anaesthesia procedures for interventions on the lower extremities

ANAESTHESIA PROCEDURES FOR INTERVENTIONS ON THE LOWER EXTREMITIES
ANÄSTHESIE-VERFAHREN BEI EINGRIFFEN AN DEN UNTEREN GLIEDMASSEN
Information and medical histor y for adult and adolescent patients in preparation of the required explanator y appointment with the physician.
Clinic / Practice / Hostpital: [Klinik / Praxis / Krankenhaus:]
Patient data: [Patientendaten:]
Klinik für Anästhesie, Intensivmedizin und Schmerztherapie
Alte Landstraße 179
40489 Düsseldorf
Anaesthesia is planned for the following operation/examination/treatment:
[Die Betäubung ist für die folgende Untersuchung/Behandlung vorgesehen:]
left leg / foot
on (date): [am (Datum):]
linkes/r Bein/Fuß
right leg / foot
rechtes/r Bein/Fuß
Dear Patient,
In the interests of eliminating pain during the upcoming medical procedure of your leg or foot, your anaesthetist (hereinafter physician) recommends use of one or more of the anaesthesia procedures described below.
By providing the explanations below, we wish to inform you and your family of the most frequent anaesthesia procedures for the legs and feet,
the possible complications, and what you should do before and after anaesthetization. You might be shown a short film. This form and the film
are designed to prepare you for the explanatory appointment with your physician. Your physician will describe the advantages and disadvantages of the procedure selected for you relative to those of alternative methods and explain and clarify the risks that apply to your case and
the complications that can ensue. Please read the following explanations and fill in the questionnaire with care. Of course, the information you
provide will be treated as strictly confidential.
Your physician will also answer all of your questions to help relieve you of worry and fear. At the end of your explanatory appointment you can
grant or refuse your consent to use of the anaesthesia procedure proposed for you. Your physician will give you a copy of the completed, signed
form at the end of your explanatory appointment.
COURSE OF THE VARIOUS PROCEDURES
ABLAUF DER VERSCHIEDENEN VERFAHREN
The anaesthesia procedure to be proposed to you will be selected on
the basis of a number of factors. In particular, these will include the
level of difficulty, type and anticipated duration of the medical procedure to be performed, your general state of health and any diseases,
illnesses or disorders that you already have.
During anaesthetization and the entire medical procedure, your vital
functions (e.g. blood pressure, heart beat, oxygen saturation) will be
monitored continually and immediate action (countermeasures) will be
taken if there are any problems. It will be possible for infusions and
medications to be administered at any time through an indwelling venous cannula that has been inserted in the back of one or your hands
or lower arms (venous access).
Your physician will mark the anaesthesia procedure(s) planned for you
and discuss it (them) with you in detail.
Local Anaesthesia (infiltration anaesthesia)
Lokalanästhesie (Infiltrationsanästhesie)
In some cases it suffices to inject the local anaesthetic agent directly
into and / or around the site of the medical procedure to eliminate pain
in a small, restricted area.
are used most frequently for medical procedures on the lower extremities. If some other procedure that is not explained below would be
appropriate for you, your physician will explain it to you separately.
Femoral Block (3in1 block) Femoralis-Blockade (3in1-Block)
(Puncture below the groin): This procedure
is primarily suitable for eliminating pain
during medical procedures on the thigh
and lower leg.
Sciatic Block Ischiadikusblockade
at the buttocks am Gesäß (transgluteal)
in the groin in der Leiste (anterior)
behind the knee in der Kniekehle (distal)
These anaesthesia procedures are primarily
used for medical procedures on the lower leg
and foot.
Other procedures: Sonstige Verfahren:
Diagram for marking the puncture points
Abb. zum einzeichnen der Punktionsstellen
Regional Anaesthesia (Conduction Anaesthesia)
With regional anaesthesia, the nerves that serve the site of the
medical procedure are anaesthetized at a place that lies at a distance
from it. Pain is eliminated at the site of the medical procedure for a fairly
long time and the leg is temporarily restricted in its ability to move or
possibly unable to move at all. You will stay awake and be responsive.
In the following we describe the regional anaesthesia procedures that
Herausgeber: e.Bavarian Health GmbH
Nürnberger Straße 71, 91052 Erlangen
phone. +49(0)9131-812 88-290
fax .
