INFORMED CONSENT DISCUSSION FOR ANESTHESIA / SEDATION
INFORMED CONSENT DISCUSSION FOR ANESTHESIA / SEDATION
Patient name : ____________________________________________________ Patient ’ s Weight : _________________
Date of Birth : ____________________ DIAGNOSIS : _____________________________________________________________________________________ Facts for Consideration
Anesthesia is a matter of degrees on a continuum beginning at a low level called “ light ” and adjusted to lighter or deeper levels depending on the patient ’ s tolerance for pain and / or response to the drugs used .
Occasionally , during dental treatment patients cannot understand or cooperate due to psychological or emotional immaturity , a cognitive , physical or medical disability , or fear and anxiety . Under such conditions they may become dangerous to themselves , the staff and the dentist . In addition to behavior management through communication techniques or immobilization to provide safe delivery of dental treatment , the dentist may also identify the need for a chemical sedation or anesthesia for the patient ’ s comfort and behavior management .
Patients may require local anesthesia , light to moderate conscious sedation , deep sedation , or general anesthesia for their comfort during the performance of dental restorations or surgical procedures . Your dentist will recommend and explain to you which type of anesthesia might be appropriate for your individual medical / dental needs .
Option 1 : Nitrous Oxide / Oxygen Inhalation Sedation
Patient ’ s / Patient ’ s Representative ’ s initials required
Nitrous oxide / oxygen inhalation is a mild form of conscious sedation used to calm an anxious patient . A colorless , odorless gas that has no explosive or flammable properties , it can act as a pain bufferer as well . Oxygen is given simultaneously with the nitrous oxide through a small mask placed over the nose . Pure oxygen , given at the end of treatment , is intended to flush the nitrous oxide out of the patient ’ s system and minimize the effects of the gas . The patient is observed while nitrous oxide is administered and until the patient is fully recovered from its effects .
Risks , include but are not limited to : An early effect is an inability to perceive one ’ s spatial orientation and temporary numbness and tingling . Nausea and vomiting may occur . If the patient will not accept the mask , nitrous oxide / oxygen cannot be used .
Potential benefits : The patient remains awake and can respond to directions and questions . Nitrous oxide helps overcome apprehension , anxiety or fear .
Option 2 : Local Anesthesia
Option 3 : Conscious Sedation
Conscious sedation is a controlled , drug induced , minimally depressed level of consciousness that allows the patient to breathe independently and continuously respond appropriately to physical stimulation and / or verbal command , e . g ., “ open your eyes ”
This type of anesthesia may be administered orally ( a drink ) or through a tube to a needle in the vein .
Risks , include but are not limited to : Infection , swelling , discoloration , bruising , headache , tenderness at the needle site and vein , dizziness , nausea and vomiting can occur . Adverse reactions to medication including allergic and life-threatening reactions are possible though rare . Complications may require hospitalization or even result in brain damage or death . With any patient , reflexes are delayed . Children : Patients can have an immediate response to oral conscious sedation similar to a temper tantrum before the medication calms them . Adults : Patients should not drive a car or operate machinery for 24 hours because the effects of sedation remain in the system even after the patient is awake and mobile .
Potential benefits : Pain is lessened or eliminated during the dental treatment . Stress and anxiety are greatly reduced and often there is no memory of the treatment .
Option 4 : Deep Sedation
Deep sedation is a controlled , drug induced state of depressed consciousness from which the patient is not easily aroused , which may be accompanied by a partial loss of protective reflexes , including the ability to maintain an open airway independently and / or respond purposefully to physical stimulation or verbal command .
This type of anesthesia is called a light general anesthesia and is usually administered in a dental office setting .
Risks , include but are not limited to : Infection , swelling , discoloration , bruising , headache , tenderness at the needle site may occur . Dizziness , nausea and vomiting can occur . Adverse reactions to medication including allergic and life-threatening reactions are possible though rare . Complications may require hospitalization or even result in brain damage or death . A responsible escort must bring the patient to the office and take the patient home . Patients should not drive a car or operate machinery for 24 hours because the effects of the sedative remain in the system even after the patient is awake and mobile .
Potential benefits : Pain is lessened or eliminated during the dental treatment . Stress and anxiety are greatly reduced and often there is no memory of the treatment .
Option 5 : General Anesthesia
General anesthesia is a controlled , drug induced state of unconsciousness , accompanied by partial or complete loss of protective reflexes , including an inability to independently maintain an airway and / or respond purposefully to physical stimulation or verbal command .
This type of anesthesia is usually administered in a hospital or surgery center .
Anesthetizing agents are infiltrated into a small area or injected as a nerve block directly into a larger area of the mouth with the intent of numbing the area to receive dental treatment .
Risks , include but are not limited to : It is normal for the numbness to take time to wear off after treatment , usually two or three hours . However , it can take longer and rarely the numbness is permanent if the nerve is injured . Infection , swelling , allergic reactions , discoloration , headache , tenderness at the needle site , dizziness , nausea , vomiting , and cheek , tongue , or lip biting can occur .
Potential benefits : The patient remains awake and can respond to directions and questions . Pain is lessened or eliminated during the dental treatment .
Risks , include but are not limited to : Infection , swelling , discoloration , bruising , tenderness at the needle site may occur . Dizziness , nausea and vomiting can occur . Adverse reactions to medication including allergic and lifethreatening reactions are possible though rare . Complications may require hospitalization or even result in brain damage or death . A responsible escort must bring the patient to the office and take the patient home . Patients should not drive a car or operate machinery for 24 hours because the effects of sedation remain in the system even after the patient is awake and mobile .
Potential benefits : Pain is eliminated and the patient has no recall of the surgical procedure
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