! Read the preoperative instructions, nothing to eat/drink after midnight, except what is explained. Take any medications as explained.
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1 We are honored to have the opportunity to provide anesthesia services for your upcoming procedure. In order for us to provide safe anesthesia care, please review the instructions included. There are some forms that will need to be completed prior to your arrival. The checklist below indicates what needs to be completed. Bring this entire packet with you, with the checklist completed, to your appointment. Failure to complete this list may delay, and in some instances, cancel your procedure. Payment for anesthesia services is required prior to your procedure. If you have questions about any of this material, please us at We will respond within 24 hours, so be sure to us early enough to receive a response. Checklist: Read the preoperative instructions, nothing to eat/drink after midnight, except what is explained. Take any medications as explained. Fill out the pre-anesthesia questionnaire, front and back. Read the anesthesia consent form. We will go over this with you and sign it the day of your procedure. Please bring a check or debit/credit card to pay your anesthesia fee. Payment is required before services are given. NO CASH PLEASE. The anesthesia fee for your procedure will be: $ Thank you in advance for your cooperation in completing this packet. We look forward to serving you. Sincerely, Chase Sossamon, APRN, CRNA, CCRN-CSC John Bean, APRN, CRNA,
2 ANESTHESIA INSTRUCTIONS FOR YOUR PROCEDURE) Please follow these instructions to help us provide the safest anesthesia possible for you or your family member. DAY BEFORE THE PROCEDURE - Make sure you have completed your packet checklist and remember to bring the packet with you. - Please refrain from eating or drinking at least 8 hours prior to your arrival time. o Pediatric Patients Only: Children may have small amounts 6 12 ounces total) of apple juice or other clear juices no pulp or soda) up to 2 hours prior to their arrival time. It is perfectly safe for children to fast prior to anesthesia just like adults, they just might be a little more irritable. - Unless your dentist/surgeon has asked you to avoid certain medications, please take all your prescribed medications on their normal schedule, including narcotics or anti-anxiety medications. Take them with as little water as possible. o Diabetic Patients Only: Please do not take your regular insulin. You may take any of your oral medications. If you have an afternoon appointment, you may eat a liquid only breakfast at least 6 hours prior to your arrival time. - Wear a loose fitting top, as we will need to place various monitors on your chest and side, and have access to your arms for the placement of an IV catheter. Also please bring a second set of clothing. MORNING OF PROCEDURE - Please brush your teeth thoroughly prior to your arrival, avoid swallowing anything. - Make sure to bring your completed anesthesia packet with you. - You must have a driver to take you to and from your appointment. You cannot drive for 24 hours following anesthesia. If you do not have someone to take you home, your procedure will be cancelled. If you fail to follow these instructions, your procedure may have to be postponed or cancelled. These guidelines are for your safety. AFTER YOUR PROCEDURE - You may be sleepy for the rest of the day. This is normal. Please make sure someone is with you for the next 24 hours. - You can return to a normal diet, or the diet that has been indicated by your dentist/surgeon. We recommend you start with lighter foods, so you don t become nauseated after anesthesia. We look forward to the opportunity of taking care of you or your family member. We pride ourselves in excellent patient care and satisfaction. You will be receiving a phone call in the evening to follow-up on your anesthesia care and to see how you are doing. If you have any questions, please us at Questions.lifeguard@gmail.com. We will respond within 24 hours. Thank you and we look forward to serving you.
3 CONSENT FOR ANESTHESIA SERVICES I,, acknowledge that my doctor has explained to me that I will have an operation or procedure performed, and has explained the risks associated with this procedure. I also understand that anesthesia services are needed so that my doctor can perform this procedure. It has been explained to me that all forms of anesthesia carry some risks and no guarantees or promises can be made concerning the result of my procedure. Although rare, unexpected severe complications with anesthesia can occur and include the remote possibility of infection, bleeding, drug reactions, loss of sensation, paralysis, stroke, brain damage, heart attack, or death. I understand these risks apply to all forms of anesthesia and that specific risks related to the type of anesthesia I will be receiving are explained further below. I will be receiving: Monitored Anesthesia Care with moderate or deep sedation) Expected Result Technique Risks Reduced anxiety and pain, partial or total loss or memory, moderate to deep levels of sedation Drug injected into the bloodstream, either by intravenous access or intramuscular injection An unconscious state, depressed breathing, injury to blood vessels I hereby consent to the anesthesia service listed above and authorize that it be administered by the associates of LifeGuard Anesthesia Services Incorporated, all of whom are licensed and credentialed to provide anesthesia services in the state of Oklahoma and in this healthcare facility. I also consent to any alternative type of anesthesia, if necessary, as deemed appropriate by them. I certify and acknowledge that I have read this form or had it read to me; that I understand the risks and expected results of the anesthesia service; and that I had ample time to ask questions and to consider my decision. Patient s Signature or Authorized Rep. Date and Time Relationship to Patient Witness Signature, CRNA Anesthesia Provider s Signature A list of commonly used drugs for anesthesia is listed on the back of this form.