+49(0)9131-812 88-299
mail .info@bavarian-health.com
Lizenznummer: 0711_02_AN4_5a
Wissenschaftlicher Fachberater: Prof. Dr. med. Dr. h.c. Jürgen Schüttler
Dr. med. Sven Eric Goddon
Juristische Beratung: Dr. jur. Bernd Joch
Fotokopieren und Nachdruck auch auszugsweise verboten
© 2010 e.Bavarian Health GmbH Reddat.: 08/2010 V1
Lizenz-Start: 15.07.2013
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First the puncture points are thoroughly disinfected, covered sterilely
and locally anaesthetized. It is important that you do not move during
the puncture procedure. The physician locates the puncture point and
searches for the nerve bundle using an injection needle. A brief feeling
of “pins and needles” is quite normal and no reason at all for you to
worry. The search can also be supported by ultrasound control or by a
nerve stimulator attached to the needle. The stimulator transmits weak
electric impulses to the nerves. These impulses stimulate the nerves and
trigger involuntary muscle twitches. This indicates the proper position
for the injection needle to the physician, who then injects the local
an-aesthetic into the immediate vicinity of the nerve trunks of the leg.
This injection is generally not painful. There can only be a temporary
feeling of pressure and warmth. The anaesthetic agent takes effect after
approximately 10 to 30 minutes, depending on the injection point, type
and quantity of the anaesthetic agent used. The leg or foot will have
no feeling and will not be able to move for several hours.
The anaesthetic effect usually lasts for several hours after a single
injection. A catheter (thin plastic tube) can be laid, if necessary. This
makes it possible for the physician to administer the anaesthetic agent
several times or continuously, such as for medical procedures that take
an especially long time. This catheter can also be used to administer
treatment of pain after the medical procedure is over.
General Anaesthesia
Allgemeinanästhesie (Narkose)
With general anaesthesia medications are administered to induce and
maintain a state that is similar to a deep sleep until the medical procedure being performed is over. The patient loses consciousness and all
sensation of pain is eliminated in the patient’s entire body.
Before general anaesthesia begins, your
physician will ask you to breathe in oxygen
through a mask. Then the physician will start
anaesthetization by injecting a rapidly effective anaesthetic agent into a vein in an arm.
This anaesthesia can last long enough for very
short medical procedures (short intravenous anaesthesia). For
longer medical procedures, the anaesthesia is continued by repeated
administration of anaesthetic medications. Other medications such as,
for example, pain killers and muscle relaxants, are administered as appropriate. Since, due to the effects of the general anaesthesia, the patient’s own breathing stops or is at least impaired, the patient is
generally forced to breathe by artificial means. This is done either by a
mask that lies on the patient’s mouth and nose (for short operations),
or by a respiration tube. The tube is passed through the mouth or nose
and inserted into the wind pipe (intubation). A further method is to
pass a special tube through the mouth using what is known as a laryngeal mask to position it just before the voice box (larynx). Intubation
makes it possible for a high degree of safety to be achieved for forced
breathing and protects against aspiration of stomach contents into the
lungs.
The physician will discontinue administration of anaesthetic agents as
soon as the medical procedure is over. You will then wake up as if from a
deep sleep. The mask, laryngeal mask or respiration tube can be re-moved
as soon as you are able to breathe on your own again. You will probably
still be monitored in the recovery room for a while until it is clear that all
of your important organ functions are stable and you are sufficiently alert.
COMBINATION OPTIONS
KOMBINATIONSMÖGLICHKEITEN
Various methods of anaesthesia are frequently combined with one
an-other for medical procedures on the lower extremities. Femoral and
sciatic blocks are often conducted in addition to general anaesthesia so
that pain therapy is possible after the medical procedure is over. Femoral and sciatic blocks or other regional anaesthesia procedures can also
be combined with one another. If such a combination is planned for
you, your physician will explain it in detail.
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POSSIBLE SUPPLEMENTARY MEASURES
MÖGLICHE ERWEITERUNGSMASSNAHMEN
As needed, or if you feel disturbed by the atmosphere in the operating
room during local or regional anaesthesia, you will be given a light sedative through the venous access. This will cause you to dose off so that you
might not be able to remember the entire medical procedure or maybe
you won’t remember any of it at all.
