Scribd
Upload
4K views

Anesthesia Consent Form

This document outlines the informed consent process for a patient undergoing anaesthesia or sedation. It details the risks and benefits of general anaesthesia, spinal/epidural anaesthesia, nerve block anaesthesia, monitored anaesthesia care, and procedural sedation. The patient consents to the planned anaesthesia procedure and acknowledges being informed of alternative options and potential risks. The consent form must be signed by the patient and anaesthetist, with provisions for a family member to provide consent if the patient is unable. Interpreter statements are required if applicable. For high risk procedures, additional consent for specific risks is included.

Uploaded by

Srisachidanand Shukla
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
4K views

Anesthesia Consent Form

This document outlines the informed consent process for a patient undergoing anaesthesia or sedation. It details the risks and benefits of general anaesthesia, spinal/epidural anaesthesia, nerve block anaesthesia, monitored anaesthesia care, and procedural sedation. The patient consents to the planned anaesthesia procedure and acknowledges being informed of alternative options and potential risks. The consent form must be signed by the patient and anaesthetist, with provisions for a family member to provide consent if the patient is unable. Interpreter statements are required if applicable. For high risk procedures, additional consent for specific risks is included.

Uploaded by

Srisachidanand Shukla
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 3

INFORMED CONSENT

AUTHORIZATION OF ADMINISTRATION OF ANAESTHESIA/SEDATION


I................................... (Name of patient) understand that anaesthesia services are needed so that my doctor can perform the
operation or procedure .................................................................................
............................................................................................................................. ..................................
(Name of surgery/Procedure). I hereby consent to the anaesthesia/sedation service check below and authorize that it can be
administered by Anaesthesiologist or physician who are credentialed to provide anaesthesia or sedation services at Name of
hospital
o General Anesthesia
Benefits Complete Control of airway, breathing and circulation minimizing undue stress to the
patient and allowing compete stillness during the procedure.
Permits surgery in widely separated area of the body at the same time.
Can be administered without moving the patient from supine position.
Techniques Drug Injected into the bloodstream, breathed into the lungs, or by other routes.
Risks Mouth or throat pain, hoarseness, injury to mouth or teeth, awareness under anaesthesia,
injury to blood vessels, aspiration, pneumonia.
Weakness, numbness in the limbs, parathesias.
o Spinal Or Epidural
Benefits Optimum method of anaesthesia for procedure in the lower half of the body.
Easy post-Operative mobilization.
analgesia/ Anaesthesia Reduced post operative pulmonary, thromboembolic and cardiac complications.
o With Sedation Techniques Drug injection through a needle/catheter placed either directly into the spinal canal or
immediately outside the spinal canal.
o Without Sedation
Risks Headache, Backache, Buzzing in the ears, convulsions, infection, persistent weakness,
numbness, residual pain, injury to blood vessels.
May requires conversation to General Anaesthesia.

o Major/Minor Nerve
Benefits Patient can remain awake and breathe normally.
Side effects such as nausea and vomiting are avoidable.
block anaesthesia
Excellent pain relief.
o With Sedation No Need for tracheal intubation.
o Without Sedation
Techniques
Risks
Drug injected near nerves providing loss of sensation to the area of operation
Infection, Convulsion, persistent numbness, residual pain, injury to blood vessels.
May require conversation to General Anaesthesia.
o Monitored
Benefits Safe Sedation, control of patient anxiety and pain control
Protection of airways.
anaesthesia care (with
Techniques Drug injected into the bloodstream, breathed into the lung or by other routes
sedation)
producing a semi-conscious state.
Risks An unconscious state, depressed breathing.
May require conversation to general anaesthesia.
o Anaesthesia standby
Benefits Measurement of vital signs, availability of anaesthesia provider for further
intervention, no sedation.
(Without sedation)
Techniques Not applicable.
Risks Anxiety and/or discomfort.
o Moderate/ Deep/
Benefits Reduce or eliminated pain and patient anxiety.
Patient can breathe normally and respond to verbal commands during moderate
Procedural Sedation
sedation.
Monitoring of vital signs.
Techniques Drug injected into the bloodstream producing a sedative state.
Risks Depressed Breathing
Conversation to anaesthesia

Alternatives _______________________________________________________________________________
1. The benefits, techniques of sedation or anaesthesia to be used, alternative and risks have been explained to
me in my language.
2. I understand that rarely there may be unforeseen complications, in such an even the anaesthesia team
change the type of anaesthesia or take suitable steps taking my best interest in mind and I give my consent
for the same.
3. I have been informed that during sedation possible complications may occur and at times deeper sedation
and anaesthesia may be required with an anaesthesiologist support during the procedure and I agree to this
support.
4. During the course of the procedure I agree to the insertion / use of monitoring lines-invasive/ non invasive,
use of endoscope and any other procedure for the purpose of safe conduct of anaesthesia and monitoring.
5. I agree that I may be transfused blood and blood product during the course of the procedure as deemed
necessary.
6. I consent to Photography/video recording of procedure, which may be viewed for academic purpose only
subjected to the identity being adequately protected. I further give my consent to the release of professional
and/ or other information from the medical records as deemed necessary in accordance with the rules and
policies of the hospital.
7. I/My relative have been educated on the modalities of post operative analgesia.
8. I certify that I had the opportunities to ask question and they have been explained to me to my satisfaction
in a language that I can understand.

Patient Full Name__________________________ Signature_____________ Date & Time________

Anaesthetist or Sedating Physician Name ________________Signature_______ Date & Time______

Attendant Consent (If applicable)


If patient is unable to give consent, State the reason ______________________________________
(Minor/Unconscious/Under-sedation/incapacity, other please specify)
Attendant Name ___________________________ Relationship to the patient_________________
Signature_______________________ Date:-_______________ Time:-_______________________
Witness Name_____________________________ Signature_______________________________
Date________________ & Time____________

Statement of interpreter (Where appropriate)


I have comprehensively explained the information above along with the discussion/Explanation provided by the
doctor, to the patient and/ or his/her attendant and in way which I believe he/she/they can understand and the patient
and/or his/her attendant have informed me that have understood the aforesaid information completely.
Interpreter’s Name__________________ Signature ______________ Date &Time ________________

High Risk Consent


It has been explained to me that I have acknowledge that the risk to the patient during and after that
surgery/Anaesthesia is high/Very high due to the following problems and their implication have been explained to
me in details.
1._____________________________________________________________________________
2._____________________________________________________________________________
3._____________________________________________________________________________
4._____________________________________________________________________________

Patient’s Full Name______________________ Signature_______________Date& Time______________


Anaesthetist Full Name ____________________Signature______________ Date& Time______________
If patient is unable to give consent, State the reason ____________________________________________
(Minor/Unconscious/Under-sedation/incapacity, other please specify)
Attendant Name ___________________________ Relationship to the patient_________________

Signature_______________________ Date:-_______________ Time:-_______________________

You might also like