圣保禄医院

圣保禄医院 SPHF-OTCAE-001 Patient Information (or Patient Label) Patient No.: St. Paul’s Hospital Patient Name: 聖保祿醫院 Sex: Age: Consent for Anaesthesia Room no.: Doctor: *This form is valid for 180 days (6 months) from the date of signing ******TO BE READ IN CONJUNCTION WITH CONSENT FOR SURGICAL PROCEDURE****** Part I. The anaesthesia and anaesthetic risks – To be explained and completed by an anaesthesiologist / the doctor who performs the Procedure if no anaesthesiologist is needed. 1. Type of anaesthesia: General Anaesthesia Monitored Anaesthetic Care Regional / Spinal Anaesthesia Local Anaesthesia Intravenous Sedation Possible combination of the above 2. The possible risks / complications associated with anaesthesia. 2.1. General risks / complications Serious complications from anaesthesia are uncommon. They include: 2.1.1 *Breathing difficulties 2.1.2 *Stroke or brain damage leading to permanent disability 2.1.3 *Strain on the heart, resulting in heart attack 2.1.4 *Anaphylactic drug reactions 2.1.5 Awareness whilst under general anaesthesia 2.1.6 Damage to teeth & lips * Some of these serious complications can be fatal. Minor problems are common. They include: 2.1.7 Nausea and vomiting 2.1.8 General aches and pains 2.1.9 Shivering 2.1.10 Headache 2.1.11 Post operative pain and pain at injection sites 2.1.12 Sore throat 2.2. Any risks relevant to the patient Risks may be increased due to co-existing problems: 2.2.1 Diabetes 2.2.2 High blood pressure 2.2.3 Heart disease 2.2.4 Kidney disease 2.2.5 Respiratory disease including asthma 2.2.6 Common cold or influenza 2.2.7 Smoking 2.2.8 Overweight 2.2.9 Elderly St. Paul’s Hospital – 2 Eastern Hospital Road, Causeway Bay, Hong Kong (Tel: 2890 6008) Pg. 1 of 3 2.3. Specific risks / complications associated with regional / spinal anaesthesia are uncommon. They include: 2.3.1 Block may not work or work only partially, requiring supplementary anaesthesia 2.3.2 Block may be too extensive requiring cardiovascular and respiratory support 2.3.3 Headache after spinal anaesthesia 2.3.4 Pain, bleeding or infection at site of injection 2.3.5 Damage to adjacent nerves, blood vessels or organs Part II. The Consent: I acknowledge that: 1. The doctor has explained my / the patient’s proposed anaesthesia, the likely outcome, and the risks of this anaesthesia. I understand the risks of the anaesthesia, including the risks that are specific to me / the patient, and the likely outcome. 2. The doctor has explained other relevant anaesthetic options and their associated outcomes and risks. 3. I was able to ask questions and raise concerns with the doctor about my / the patient’s condition, the anaesthesia and its risks, and anaesthestic options. My questions and concerns have been discussed and answered to my satisfaction. 4. The quoted complications / risks of the procedure are not exhaustive. Rare complications may not be listed. 5. I understand that an anaesthesiologist other than the explaining anaesthesiologist may conduct the anaesthesia. On the basis of the above statements, I agree to have the anaesthesia performed. Name of Signatory (in Block letters) Signature Date Name of doctor (in Block letters) Signature Date Name of Witness (in Block letters) Signature of witness Date St. Paul’s Hospital – 2 Eastern Hospital Road, Causeway Bay, Hong Kong (Tel: 2890 6008) Pg. 2 of 3 St. Paul’s Hospital – 2 Eastern Hospital Road, Causeway Bay, Hong Kong (Tel: 2890 6008) Pg. 3 of 3