In some cases, the effort to eliminate the sensation of pain by means of
local or regional anaesthesia is not completely successful. Then, in addition, a strong pain killer can be administered or another local anaesthesia
procedure can be employed. If, despite all efforts, it will not be possible
to achieve sufficient anaesthetic effects for the anticipated duration of
the medical procedure, or if there are other problems, then the medical
procedure will have to be continued under general anaesthesia.
PREPARATION AND POST-ANAESTHESIA CARE
HINWEISE ZU VORBEREITUNG UND NACHSORGE
Please strictly follow the instructions of the physician and his or her
assistants. These instructions can vary, depending on the type of anaesthesia and medical procedure.
Preparation:
Intake of Medications: It is important that you tell your physician
which medications you take or are injected on a regular basis (especially anticoagulants such as aspirin® [ASS], Marcumar®, heparin,
Plavix®, etc.) and which other medications you have taken in the 8
days before the medical procedure (e.g. pain killers like ibuprofen,
paracetamol, etc.). This includes all nonprescription medications and
herbal preparations. You will then be told which medications, if any,
must be discontinued and for how long.
Eating, Drinking and Smoking: If a combination of regional and
general anaesthesia is planned, please only take light meals on the day
before the medical procedure. In principle, nothing should be ingested
after 6 hours, if possible 8 hours, before general anaesthesia. This
prohibition covers not only solid foodstuffs but also soups, sweets,
candy, chewing gum and beverages such as juices with pulp (fruit or
vegetable particles), milk, broths and alcohol. In addition, you may not
smoke. Small amounts of clear fluids (e.g. one or two small cups of
water or unsweetened tea) are allowed until 2 hours before the start
of anaesthesia. Your physician will give you more precise instructions.
Your physician might also ask you to follow these instructions even if
only a local or regional anaesthesia procedure is planned for the medical
procedure. In this case local or regional anaesthesia might not be able
to eliminate pain to the extent required, so that the medical procedure
will have to be performed under general anaesthesia.
These restrictions must be strictly observed to prevent contents of the
stomach from passing into the lungs during general aesthesia. That
is why it is very important that you tell the physician before
anaesthesia starts if you were not able to observe any of
these prohibitions on eating, drinking and smoking during
the time required.
Objects on your body: Contact lenses, hearing aids and any other
objects that can be removed from your body such as eyeglasses, necklaces, bracelets and earrings must be removed. Please do not use
makeup or facial cream. Ask the physician whether removable dental
pieces (such as dentures), piercings, hair pieces, and polish on the finger nails or toe nails must be removed.
Post-Anaesthesia Care:
After the medical procedure, you will be monitored until your vital
functions are stable. Anaesthetization of a leg generally lasts for quite
some time. For this reason you must take care to protect your leg from
harm that might be caused by pressure, cold, heat or injuries. Nausea
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and vomiting caused by the anaesthetic or pain killers are temporary
and can generally be treated effectively as required. If the medical
procedure was performed under general anaesthesia, you will still be
tired and sleepy or temporarily disoriented for some time after you wake
up. This is normal and is no reason for worry.
If you are treated as an outpatient, an adult must pick you up when
the procedure is over. You should also arrange for an adult to be with
you at home to watch over you for 24 hours or for the period of time
recommended by your physician. Your abilities to react will be severely
limited after the anaesthesia. For this reason, you must refrain for 24
hours after you have been released from the hospital from participating
actively in road traffic, not even on foot as a pedestrian, and you must
also avoid doing anything that might be hazardous, especially anything
that might allow you to lose your balance. During this recovery period,
you should also refrain from taking decisions that are important for
personal or financial reasons.
Please be sure to inform your physician immediately or visit the clinic in
the event of any complaints such as, for example, pain, heart problems,
respiratory and circulatory disorders, fever, cramps, tingling or numbness, signs of paralysis or restrictions in movement of the anaesthetized
leg. Such complaints can also occur several days after the medical
procedure. They must be treated immediately.
You must be sure to follow the instructions of your physician regarding
other activities such as eating, taking medications and physical exertion. Please refrain from smoking and drinking alcohol for 24 hours
after the anaesthesia.
