ASC Procedure Instructions & Forms

Endoscopy - Anesthesia Consent

I consent to the administration and maintenance of anesthesia for (check one)
,as planned by the anesthesia care team, and to the procedures performed by the anesthesia care team in the provision of anesthesia including placing an intravenous catheter (IV) and maintaining an airway.

The risks associated with anesthesia were provided by the Anesthetist, and include but are not limited to reactions to medications, worsening of a preexisting medical problem, bleeding, airway difficulties, infections and aspiration pneumonia. Drug reactions can include a rash, itching, burning, nausea, vomiting, dizziness, muscle aches, headache, delirium, hives, wheezing and, very rarely, shock or even death. Maintaining an airway may include placement of an oral or nasal airway or an endotracheal tube. Reactions to artificial airways include laryngospasm and wheezing, which require immediate corrective treatment. Manipulation of the airway may result in damage to caps, bridges or teeth. Some individuals experience a sore lip, gums, tongue, throat or hoarseness. If blood transfusion is necessary, there is a small risk of a transfusion reaction or infection.

Medical problems such as high blood pressure, asthma or heart conditions may occasionally worsen and require · treatment. Intravenous catheters can cause inflammation, swelling, bleeding, bruising or phlebitis.

Aspiration pneumonia results from acid in the stomach being brought up into the lungs. Acid causes a chemical burn to the lungs and can be very serious. This is most common in individuals who have eaten recently.

Very rarely, patients may develop a cardiac or respiratory arrest, anaphylactic shock, malignant hyperthermia or airway closure. These are true medical emergencies which can cause temporary or permanent brain damage or death.

In general, the risk of anesthesia is proportionate to how sick you are. Healthy individuals with a normal airway are at low risk. Patients with serious medical problems or an abnormal airway are at increased risk. Respiratory infections in Children increase the risk for complications.

Your anesthesia “Monitored Anesthesia Care Deep Sedation” will be given by an anesthesiologist or by the anesthesia care team. The anesthesia care team is directed by an anesthesiologist in collaboration with a nurse anesthetist. A nurse anesthetist is a registered nurse who has satisfactorily completed an approved nurse anesthesia training program.

Further, I understand that many of the physicians on staff of this hospital are not employees or agents of the hospital but, rather, are independent contractors who have been granted the privilege of using its facilities for the care and treatment of their patients. I understand that if the employment status of an individual is important to me in making treatment and other healthcare decisions, I may inquire as to that individual's employment status.

The anesthesia plan has been explained to me. I understand the potential material risks, benefits, side effects/complications, probability of success and alternatives available to me. My questions have been answered and I accept this procedure. I understand that there is no guarantee of results

Patient Name:
Patient Signature of Consent:
(name in corresponding box will act as signature)
Telephone Consent
(Check if obtained by phone)

Surrogate Signature of Consent:
(name in corresponding box will act as signature)
Relationship to Patient:

•  Patient is unable to sign due to:

•  Witness Signature:
(name in corresponding box will act as signature)

Anesthesia Care Team Date: Time: