PLACE LABEL HERE
ANESTHESIA INFORMED CONSENT
American Anesthesiology Associates of Georgia, LLC.
Anesthesia Services for your Surgery:
American Anesthesiology Associates of Ga., LLC is a group of physicians, nurse anesthetists, and physician assistant
anesthetists providing anesthesia services to GWINNETT HOSPITAL SYSTEM. Members of American Anesthesiology
Associates of Ga. are independent contractors of the hospital and are not the hospital’s employees or agents.
Types of Anesthesia
Surgical anesthesia may be monitored, regional, or general depending on the anesthetic agents used and the area of the
body to be anesthetized. The type of anesthesia chosen in a given case will be determined by an anesthesiologist from
American Anesthesiology Associates of Ga. and will depend on your medical condition, the nature of the procedure to be
performed, and the preference of the patient and the surgeon. One of our physicians will visit with you prior to your
procedure. Be sure to ask questions and express your concerns or fears regarding anesthesia. The physician performing
your preoperative evaluation may not be the physician supervising your anesthesia. However, you will be evaluated again
by an anesthesiologist just prior to your procedure and your requests and concerns will be communicated to all members
of the anesthesia team.
Monitored anesthesia (MAC) involves the injection of an anesthetic agent into or near the area to be operated on to
reduce or eliminate pain in that limited area of the body. Often sedative drugs will be given to calm the patient and make
the patient less aware of the procedure. The patient may recall voices or mild discomfort from the procedure.
Regional anesthesia is a method of surgical anesthesia in which an anesthetic agent is used to block a group of sensory
nerves in order to make an area of the body insensitive to pain. Epidural, spinal, or selective nerve blocs are commonly
used techniques to numb an arm or leg, or the lower half of your body. This allows more extensive surgery than with local
anesthesia alone. The patient may receive sedatives for relaxation and may recall some events of the surgery. Even with
good technique, regional anesthesia may not completely numb the surgical site or provide complete analgesia. In these
situations, the patient may receive a general anesthetic to supplement the regional anesthetic.
Epidural Anesthesia Epidural anesthesia is a type of regional anesthesia. Epidural anesthesia is commonly used during
the labor and delivery process. An epidural is not necessary for childbirth, and other methods of pain relief are available.
In certain surgeries an epidural catheter is placed in the patient’s back near the spine to provide post-operative pain
control. The advantage of epidural post-operative pain control versus the risks (occasionally nausea, itching,
breakthrough pain, or rarely persistent back pain, meningitis, spinal headache, or paralysis) will be discussed by your
anesthesiologist.
General anesthesia is a method of surgical anesthesia in which the patient is “put to sleep” (rendered unconscious and
insensitive to pain) through the use of anesthetic agents administered by inhalation (breathing anesthetic gas through a
mask), and/or by intravenous injection. The anesthetic agent, route of administration, the dosage and the depth of
general anesthesia are dependent on the nature of the surgery to be performed, the medical condition of the patient and
other considerations. Endotracheal intubation (in which a tube is placed into the windpipe from the patient’s mouth or
nose) is frequently required to provide a safe airway and support your breathing during the surgery. This tube, if
necessary, is generally placed immediately after the patient is rendered unconscious. Usually this tube will be placed by a
member of American Anesthesiology Associates of Ga. Alternatively, the tube may be placed by a respiratory therapist
employed by Gwinnett Hospital System. The patient will awaken in the recovery room usually breathing oxygen via a
mask. Occasionally a breathing tube will remain in place until the patient is fully awake and strong enough to breathe
independently.
*2-18273*
FORM 2-18273 REV. 04/2014
Page 1 of 2
PLACE LABEL HERE
ANESTHESIA INFORMED CONSENT
American Anesthesiology Associates of Georgia, LLC.
RISKS AND COMPLICATIONS OF ANESTHESIA
If a special catheter is needed to monitor blood pressure (arterial line) or fluid status (central line or pulmonary artery
catheter), adverse reactions to the use of these special catheters include but are not limited to bleeding, infection, lung
collapse, blood clots, loss of limb and rarely death. Transesophageal echocardiography may be used to monitor cardiac
functions. Complications associated with this include esophageal or oropharyngeal injury, stomach injury, or difficulty
swallowing.
Potential injuries associated with the administration of anesthesia include but are not limited to dental damage, eye injury,
blindness, infection, hemorrhage (excessive bleeding), drug reaction (including rash, itching, nausea, vomiting, shock, and
cardiac/respiratory arrest), blood clots, loss of sensation, loss of limb function, paralysis, organ damage, heart attack,
stroke, nerve damage, brain damage, awareness under anesthesia, lung collapse, retained catheters and death.
ACKNOWLEDGEMENT AND CONSENT FOR ANESTHESIA:
My signature below certifies that:
I have read and understand this consent form (or it has been read to me), and that I have been given an adequate
opportunity to ask questions above the plan for my anesthesia and proposed procedures.
I understand the plan for my anesthesia and, that I have been informed in general terms of the nature and purpose of the
related procedures, the material risks and the practical alternatives, if any.
I understand the physicians, nurse anesthetists, physician assistant anesthetists and nurse practitioners are members of
American Anesthesiology Associates of Ga., LLC and not employees of Gwinnett Hospital System. American
Anesthesiology Associates of Ga., LLC is an independent contractor and is responsible for its own actions.
I understand that the practice of medicine is not an exact science and that NO GUARANTEES OR ASSURANCES HAVE
BEEN MADE TO ME concerning the results of this procedure.
I consent to members of American Anesthesiology Associates of Ga., LLC performing procedures as they may deem
reasonably necessary or desirable in the exercise of their professional judgment, including those procedures that may
be unforeseen or not known to be needed at the time this consent is obtained.
I voluntarily consent to the administration of anesthesia by a member of American Anesthesiology Associates of Ga. and
to all associated procedures, which may be necessary or appropriate. I consent to a student anesthetist or student EMT
participating in my care under direct supervision of an American Anesthesiology Associates of Ga. member.
_______________________________________
Signature of Person Giving Consent
__________________________________________
Relationship to Patient if Not the Patient
_______________________________________
Date
__________________________________________
Patient unable to sign because
Responsible Practitioner’s Statement:
I have reviewed the contents of this form, including the risks, benefits and alternatives to the proposed anesthesia with the
patient or the patient’s decision-maker, and have provided the patient/decision-maker with an opportunity to ask
questions.
_____________
______________
_______________________________
_____________
Date
Time
Physician/Practitioner Signature
PID Number
FORM 2-18273 REV. 04/2014
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