POSSIBLE RISKS, COMPLICATIONS AND SIDE EFFECTS
MÖGLICHE RISIKEN, KOMPLIKATIONEN UND NEBENWIRKUNGEN
Every medical procedure has its risks. The frequency of possible
side effects and complications depends on several factors such as, for
example, age, general condition, underlying diseases and lifestyle as
well as the type and difficulty of the procedure. In exceptional cases,
perception of pain and waking up from general anaesthesia during
the medical procedure cannot be prevented with absolute certainty by
proper, careful anaesthetisation. However, virtually all such patients do
not remember this afterward. Here we list possible anaesthesia related
incidents that might, under certain circumstances, require subsequent
treatment or operations or even − possibly later on − become lifethreatening. During your explanatory appointment, your physician will
explain the risks that apply to you in greater detail. If you do not wish
to receive detailed explanations, please confirm this wish with your
signature in the relevant section of the patient consent form at the
end of this document. Even in this case, however, we must ask you to
carefully fill in the section with questions about your medical history.
General Risks
Bruises (haematomas) occasionally occur at or near the puncture point.
These can cause formation of hard, painful swellings. Most of them
disappear by themselves without treatment after a few days or weeks.
Damage to the skin, soft tissue, or nerve irritations caused
in spite of proper bedding or due to disinfectants. This can result in
impaired sensations, disturbed feeling, numbness, paralysis, pain and
scars. Most of these complaints go away by themselves or can be
treated with good effect. In very rare cases such complaints can become
permanent despite appropriate efforts to treat them.
Infections with an abscess such as at the place where an injection
needle, cannula or catheter was inserted, as well as necrosis (tissue
death), formation of scars, and vein inflammation (phlebitis) are rare.
They result in swelling, reddening, pain, excessive warmth in the skin
and fever. In most cases such infections can be treated effectively with
antibiotics. In extreme cases the germs can enter the bloodstream
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(bacteraemia) and cause dangerous blood poisoning (sepsis) or even
an infection of the inner lining of the heart (endocarditis). Intensive
medical treatment will then be required. In extremely rare cases, blood
poisoning can lead to death in spite of all efforts to treat it.
Allergic reactions, such as to anaesthetic agents or other medications are rare. They can result in reddening of the skin, rashes, lumps in
the skin, itching, and swelling as well as nausea and coughing. These
symptoms usually go away on their own without treatment. Severe
allergic reactions such as swelling of the laryngeal mucous membrane,
disturbances of the cardiovascular system or of the functioning of the
lungs are very rare. The resulting laboured breathing, cramps excessively
rapid heartbeat or circulatory shock require intensive medical care.
Temporary or even permanent damages to organs such as brain damage, impaired vision, impaired sensations, or even paralyses, impaired
kidney function or kidney failure can occur despite the best of treatment.
Injury of major blood vessels near the puncture point is very rare.
Circulatory disorders (disturbances of blood flow) or formation of blood
clots (thromboses) can lead to dam-age to neighbouring tissue (with
painful swelling) and the organs affected. A blood clot can also be
carried along to block the blood vessels of other organs (embolism).
This can lead to permanent damage to the affected organ (e.g. lung
embolism, stroke with permanent paralyses, kidney failure) despite immediate intensive medical or surgical treatment. In the case of major
bleeding, a transfusion of foreign blood or blood components can be
necessary in exceptional cases. This can lead to infections with pathogens such as: in very rare cases hepatitis viruses (cause of dangerous
liver infections), in extremely rare cases the HIV virus (cause of AIDS),
BSE (cause of a variant of the Creutzfeld-Jakob or mad cow disease) or
other dangerous, possibly still unknown pathogens. A blood donation
by the patient for later use if a transfusion is needed is only appropriate
in certain exceptional cases.
Special Risks of General Anaesthesia
Under general anaesthesia, the body loses the protection that its reflexes normally provide. This can also cause the gate at the exit from
the stomach (pylorus) to open involuntarily. The contents of the stomach
can then flow back into the gullet (oesophagus) and enter the lungs
from there. The life-threatening consequences can be acute closure
of the breathing (respiratory) passages, suffocation or lung
infection with potentially long-term damage to lung tissue, or even
pulmonary (lung) failure. This is a particularly great danger if the
instructions on not eating, drinking or smoking before the anaesthesia
are not strictly followed.
