Anesthesia Consent Form

NOTE: if you weigh over 250lbs - please call us for clearance first (your weight may make it difficult to safely evacuate you in case of an emergency!)

Who has the legal authority to sign the CONSENT on pages 10 and 11 (if the patient cannot):

Note: this individual must be reachable at the time of anesthesia! If informed consent cannot be obtained, the surgery cannot proceed.

INSTRUCTIONS TO PATIENTS RECEIVING SEDATION/ANAESTHESIA

BEFORE SURGERY

1. Food in the stomach may result in vomiting and subsequent pneumonia during anaesthesia. This is unsafe and can be fatal. It is therefore extremely important that the patient follow these fasting guidelines:
   1. 8 hrs - meal that includes meat, fried or fatty foods
   2. 6 hrs - light meal (such as toast and a clear fluid) or ingestion of infant formula or non-human milk
   3. 4 hrs - ingestion of breast milk (no additions are allowed to pumped breast milk)
   4. 2 hrs - clear fluids (including water, pulp-free juice and tea or coffee without milk)

   Note: adults and children should be encouraged to drink clear fluids (including water, pulp-free juice and tea or coffee without milk) up to 2 hrs before elective surgery.

2. Usually the routine medications may be taken on schedule with a small sip of water unless otherwise directed by the anaesthetist.

   Please note: do not take diabetic medications or fluid pills on the day of surgery; for blood pressure medicines, please call us if necessary. If you are diabetic, you must bring all your diabetic supplies (including, but not limited to glucometer, strips, lancets, insulin, syringes, pumps etc.)

3. Patients should wear loose-fitting clothes so that monitoring equipment can be applied easily. Please bring a change of clothes (for children: please bring an extra diaper, if necessary).
4. Patients are not to wear: contact lenses, make-up or nail polish. Leave valuables at home.
5. If there is even a small chance that the patient may be pregnant on the day of the surgery, consider doing a urine pregnancy test on the morning of the surgery to rule out that possibility.
6. Please advise us of any recent change in health such as fever, vomiting, diarrhea, cold, or flu in the days before by calling us before coming for surgery.
7. Patients cannot go home alone! Please confirm the person who will be accompanying the patient after surgery (and who will stay with the patient during the first 24 hours). The companion must be at the patient's side on the ride home (i.e. NOT be driving the car and leaving the patient unattended in the back of the car). For most children (and some adults) there will need to be two individuals coming with the patient!
8. The patient will need a responsible person at arm's length for the first 24 hours after surgery.
9. If the patient does not speak English well enough, it is imperative that the patient arranges for a competent translator to be present for the duration of the surgery. If informed consent cannot be obtained, the surgery cannot proceed.
10. If the patient is unable, for whatever reason, to give his/her own consent, it is imperative that the individual who has power of attorney be present or available by phone. The patient must bring this information on the day of surgery. If informed consent cannot be obtained, the surgery cannot proceed.

INSTRUCTIONS TO PATIENTS RECEIVING SEDATION/ANAESTHESIA

DURING SURGERY

1. The patient will be given fresh oxygen (and possibly sleep medicine) through a mask to breathe. Monitor stickers will be placed on the patient's chest and a clip placed on the finger. A blood pressure cuff will be placed on the arm.
2. In adult patients, a small intravenous catheter is usually placed in the back of the hand before going to sleep (faster and preferred), whereas in children, due to the fear of needles, the intravenous catheter will often be placed after falling asleep, to allow the fluids or medications to be given. In some adults, upon special request, and depending on the type of surgery, the possibility of placing the intravenous after falling asleep with a mask may be considered prior to a general anesthesia.
3. Most patients, especially children, toss/turn, stretch out their arms, roll their eyes, and their breathing patterns change as they go to sleep.
4. In general we encourage the presence of one parent (sometimes both) with a paediatric patient for the induction of anaesthesia (not for the duration of surgery). Due to a variety of factors this may not always be possible or be in the best interest of the child. Your understanding and cooperation in this context is very important (if, for example, you are asked to step outside to the waiting area).
5. In some circumstances (for example young patients of adults with special needs) patients may not be able to cooperate and some form of temporary restraint may be required to conduct the anesthetic safely. If this is not acceptable, please discuss this with the anesthetist prior to treatment.
6. In the case of general anaesthesia, the patient will be completely asleep for the entire procedure and will normally be asleep for about 15-30 minutes longer than the time it takes for the procedure to be completed.
7. Parents of children must wait in the waiting room during surgery until they are called in. While every effort is made to let parents see their child as early as possible after the anaesthetic ends, children will in general have to be awake and stable enough to permit their parents to be with them after emergence. As children are often agitated, confused and cranky when they awake from anaesthesia, parents may hear their child cry without being able to see them (yet).
8. Please be aware that there may be delays during surgery and patients, parents, and companions should clear their schedules of any other appointments or commitments on the date of surgery.

