Page 3322 - Cote clinical veterinary advisor dogs and cats 4th

Consent to Perform General Anesthesia

VetBooks.ir Patient name:_________________________________
Pet owner’s name:_____________________________ Med rec #____________
Best contact during/after procedure (e.g., cell phone number):____________________

INTRODUCTION
We want to make sure that you understand the planned anesthetic Other anticipated risks specific to your pet:___________________
procedure to be performed on your pet. You should know why
general anesthesia has been suggested, what the potential benefits _________________________________________________________
are for your pet, and the most common/important risks of general
anesthesia. Alternatives to anesthesia, when applicable, can be
discussed with you if you wish. It is also important that you recognize ALTERNATIVES TO THE PROCEDURE
that medicine is not an exact science, and that the outcome cannot In some instances, heavy sedation in combination with local anes-
be guaranteed. We encourage you to ask us as many questions thetics and/or epidural anesthesia can be considered for various
as required for you to make a well-informed decision. diagnostic and therapeutic interventions. Sedatives will make an
animal sleepy and quiet, but they are not always sufficient and might
BENEFITS/OPTIMAL OUTCOME OF THE PROCEDURE not be a good substitute for general anesthesia. We answer your
General anesthesia causes your pet to become unconscious so that questions and discuss if these alternatives might be appropriate
other procedures, including surgery, can be performed safely and for your pet for our planned procedures.
humanely. General anesthesia will prevent your pet from moving
during diagnostic tests or during treatments. Essentially, general AUTHORIZATION
anesthesia causes your pet to enter a very deep sleep. Anesthesia By signing this form below, you agree that:
will also prevent your pet from experiencing pain, discomfort, or • You understand how/why general anesthesia is considered
fear during the planned procedures. General anesthesia is not itself necessary to help your pet
a treatment for any disease process. • You understand what will be done to your pet during anesthesia
• You understand the known risks that accompany anesthesia,
EXPLANATION OF THE PROCEDURE and also understand that unforeseen complications may occur
Typically, a catheter is placed in a vein to allow for administration • You understand that the anesthetic procedure may not produce
of medications and fluids. Most often, an injection is given through the results we hope to achieve
the catheter to induce anesthesia (bring about an immediate loss of • You understand the alternatives to anesthesia for your pet
consciousness), usually followed by the placement of a breathing • You agree that you have been given time to ask questions regard-
tube in the mouth and throat. The tube allows for administration ing anesthesia, that these have been answered satisfactorily,
of supplemental oxygen and inhaled (gas) anesthesia, and it helps and that you are free to decline the procedure.
protect the airways from fluid going down the trachea (wind pipe).
The patient is monitored during anesthesia to make sure that any
problems are recognized quickly. Following completion of the planned ____________________________________ ______________
procedure or surgery, the anesthetic medications are stopped, the
breathing tube is removed (if one was used), and the patient is Signature of pet owner/owner’s agent Date
monitored until they are fully awake.
Additional procedures planned for your pet at the same time ____________________________________ ______________
as general anesthesia:
Witness to consent (signature) Date
____________________________________________________________
____________________________________
FORESEEABLE RISKS TO THE PROCEDURE
Anesthesia is performed routinely with good outcomes, but it does Witness to consent (printed name)
have associated risks. The main risks of general anesthesia are respira-
tory depression (trouble breathing), abnormal heartbeats (arrhythmias),
low blood pressure (hypotension), gastrointestinal upset (regurgitation,
which can cause aspiration pneumonia), low body temperature, and
very rarely even death. As compared to healthy animals, the risks
of complications are greater for animals with severe illnesses before
anesthesia. Careful monitoring will allow us to catch problems early
so that we can try to correct problems quickly.

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Also available in Spanish.

From Cohn and Côté: Clinical Veterinary Advisor, 4th edition. Copyright © 2020 by Elsevier Inc. All rights reserved.