In extremely rare cases, given a certain genetic disposition the body
temperature can suddenly rise to a life-threatening level (malignant
hyperthermia) through the medications that are administered. The
result can be cardiovascular and respiratory failure and functional loss
of one or more organs. In such cases intensive medical care is started
at once to ward off these threats.
The following complications can arise when the respiratory tube is
inserted: occasional sore throat, hoarseness or problems with
swallowing, which usually go away by themselves without treatment;
injuries to the throat, voice box, vocal cords or windpipes with
impaired sensations, laboured breathing, permanent problems with
swallowing or hoarseness are very rare; damage to or even loss of
teeth especially if they are loose teeth, cavities, paradontosis or fixed
dentures (e.g. prostheses, bridges, implants, etc.) require treatment
by a dentist.
Special Risks of Regional Anaesthesia
Impaired sensations such as, for example, feelings of heaviness
or numbness, trembling muscles and itching and aches in the
anaesthetized leg/foot generally go away after a few weeks.
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Urinary retention may occur temporarily after a sciatic block. It can
be necessary to insert a bladder catheter to empty the bladder.
If anaesthetics enter the bloodstream by accident, the result may be
cramps, disorders of the cardiovascular system, or even unconsciousness and cessation of breathing. Immediate intensive
treatment will be required to prevent permanent damage to the brain.
impaired sensations, feelings of numbness, motor disturbances or even
muscle paralysis. Most of these complaints are temporary and go away
by themselves or can be treated with good effect. In very rare cases
such complaints can become permanent despite appropriate efforts
to treat them.
Damage to nerves (for instance, caused by puncture, inserting a
catheter, haemorrhages or infections) are rare. This can lead to pain,
Questions about Your Medical History
Please fill in the following questionnaire with care before your explanatory appointment. The information you provide will help the physician to better assess the risks of anaesthesia in your particular case, to advise you of the complications that could result, and to take any
steps needed to prevent complications and side effects.
yes=ja no=nein
Gender:
M/
Geschlecht:
m/
F, age:
w,
Alter:
years, weight:
kg, height:
cm, occupation:
Jahre,
kg, Größe:
cm,
Gewicht:
Beruf:
1. Do you normally use corrective lenses (eyeglasses, contact lenses, etc.)? yes
no
2. Do you usually wear a hearing aid? yes
no
3. Have you recently received medical treatment? If so, why? yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
Verwenden Sie normalerweise eine Sehhilfe (Brille, Kontaktlinse, etc.)?
Tragen Sie gewöhnlich ein Hörgerät?
Wurden Sie in der letzten Zeit ärztlich behandelt? Wenn ja, weswegen?
4. Have you been operated on before? If so, when and why?
Wurden Sie bereits früher operiert? Wenn ja, weswegen und wann?
Were there any complications with anaesthesia or treating pain?
Ergaben sich damals bei der Anästhesie oder Schmerzbehandlung Komplikationen?
If so, which ones?
Wenn ja, welche?
Have any blood relations (parents, brothers, sisters) ever experienced an unforeseen incident in connection with an anaesthesia procedure? Kam es bei Blutsverwandten (Eltern, Geschwister) zu Zwischenfällen im Zusammenhang mit einem Anästhesie-Verfahren?
5. Have you ever received a blood transfusion? If so, when? Haben Sie schon einmal eine Bluttransfusion erhalten? Wenn ja, wann?
Were there any complications? Wenn ja, ergaben sich dabei Komplikationen? Welche?
not sure
6. Are you pregnant?
nicht sicher
Besteht eine Schwangerschaft?
Are you currently breast feeding a baby? Stillen Sie?
7. Information about medications:
Do you regularly require blood thinning medications (anti-coagulants) or have you taken any or have any been injected
during the past 8 days? Angaben zur Medikamenteneinnahme:
Benötigen Sie regelmäßig blutgerinnungshemmende Mittel oder haben Sie in der letzten Zeit (bis vor 8 Tagen) welche eingenommen bzw. gespritzt?
If yes, please underline the ones in the following list that apply: Aspirin® (ASS), Heparin, Marcumar®, Plavix®, Ticlopidin,
Clopidogrel
Wenn ja, bitte Zutreffendes unterstreichen: Aspirin® (ASS), Heparin, Marcumar ®, Plavix®, Ticlopidin, Clopidogrel
Other:
Sonstiges:
When did you last take an anti-coagulant?
