英文麻醉知情同意书

CONSENTFORANESTHESIASERVICESI,,acknowledgethatmydoctorhasexplainedtomethatTwillhaveanoperation,diagnosticortreatmentprocedure.Mydoctorhasexplainedtherisksoftheprocedure,advisedmeofalternativetreatmentsandtoldmeabouttheexpectedoutcomeandwhatcouldhappenifmyconditionremainsuntreated.lalsounderstandthatanesthesiaservicesareneededsothatmydoctorcanperformtheoperationorprocedure.Ithasbeenexplainedtomethatallformsofanesthesiainvolvesomerisksandnoguaranteesorpromisescanbemadeconcerningtheresultsofmyprocedureortreatment.Althoughrare,unexpectedseverecomplicationswithanesthesiacanoccurandincludetheremotepossibilityofinfection,bleeding,drugreactions,bloodclots,lossofsensation,LossofLimbfunction,paralysis,stroke,braindamage,heartattackordeath.Iunderstandthattheserisksapplytoallformsofanesthesiaandthatadditionalorspecificriskshavebeenidentifiedbelowastheymayapplytoaspecifictypeofanesthesia.Iunderstandthattherype(s)ofanesthesiaservicecheckedbelowwillbeusedformyprocedureandthattheanesthetictechniquetobeusedisdeterminedbymanyfactorsincludingmyphysicalcondition,thetypeofproceduremydoctoristodo,hisorherpreference,aswellasmyowndesire.Ithasbeenexplainedtomethatsometimesananesthesiatechniquewhichinvolvestheuseoflocalanesthetics,withorwithoutsedation,maynotsucceedcompletelyandthereforeanothertechniquemayhavetobeusedincludinggeneralanesthesia.0GeneralAnesthesiaExpectedResultTotalunconsciousstate,possibleplacementofatubeintothewindpipe.TechniqueDruginjectedintothebloodstream,breathedintothelungs,orbyotherroutes.RisksMouthorthroatpain,hoarseness.injurytomouthorteeth,awarenessunderanesthesia,injurytObloodvessels,aspiration,pneumonia.0SpinalorEpiduralAnalgesia/ExpectedResultTemporarydecreasedorlossoffeelingand/ormovementtolowerpartofthebody.AnesthesiaTechniqueDruginjectedthroughancedle/caLheterplacedeitherdirectlyintothespinalcanalor0Withsedationimmediatelyoutsidethespinalcanal.0WithoutsedationRisksHeadache,backache,buzzingintheears,convulsions,infection,persistentweakness.numbness,residualpain,injurytobloodvessels,totalspinal.0MajorIMinorNerveBlockExpectedResultTemporarylossoffeelingand/ormovementofaspecificlimborarea.0WithsedationTechniqueDruginjectednearnervesprovidinglossofsensationtotheareaoftheoperation.0WithoutsedationRisksInfection,convulsions,weakness.persistentnumbness,residualpain,injurytobloodvessels.0IntravenousRegionalAnesthesiaExpectedResultTemporarylossoffeelingand/ormovementofalimb.0WithsedationTechniqueDruginjectedintoveinsofannorlegwhileusingatourniquet.DWithoutsedationRisksInfection,convulsions,persistentnumbness,residualpain,injurytobloodvessels.0MonitoredAnesthesiaCareExpectedResultReducedanxietyandpain,partialortotalamnesia.(withsedation)TechniqueDruginjectedintothebloodstream,breathedintothelungs.orbyotherroutesproducingasemi-consciousstate.RisksAnunconsciousstate,depressedbreathing,injurytobloodvessels.0MonitoredAnesthesiaCareExpectedResultMeasurementofvitalsigns,availabilityofanesthesiaproviderforfurtherintervention.(withoutsedation)TechniqueNone.RisksIncreasedawareness,anxietyand/ordiscomfort.Iherebyconsenttotheanesthesiaservicecheckedaboveandauthorizethatitbeadministeredbyorhis/herassociates,allofwhomarecredentialedtoprovideanesthesiaservicesatthishealthfacility.Ialsoconsenttoanalternativetypeofanesthesia,ifnecessary,asdeemedappropriatebythem.Iexpresslydesirethefollowingconsiderationsbeobserved(orwritenone):IcertifyandacknowledgethatIhavereadthisformorhaditreadtome,thatIunderstandtherisks,alternativesandexpectedresultsoftheanesthesiaserviceandthatIhadampletimetoaskquestionsandcoconsidermydecision.Subs1iwte'.tSig11ar1utP91·6DateondTimeRelutionshiptuPatientOeve)OpedtytneAmencanA$SOC1a11onofNvrseAnestllebSIS·1991