Axillary Surgery CHA3229V1

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CONSENT FORM 1 (Patient copy)Procedure Specific Patient AgreementInfection: All surgery has a risk of infection. If the wound becomes red, hot or weeps, or you feelunwell you should consult your doctor. Treatment will involve taking antibiotics.DVT/PE: With all surgical procedures there is a risk of developing a clot in the deep veins of theleg, deep vein thrombosis (DVT). In a very small number of patients a bit of this clot breaks offand lodges in the lungs. This is a pulmonary embolus and in very extreme cases can be lifethreatening.Your surgical team will prescribe you compression stockings and/or blood thinningmedication after careful assessment of your individual risk.Risks specific to axillary surgeryReaction to blue dye: This may occur if your surgeon chooses this method of identifying thesentinel lymph node. The skin may become stained with blue around the site of injection andmay take months to fade. In a small number of patients this staining is permanent. A severereaction to the dye (anaphylaxis) has been reported and occurs in less than 1 in 1000 patients.If this occurs you may need to be monitored in an area of high dependency after your surgery,or your surgery may be abandoned.Pain: A degree of pain is likely after any surgery. We aim to manage your pain with painkillers toan acceptable level. In about 30 in 100 patients undergoing axillary surgery some degree ofpain continues beyond the early post-operative period. There is evidence to suggest that if weget on top of your pain in the early post-operative period we can reduce the chance of itbecoming a chronic problem. If the pain or numbness and tingling continues to be troublesomeplease let your surgeon or breast care nurse know and we can give you a medication tomanage the pain.Numbness: The nerves which supply sensation to the back and inner part of your upper armmay be damaged during the procedure. You may experience numbness and discomfort in thearmpit and upper arm. The numbness usually lessens slowly over time and you will becomeused to it.Shoulder stiffness: Your shoulder may become stiff after your operation. Performing theexercises from your information leaflet will help to prevent this.Seroma: This is a collection of fluid under the skin after surgery. It is quite common after axillaryclearance, but is easily treated by drainage through a small needle. Draining the seroma is avery simple procedure that can be done by a member of the Breast Team.Lymphoedema: This is swelling in the tissue below the skin caused by lymph fluid which cannotdrain away. This can occur when the lymph glands are removed (by surgery) or blocked (byradiotherapy). Your hand and arm may swell at any time after surgery. It can affect about 20 to30% of women but only around 5% to a significant degree. There are certain precautions youneed to take to prevent lymphoedema, these will be discussed with you by the BreastCare Team.Winged scapula: This is a rare complication which occurs if one of the nerves in your axilla isstretched or cut during the procedure. If it occurs the shoulder blade becomes prominent andyou may notice less function in your arm and shoulder. It occurs in less than 1 in 100 patientsand may resolve over time with physiotherapy. Occasionally if the nerve is cut it maybe permanent.Page 4 of 6 – Patient copyCHA3229 V1PILOT 06/2013 Review due 07/2013
CONSENT FORM 1 (Patient copy)Procedure Specific Patient Agreement……… Axillary surgery+/- Sentinel node biopsy+/- Intraoperative assessment (OSNA)+/- Axillary clearanceSTATEMENT OF HEALTH PROFESSIONAL (to be filled in by health professional with appropriateknowledge of proposed procedure, as specified in consent policy)I have explained the procedure to the patient. In particular, I have explained the intended benefitsand summarised the risks, as below:• To determine whether the lymph nodes under your arm contain cancer and remove all the lymphnodes if they contain cancerSignificant, unavoidable or frequently occurring risks:• Bleeding, infection, DVT/PE, reaction to blue dye, pain, numbness, shoulder stiffness, seroma,lymphoedemaUncommon but more serious risks:• Anaphylaxis to blue dye, winged scapulaRare but serious risks:• Anaesthetic risk which includes a very small risk to life or limb from complications such as heartattack and stroke.Any extra procedures which may become necessary during the procedure:• Blood transfusion (required very infrequently)• Other procedure (please specify):I have also discussed what the procedure is likely to involve, the benefits and risks of anyavailable alternative treatments (including no treatment) and any particular concerns of this patient.I have given and discussed the Trust’s approved patient information leaflet for this procedure:Axillary surgery CHA3229 which forms the first four pages of this document.I am satisfied that this patient has the capacity to consent to the procedure.This procedure will involve:General and/or regional anaesthesia Local anaesthesia SedationHealth Professional signature:Date:Name (PRINT):Job title:STATEMENT OF INTERPRETER (where appropriate)I have interpreted the information above to the patient to the best of my ability and in a way in which Ibelieve he/she can understand.Interpreter signature: Name (PRINT): Date:Page 5 of 6 – Patient copyCHA3229 V1PILOT 06/2013 Review due 07/2013
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Axillary Surgery CHA3229V1

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