Wann war die letzte Einnahme?
Do you take any other medications?
Nehmen Sie andere Medikamente ein?
yes
no
If yes, please list them:
Wenn ja, bitte auflisten:
(Please include nonprescription medications, herbal and other natural remedies, vitamins, etc.)
(Auch rezeptfreie Medikamente, natürliche oder pflanzliche Heilmittel, Vitamine, etc.)
Do you have or have you ever had any of the following diseases or symptoms thereof?
Liegen oder lagen nachstehende Erkrankungen oder Anzeichen dieser Erkrankungen vor?
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8. Blood diseases / blood clotting disorders? If yes, please underline the ones in the following list that apply: increased tendency to bleed (e.g. frequent nosebleeds,
increased bleeding after surgery, minor wounds or dental treatment), tendency to bruise (frequent bruising, possibly for
no particular reason)
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
13.Thyroid diseases?
If yes, please underline the ones in the following list that apply: overactive thyroid, underactive thyroid, nodules, swelling
(goitre).
yes
no
14.Kidney diseases?
If yes, please underline the ones in the following list that apply: kidney functional disorder (kidney insufficiency), kidney
inflammation.
yes
no
15.Liver diseases?
If yes, please underline the ones in the following list that apply: jaundice, cirrhosis. Other:
yes
no
16.Gastrointestinal diseases?
If yes, please underline the ones in the following list that apply: stricture in digestive tract, ulcer, heartburn.
yes
no
yes
no
Bluterkrankung/Blutgerinnungsstörung?
Wenn ja, bitte Zutreffendes unterstreichen: Erhöhte Blutungsneigung (z.B. häufiges Nasenbluten, verstärkte Nachblutung nach Operationen, bei kleinen Verletzungen oder Zahnarztbehandlung), Neigung zu Blutergüssen (häufig blaue Flecken auch ohne besonderen Anlass).
Do you have any blood relatives with signs of blood diseases / clotting disorders? Gibt es bei Blutsverwandten Hinweise auf Bluterkrankungen/Blutgerinnungsstörungen?
9. Allergies (hay fever/ asthma) / Oversensitivity to medications, anaesthetics, contrast agents, iodine, adhesive bandages, latex (e.g. rubber gloves, balloons) or foodstuffs? Allergie (Heuschnupfen/Asthma)/Überempfindlichkeit auf Medikamente, Betäubungsmittel, Kontrastmittel, Jod, Pflaster, Latex (z.B. Gummihandschuhe, Luftballon) oder Lebensmittel?
10.Heart, circulatory or blood vessel diseases (you or blood relatives)? If yes, please underline the ones in the following list that apply: heart attack, angina pectoris (chest pain / tightness), heart
defect, irregular heart rhythm, inflammation of heart muscle, heart valve disease, shortness of breath while climbing stairs,
heart surgery (possibly with insertion of an artificial heart valve, pacemaker, defibrillator, etc.), high blood pressure, low
blood pressure, stroke, varicose veins, inflammation of a vein (phlebitis), thrombosis, embolism.
Herz-/Kreislauf-/Gefäß-Erkrankungen (auch bei Blutsverwandten)?
Wenn ja, bitte Zutreffendes unterstreichen: Herzinfarkt, Angina pectoris (Schmerzen im Brustkorb, Brustenge), Herzfehler, Herzrhythmusstörungen, Herzmuskelentzündung, Herzklappenerkrankung, Luftnot beim Treppensteigen, Herzoperation ggf. mit Einsatz einer künstlichen Herzklappe, Herzschrittmacher, Defibrillator, hoher Blutdruck, niedriger Blutdruck, Schlaganfall,
Krampfadern, Venenentzündung, Thrombose, Embolie.
Other:
Sonstiges:
11.Diseases of the respiratory tract (breathing passages) or lungs?
If yes, please underline the ones in the following list that apply: asthma, chronic bronchitis, inflammation of the lungs,
emphysema, sleep apnoea (heavy snoring), vocal cord/diaphragm paralysis.
Erkrankung der Atemwege/Lungen?
