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ANESTHESIA CONSENT FORM
Because you, in consultation with your surgeon, have decided to have surgery
requiring anesthesia, IT IS IMPORTANT THAT YOU, THE PATIENT, READ THIS
CONSENT FORM CAREFULLY.
General anesthesia involves making the patient unconscious using intravenous drugs
(such as sedatives, narcotics, and muscle relaxants) and inhalational agents (such as
nitrous oxide, oxygen, and anesthetic gases). This frequently involves the use of a
breathing tube, which is inserted into the windpipe to insure proper breathing while
you are under anesthesia. It is not possible to inform you of every agent to be used or
dosage to be given since this is determined by the patient's reactions and the needs
of surgery.
Side effects and complications of general anesthesia are relatively uncommon, but
can occur. While it is impossible to advise you of every conceivable complication,
some possible examples are;
Soreness of the throat and hoarseness are very common occurrences.
Aspiration (inhaling stomach contents into the lungs), asthma attacks, and
Pneumonia.
Nerve injuries and possible weakness or paralysis.
Allergic-type reactions leading to cardiac arrest and death.
Nodules, polyps, or other damage to the vocal cords or windpipe.
Possible traumatic damage to larynx (voice box), pharynx (throat), esophagus,
lung or surrounding structures.
Blood transfusions may be required. If so, there is some risk of hepatitis, AIDS, or
other infections or reactions. No tests exist which can prevent every possibility of
blood infected with hepatitis or AIDS being transfused.
Rarely, there may be recall of events during the procedure. This is more common
during anesthesia for cesarean section, heart and emergency surgery.
Sometimes dreams during anesthesia are confused with recall of real events.
A breathing machine may be required after surgery, which could lead to damage to
the windpipe.
Medical complications involving damage to the eyes, heart, lungs, and circulatory
system such as blindness, stroke, blood clots, abnormal heart rhythms,
phlebitis, collapsed lung, and heart attack.
Possible traumatic injury to the jaw which may include dislocation, arthritis,
temporomanidibular joint (TMJ) disorder or chronic pain.
Teeth and dental prosthetics may become loose, broken, or dislodged,
especially if loose or in poor repair regardless of the care provided by the
anesthesiology provider. By signing this consent you are acknowledging that your
anesthesia providers and Martin Memorial Health Systems will not be liable for any
dental damage or repairs.
MAC (Monitored Anesthesia Care): MAC is not General Anesthesia. MAC involves
local anesthesia or nerve blocks performed by
the surgeon, with monitoring of the patient's vital signs and selection and
administration of sedatives and tranquilizers by the anesthetist. Unlike General
Anesthesia, the patient maintains their heart and lung function without direct support
or intervention on the part of the anesthetist. The patient is usually very sedated, but
may still be able to hear and respond to their medical providers and remembers some
or all of their experience. In surgery of the eye, sometimes the anesthesiologist will
numb the eye with a nerve block and also provide Monitored Anesthesia Care. The
potential complications or side effects during MAC are the same as those reviewed
above and below for General Anesthesia and Regional Anesthesia.
Regional Anesthesia: Regional Anesthesia involves one of a number of methods for
producing numbness in the area of surgery and is performed by the anesthesia
provider. These methods include;
Local: Local anesthesia is injected into and around the area of the surgery to
produce numbness
Nerve Block: A nerve block involves the injection of local anesthetic around the
major nerves going to the area of surgery to produce numbness.
Intravenous regional: This technique involves the injection of a local anesthetic into
a vein in the arm or leg and keeping it there using a tourniquet, causing the arm
or leg to get numb.
Spinal: Spinal anesthesia involves injecting a local anesthetic directly into the fluid
surrounding the spinal cord in the back.
Epidural:Epidural anesthesia involves injecting a local anesthetic directly outside
the spinal canal in the epidural space. This is done in the back directly through
a needle and/or by threading a plastic tube (catheter) into the epidural space.
The needle is then removed, leaving the catheter in place. Local anesthetic
agents and/or narcotics are then injected through the catheter. This catheter
may be used postoperatively for pain control.
The intention of regional anesthesia is to produce numbness in the area of surgery.
Like Monitored Anesthesia Care, regional anesthetic methods are usually
supplemented by sedatives and tranquilizers which cause drowsiness or sleep. The
patient may still be able to hear and respond to their medical providers and
remembers some or all of his/her experience. In the vast majority of cases, these
techniques are safe, effective methods of providing surgical anesthesia. HOWEVER,
SOMETIMES THE ANESTHESIA IS NOT ADEQUATE OR WEARS OFF AND
SURGICAL ANESTHESIA MUST BE OBTAINED BY OTHER METHODS
INCLUDING GENERAL ANESTHESIA.