INSTRUCTIONS TO PATIENTS RECEIVING SEDATION/ANAESTHESIA

AFTER SURGERY

1. It usually takes approximately 30-60 minutes after surgery before the patient can go home safely. It is not uncommon for the patient to feel dizzy and disoriented when upon awakening. Children frequently cry, even if they do not experience any discomfort. The intravenous catheter will remain in place until the patient is fully awake.
2. Children often get very irritable after they have extensive dental work, especially with placement of crowns. This is a result of their bite feeling different and will usually resolve after a couple of days when they get used to it.
3. A responsible adult must accompany the patient home and someone has to stay with the patient for the first 24 hours. The companion must be at the patient’s side on the ride home (i.e. NOT be driving the car and leaving the patient unattended in the back of the car). For most children (and some adults) there will need to be two individuals coming with the patient!
4. Some patients (especially older patients and patients with certain medical conditions and mobility issues) may experience some dizziness after the anesthesia, particularly when getting up from the sitting position (and starting to walk). It is important that the responsible adult being at their side is capable to support the patient to prevent any falls and injuries! In some households this may require an additional second adult person to be with the patient.
5. Patients should rest at home for the post-operative period (24 hours). DO NOT WORK, DRIVE, OPERATE HAZARDOUS MACHINERY OR MAKE IMPORTANT DECISIONS FOR 24 HOURS FOLLOWING ANAESTHESIA. A responsible adult must be with the patient. Children must not participate in activities that may cause injury, i.e. running, riding a bicycle.
6. The patient should not be allowed to fall asleep in an upright position (i.e. car seat, stroller) on the day of surgery to prevent the possibility of air passage obstruction.
7. The patient should drink plenty of fluids (water, juice) after anaesthesia but should not drink alcoholic beverages or take sedative medication for 24 hours after surgery.
8. If the patient is not experiencing any nausea or vomiting, he/she may eat solid food as tolerated (please begin with easily-digested foods).
9. A sore throat or sore nose (with small amounts of blood, especially nose bleeds) is common after anaesthesia and will resolve on its own. Some muscle ache in the neck and shoulders is also common.
10. Take medications as advised. Unless instructed otherwise, Tylenol or Motrin can be used to control pain. The surgeon/dentist will usually write a prescription for additional pain killers as needed.
11. The area where the intravenous catheter was placed may be sore and bruised for a few days after surgery. Should this persist or worsen, please call us.
12. A slight rash in the face may be visible where tape was applied (as well as where the cardiogram stickers were placed - usually shoulders and abdomen).

INSTRUCTIONS TO PATIENTS RECEIVING SEDATION/ANAESTHESIA

AFTER SURGERY cont'd

13. Especially children may at times complain about 'burning in the eyes' which can be the result of them having rubbed and scratched their eyes during the wake-up phase. These symptoms usually resolve with conservative treatment over the first 24-48 hours.
14. For follow-up with the dentist/surgeon please call his/her office as instructed.
15. If necessary contact or visit your family physician, local walk-in clinic or the nearest emergency room. Please also call us for any concerns or unexpected events (we will attempt to return your call as soon as feasible, however please do not delay seeking medical attention while waiting for our return phone call as we may be busy with other patients or not be available, especially after hours or on weekends and holidays), i.e.:
    1. if the patient vomits beyond 4 hours after anaesthesia
    2. if the patient does not pass urine
    3. if the patient develops a fever over 38.5o C
    4. if there is any difficulty breathing
    5. if there is any significant bleeding
    6. if there is severe pain, not relieved with rest and medication
    7. if the patient has to go to the emergency room or seek medical attention related to the surgery or anesthesia
    8. if there are any other unexpected events or concerns.

INFORMED CONSENT for Sedation/General Anaesthesia pg 1 of 3

I understand that the following has been provided to me so that I may be informed of the choices and risks involved with having a procedure performed under anaesthesia. It is my understanding that this information has been presented to enable me to make well-informed decisions concerning my or my child's treatment, not to make me anxious.

I have been informed that aside from drowsiness, the most frequent side-effects of any anaesthetic include, but are not limited to, nausea, vomiting, sore throat, hoarseness, general muscle soreness and inflammation with tenderness and/or bruising around the intravenous site. Depending on the procedure performed, some degree of post-operative pain is to be expected. Since anaesthesia may cause drowsiness and incoordination that may be enhanced by the use of alcohol or drugs, it is understood that (other than usual prescription medications or medication prescriptions provided for the relief of post-operative discomfort) they are to be avoided until completely recovered from the effects of anaesthesia. I understand that the operation of any vehicle or any hazardous device/machine, or the making of any important decisions is to be avoided for at least 24 hours or until completely recovered from the effects of anaesthesia. Parents are advised of the necessity for direct parental supervision of children for 24 hours following their anaesthesia.

I understand that on rare occasions there are anaesthesia-related complications which include, but are not limited to, pain, hematoma, numbness, infection, swelling, bleeding, urinary retention, visual loss, aspiration, negative pressure pulmonary edema, organ failure, malignant hyperthermia, skin discoloration, allergic reaction, oral dental damage, and fluctuations in heart rhythm and/or blood pressure. I further understand and accept the extremely remote possibility that complications may arise which may require hospitalization, result in brain damage, failure to recover, coma from anesthesia or death. I have been made aware that local anaesthesia carries with it the least amount of risk and sedation/general anaesthesia the most. However, local anaesthesia alone may not be appropriate for some patients or procedures.

