmia,

respiratory and cardiac arrest, etc.

3)Pleural reactions: chest distress, cardiopalmus, dizziness, sweat, low blood pressure,

and shock, etc.

4)Local bleeding, effusion, errhysis, infection, or hematoma in incision site of chest

wall.

5)Injuries to intercostal blood vessels and lungs during the surgery, pneumothorax,

hemothorax, pneumohemothorax, subcutaneous emphysema after the surgery, or even

surgical procedures (thoracoscope or thoracotomy) will be adopted in critical

condition.

6)Tight adhesion of thoracic cavity found during the surgery results in unsuccessful

insertion of drainage tube ;

7)Poorly location of drainage tube and inadequate drainage may result in adjustment or

reinsertion of drainage tube.

8)Breaking, retention and obstruction of puncture needle or drainage tube;

9)Reexpansion pulmonary edema after surgery, and life-threatening risk in critical

condition.

10)After the surgery, large amounts of fluid drained continuously, gas leaked

continuously, or dissatisfactory lung recruitment, results in drainage tube remaining

for long time.

11)Injuries or stimulus to intercostal nerves result in pain and numbness after surgery;

12)Injuries to other organs in the abdominal cavity, in severe cases, surgery is required;

13)Infection of incisional wound and fat liquefaction result in undesirable or delayed

healing of wound;

14)Skin necrosis, sinus tract formation, and pleural adhesions in drainage tube site;

Delayed union or even disunion of wound and esthetic effection after pulling out the

tube.

4．I understand that patients with hypertension, heart disease, diabetes, renal insufficiency, venous thrombosis, etc or with a smoking history might have increased risks described above, or experience worsening of associated medical condition or episodes of cerebro-cardiovascular accident, even death during surgery or postoperatively.

5. I understand that if I don’t follow doctor’s order or in an inappropriate position, surgical effect may be affected.

Special risks or major high-risk factors

I understand that the following special complications or risks may occur under current medical condition, apart from the forementioned situations:

Appropriate measures will be taken in the case of the risks and accidents as described above. Choices of the patient’s informed consent

●I have been informed of the method of surgery, complications and risks that may

occur during surgery and postoperatively, and other possible treatment options.

All questions regarding this procedure have been properly answered.

●I agree that adjustments to scheduled method of surgery are allowed during

surgery based on the medical condition.

●I understand that this procedure requires the collaborative efforts by several

physicians.

●I am not ensured a 100% success of this procedure.

●I authorize affected organs, tissues and specimens as well as imaging data that

are involved in this procedure can be handled by the physician, which include

pathological and cytological examinations, scientific studies, medical waste

disposal, etc.

●For the best of knowledge, I have disclosed my medical condition to the

physician in a truthful and thorough manner. I shall bear all the consequences as

a result of hidden truth.

Signature of patient Date of signature DD MM YY Hr Min

ID No. Tel

Mailing address

Signature of authorized family member should be obtained in the event that the patient was unable to sign informed consent:

Signature of authorized family member Date of signature DD MM YY Hr Min

Relationship with the patient

ID No. Tel

Mailing address

Statement of physician

I have informed the patient of the method of surgery, complications and risks that may occur during surgery and postoperatively, and other possible treatment options, and answered all questions regarding this procedure.

Signature of physician Date of signature DD MM

YY Hr Min