4 - Propofol and Ketamine are short-acting hypnotic/sedatives. These drugs are administered to put you into a state of unconsciousness or sleep. The depth of this sleep varies based on the amount given by your anesthesia provider and the level required for you procedure. Some of the desired effects, and some rare side effects, are listed. Desired effects can include: Undesired effects can include: - Sedation - Drops in blood pressure or increases in blood pressure - Amnesia - Slowed breathing - Reduced anxiety - Changes in heart rhythm or arrhythmias - Pain relief - Seizures - Increased salivation - Versed is a short acting drug given to reduce anxiety, cause amnesia, and put the patient in a relaxed state. Some of the desired effects, and some rare side effects, are listed. Desired effects can include: Undesired effects can include: - Drowsiness - Dizziness - Reduced anxiety - Nausea/Vomiting - Amnesia - Fentanyl is a strong narcotic given to reduce or eliminate pain related to your procedure. Some of the desired effects, and some rare side effects, are listed. Desired effects can include: Undesired effects can include: - Drowsiness - Slowed breathing - Reduced pain - itching - Relaxation - Nausea/Vomiting
5 PRE&ANESTHESIAQUESTIONNAIRE) Name: DateofBirth: Sex: M FAge: DateofProcedure: OfficeName: Ht: Wt: BestPhoneNumbertoCall: PrimaryCareDoctor,ifany: AllergiestoMedications,Supplements,orFoods: NoKnownAllergies Doyoucurrentlyhaveorhaveyoueverhad: Cardiovascular: Yes No HighBloodPressure Peripheralvasculardisease AtrialFibrillation HeartAttack:when Chestpain/Angina howoften Ifyes,howtreated Murmur/historyofRheumaticfever PacemakerorImplanteddefibrillator HistoryofCongestiveHeartFailure Respiratory: Asthma lastervisit COPD SleepApnea/CPAP/BIPAP Shortnessofbreath Canyouwalkoneflightofstairswithout stopping? Gastrointestinal: HiatalHernia AcidReflexGERD) Hepatitis OtherGI/Liverproblem& Musculoskeletal: Arthritis:RheumatoidorOsteoarthritis BackorNeckpain Difficultywalking Hematologic: HIV+ Sicklecell diseaseortrait Bleeding/Easybruising Bloodthinners Historyofbloodclots Genitourinary: KidneyDisease Dialysis:Hemo/peritonealMTWTHF) Neurological: Yes No StrokeorTIA when Paralysis where Parkinson sdisease Epilepsy lastseizure Alzheimer sordementia RestlessLegSyndrome Otherneurologiccondition& Endocrine: Thyroid:HyperorHypo Diabetes circle)insulinpillsdietcontrolled Females: Areyoupregnant? Lastmenstrualperiod TubalLigationorHysterectomy General: HistoryofproblemswithAnesthesia Ifyes,what? Mastectomy:LeftRight Doyousmoke howlong? Alcoholuse howmuch/often? RecreationalDruguse typeandlastuse PediatricPatientsOnly: Istheresomeonewhosmokesinthehome? Currentlysick?Cold,Flu,Allergies) Takingantibiotics?Datestarted& AnyfamilyhistoryofMalignantHyperthermia? Anyotherproblemsnotpreviouslymentioned? Pleasefilloutmedicationsheetandsurgicalhistory onthebackofthispage
6 MEDICATIONANDSURGICALHISTORY CURRENT MEDICATIONS Patient does not take any medications or supplements Please include: Prescriptions, OTC Medications, Nutritional Supplements, Vitamins, Herbs, Birth Control Pills, Patches, etc Please do not use abbreviations) Medication Name Dose Route Frequency Pleaseincludeanothersheetofpaperifnecessary PAST SURGERIES Patient has never had surgery Please include all surgeries regardless of age/year they occurred Type of Surgery Approx. Date Problems if any?
Bring this entire packet with you, with the checklist completed, to your appointment.
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