I understand that anesthetics and other medicines may be harmful to an unborn child and could result in spontaneous abortion or cause birth defects. Recognizing these risks, I accept full responsibility for informing the anaesthetist of a suspected or confirmed pregnancy with the understanding that this will necessitate the postponement of anaesthesia. For similar reasons, I understand that I must inform the anaesthetist if I am (or my child is) a nursing mother.

Some authorities believe that surgery after COVID should be delayed for approximately 2 months. This is because the rate of complications may significantly increase in patients with recent symptomatic or asymptomatic COVID infections. Please consider this when scheduling your surgery.

Nerve, muscle and tissue injury, while overall rare, can occur under anesthesia and factors that may increase this risk include pre-existing nerve damage (for example due to diabetes) and a large body mass. In many cases no clear reason is apparent (i.e. the injury occurred even though best care was taken to avoid factors such as stretch or compression). The prognosis for full (or at least substantial) recovery is generally good but some patients are unfortunately left with a permanent injury.

INFORMED CONSENT for Sedation/General Anaesthesia pg 2 of 3

I hereby authorize and request Anesthesia Service Consultants to contact persons on my behalf and obtain any previous or current medical records/information when needed to properly assess my / my child's health status prior to anaesthesia.

I hereby authorize and request the anaesthetist to perform anaesthesia as previously explained to me, and any other procedure deemed necessary or advisable as a corollary to the planned anaesthesia. I consent, authorize and request the administration of such anaesthetic(s) by any route that is deemed suitable by the anaesthetist. It is the understanding of the undersigned that the anaesthetist will have full charge of the administration and maintenance of the anaesthetic, and that this is an independent function from the surgery or dental work.

I have been fully advised and completely understand the alternatives of conscious sedation, deep sedation and general anaesthesia, and accept all possible risks and consequences. I acknowledge receipt of and completely understand both pre-operative and post-operative anaesthesia instructions. It has been explained to me and I accept that there is no warranty or guarantee as to any result and/or cure. I have had the opportunity to ask questions about my / my child's anaesthetic and I am satisfied with the information provided to me.

I hereby acknowledge that I am a resident in the province of Ontario and I agree that the resolution of any and all disputes arising from or in connection with my care by the anaesthetist (as well as his agents and/or delegates) shall be governed by and construed in accordance with the laws of the Province of Ontario and that the Courts of the Province of Ontario shall have the exclusive jurisdiction.

I hereby acknowledge that I am a resident in the province of Ontario and I agree that the resolution of any and all disputes arising from or in connection with my care by the anaesthetist (as well as his agents and/or delegates) shall be governed by and construed in accordance with the laws of the Province of Ontario and that the Courts of the Province of Ontario shall have the exclusive jurisdiction.

YOU MUST HAVE READ AND UNDERSTOOD ALL 13 PAGES OF THIS PACKAGE BEFORE SIGNING THE CONSENT!

INFORMED CONSENT cont'd pg 3 of 3

A note about awareness under general anaesthesia:

The chance for a patient to be awake (in pain and paralyzed, unable to communicate) under general anaesthesia is extremely remote and most reported cases involve patients that undergo high-risk hospital-based surgical procedures coupled with the use of paralyzing medications (cardiac surgery, emergency operations, caesarean sections etc.). The type of surgery and the anaesthetic medications for office-based general anaesthesia tend to be very different from the above-mentioned cases (for example, paralyzing medications are generally not used). While some hospitals (for selected cases) use a tool to monitor brain activity that might help to detect awareness, it is not clear that these tools make a difference to patient safety, and these monitors, particularly for office-based anaesthesia, are not routinely used.

A note about children and anesthesia:

Anesthetic and sedative drugs are widely used to help ensure the safety, health, and comfort of children undergoing surgery. There is evidence from studies which suggests the benefits of these agents should be considered in the context of their potential to cause harmful outcomes, such as adverse neurobehavioural effects. However, these studies have limitations that prevent experts from drawing conclusions on whether the harmful effects were due to the anesthesia or to other factors, such as surgery, hospitalization, or pre-existing conditions.

In the absence of conclusive evidence, it would be unethical to withhold sedation and anesthesia when necessary. It is important to recognize that current anesthetics and sedatives are necessary for infants and children who require surgery or other painful and stressful procedures.

(Extract from Smart Tots IARS Consensus Statement on the Use of Anesthetics and Sedatives in Children, Dec 2012) www.smarttots.org/resources/consensus.html

A note about older adults and anesthesia:

Elderly patients, especially when already slightly impaired at baseline (i.e. dementia) are at risk of further decrease in their function after anesthesia (including confusion, inattention and memory problems). Together with their frailty the acute confusion that is possible after anesthesia can make the management of those patients challenging and we strongly advise to have adequate support (at least two physically fit individuals) come for the appointment to safely escort the patient home and stay with him/her.