Consent Form

SERVICES PROVIDED BY ANESTHESIA ASSOCIATES OF MISSISSIPPI

INFORMED CONSENT FOR ANESTHESIA (For Review Only)

DEEP SEDATION – Deep Sedation / Analgesia / Total Intravenous Anesthesia (TIVA) is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation.  The ability to independently maintain ventilatory function may be impaired.  Patients may require assistance in maintaining a patient airway, and spontaneous ventilation may be inadequate.  Cardiovascular function is usually maintained.  It is possible that during the administration of a deep sedation, a patient can reach a state of general anesthesia as described below.  The risks of deep sedation are the same as those for a general anesthetic.

GENERAL ANESTHESIA – General Anesthesia involves making the patient unconscious using intravenous drugs (such as propofol).  Side effects and complications can occur.  While it is impossible to advise you of every conceivable complication, some possible examples are:

  • Soreness of the throat and hoarseness are 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
  • Damage to the vocal cords or windpipe
  • Blood transfusions may be required
  • Rarely, there may be a recall of events during the procedure.  Dreams during anesthesia may be confused with a recall of real events.
  • A breathing machine may be required after surgery
  • 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

TEETH AND DENTAL PROSTHETICS MAY BECOME LOOSE, BROKEN OR DISLODGED, ESPECIALLY IF LOOSE OR IN POOR REPAIR REGARDLESS OF THE CARE PROVIDED BY THE ANESTHESIA PROVIDER.  BY SIGNING THIS CONSENT YOU ARE ACKNOWLEDGING THAT NEITHER YOUR ANESTHESIA PROVIDERS NOR THE SURGERY CENTER WILL BE LIABLE FOR ANY DENTAL DAMAGE OR REPAIRS.

MAC (Monitored Anesthesia Care)  MAC is not General Anesthesia.  MAC involves local anesthesia or nerve blocks administered by the surgeon while the anesthesia provider monitors the patient’s vital signs and selects and administers sedatives.  Unlike General Anesthesia, the patient maintains his/her heart and lung functions without the direct support of the anesthesia provider.  The patient is usually very sedated, but may still be able to hear and respond to his/her medical providers and remember some or all of the procedure.  The potential complications or side effects of MAC are the same as those reviewed above for General Anesthesia.

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 food or of significant quantities of stomach contents can lead to severe pneumonia, respiratory failure and death.