Side effects and complications of regional anesthesia are relatively uncommon, but
can occur. It is impossible to advise you of every conceivable complication, but some
possible complications are as follows:
Side effects: Swelling, tenderness, bleeding, and bruising at injection site,
nausea/vomiting.
Very uncommon: Shock or extreme fall in blood pressure, convulsion/seizure.
Extremely rare: Nerve damage resulting in numbness, tingling and/or paralysis,
which may be temporary or permanent. Respiratory arrest, cardiac
arrest/death, allergic reactions to drugs. in the case of eye blocks, blindness is
possible.
In addition to the above list, spinal/epidural anesthesia may also have the following
side effects and complications:
Side effects: Mild to moderate fall in blood pressure, headache.
Very uncommon: Headache from a "wet tap" (spinal tap) during epidural which
may be severe enough to require another epidural for treatment. Headache can
also occur after spinal anesthesia, shock or extreme fall in blood pressure and
very slow heart rate, high spinal anesthesia (anesthesia level is too high)
requiring breathing assistance.
Extremely rare: Broken epidural catheter.
Epidural hematoma (blood clot around spine).
Infection of the spine or meningitis.
Paralysis, which may be permanent, and include loss of bowel/bladder control.
Emergency surgery of the spine to prevent meningitis or paralysis.
In order to minimize the possibility of aspiration, the patient is required not to eat or
drink anything for a period of time before surgery. In elective cases, this is usually
from midnight prior to surgery. It is extremely important not to eat or drink anything
during this time because aspiration of undigested food or of significant quantities of
stomach contents can lead to severe pneumonia, respiratory failure, and death.
I understand that part of the anesthesia process may require the insertion of special
monitoring and /or fluid lines, such as an arterial line, central venous line or Swan
Ganz catheter. This will be discussed with you prior to insertion by the Anesthesia
personnel.
I understand that the surgeons will be occupied solely with the surgery and that the
administration, maintenance, and termination of anesthesia are independent functions
and will be supplied by, or under the direction and responsibility of, YOUR
ANESTHESIA PROVIDERS, WHICH INCLUDES ANESTHESIOLGISTS AND
CERTIFIED REGISTERED NURSE ANESTHETISTS (CRNAs).
I have been informed that students may be performing some procedures, such as
insertion of fluid lines or performing endotracheal
intubation under the direct supervision of an Anesthesiologist.
I HEREBY CONSENT TO THE ADMINISTRATION OF ANESTHETICS AS MAY BE
CONSIDERED NECESSARY OR ADVISABLE.
_______ I have read this form or have had it read to me and fully understand the
above consent. I have had the opportunity to have my questions answered to my
satisfaction. The undersigned physician has fully explained the nature and expected
benefits, alternatives and risks involved in the anesthesia I have chosen. I hereby
consent to the administration of anesthetics as may be considered necessary or
advisable.
________As the patient's designated health care surrogate/proxy I have read this
form or I have had the opportunity to have the form read to me and fully understand
the above consent. I do not have any questions for the anesthesiologist. I hereby
consent to the administration of anesthetics as may be considered necessary or
advisable.
CONTACT NAME & NUMBER
_____________________________________________
______________________________________________ ________________
Signature of Patient Date/Time
______________________________________________
Witness to Signature
_______________________________________________ __________________
Signature of Individual with authority to sign State Relationship
_______________________________________________ __________________
Witness to signature Date/Time
__ "Language Line" SM used to interpret consent form for patient.
I hereby certify that the patient or one authorized to act in his/her behalf has been
informed, in lay terms understandable to the patient of the nature of the anesthesia
procedure, the alternatives as to treatment, and the consequences of and risks to the
patient inherent or associated with the procedure and anesthesia.
________________________________________________ _________________
Physician Signature Date /Time
MARTIN MEMORIAL HEALTH SYSTEMS
STUART, FLORIDA
ANESTHESIA CONSENT
RM055 New 10/05
G/Consent Forms/anesthesia 055 Rev 12/30/10; 1/18/10; 3/14/11; 7/11; 6/12
REVISIONS MADE TO THIS CONSENT MUST BE APPROVED BY RISK
MANAGEMENT.
PPATIENT LABEL