Wenn ja, bitte Zutreffendes unterstreichen: Asthma, chronische Bronchitis, Lungenentzündung, Lungenemphysem, Schlafapnoe (starkes Schnarchen), Stimmband-Zwerchfelllähmung.
Other:
Sonstiges:
12.Metabolic diseases?
If yes, please underline the ones in the following list that apply: diabetes (sugar sickness), fructose malabsorption.
Stoffwechsel-Erkrankungen?
Wenn ja, bitte Zutreffendes unterstreichen: Diabetes (Zuckerkrankheit), Fruchtzuckerunverträglichkeit.
Other:
Sonstiges:
Schilddrüsenerkrankungen?
Wenn ja, bitte Zutreffendes unterstreichen: Unterfunktion, Überfunktion, Kropf.
Nierenerkrankungen?
Wenn ja, bitte Zutreffendes unterstreichen: Nierenfunktionsstörung (Niereninsuffizienz), Nierenentzündung.
Other:
Sonstiges:
Lebererkrankungen?
Wenn ja, bitte Zutreffendes unterstreichen: Gelbsucht, Leberzirrhose. Sonstiges:
Magen-Darm-Erkankungen?
Wenn ja, bitte Zutreffendes unterstreichen: Engstelle im Verdauungstrakt, Geschwür, Sodbrennen.
Other:
Sonstiges:
17.Diseases of the musculosketal system (you or blood relatives)? If yes, please underline the ones in the following list that apply: congenital or acquired changes in the chest, diseases of
the joints (possibly with artificial joint), shoulder-arm syndrome, problems with the backbone (spine) muscle diseases,
muscle weakness, tendency to elevated body temperature.
Erkrankungen des Muskel- und Skelettsystems (auch bei Blutsverwandten)?
Wenn ja, bitte Zutreffendes unterstreichen: angeborene oder erworbene Veränderungen des Brustkorbs, Gelenkerkrankungen (ggf. künstliches Gelenk), Schulter-Arm-Syndrom, Wirbelsäulenbeschwerden, Muskelerkrankungen, Muskelschwäche, Neigung zur überhöhten Körpertemperatur.
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Other:
Sonstiges:
18.Diseases of the nervous system?
If yes, please underline the ones in the following list that apply: brain disease, brain injuries, paralysis anywhere, seisures
(epilepsy)
yes
no
yes
no
yes
no
yes
no
yes
no
23.Do you drink alcohol? If so, what and how much daily: yes
no
24.Do you take or have you taken drugs? If so, which ones: yes
no
Erkrankung des Nervensystems?
Wenn ja, bitte Zutreffendes unterstreichen: Gehirnerkrankungen oder -verletzungen, Lähmungen, Krampfanfälle (Epilepsie).
Other:
Sonstiges:
19.Communicable (contagious) diseases?
If yes, please underline the ones in the following list that apply: hepatitis, tuberculosis, HIV / AIDS
Other:
Infektionskrankheiten?
Wenn ja, bitte Zutreffendes unterstreichen: Hepatitis, Tuberkulose, AIDS. Sonstiges:
20.Damage to teeth/dental prostheses?
If yes, please underline the ones in the following list that apply: cavities, paradontosis, loose teeth, crown, bridge, implant,
pivot tooth, removable artificial teeth.
Zahnschäden/Zahnersatz?
Wenn ja, bitte Zutreffendes unterstreichen: Karies, Parodontose, lockere Zähne, Krone, Brücke, Implantat, Stiftzahn, herausnehmbarer Zahnersatz.
Other:
Sonstiges:
21.Any other acute or chronic diseases / illnesses?
Nicht aufgeführte akute oder chronische Erkrankungen?
Please describe:
Bitte kurz beschreiben:
Habits:
Lebensgewohnheiten:
22.Do you smoke? If so, what and how much daily:
Rauchen Sie? Wenn ja, was und wie viel täglich:
Trinken Sie regelmäßig Alkohol? Wenn ja, was und wie viel täglich:
Nehmen oder nahmen Sie früher Drogen? Wenn ja, welche:
Important Questions for Outpatient Procedures
Wichtige Fragen für ambulante Eingriffe
Who will pick you up when you are discharged from the hospital / clinic /
doctor’s practise?
Wer wird Sie abholen, sobald Sie aus Klinik/Praxis entlassen werden?
Who is your physician (the one whose care you are in / the one who
referred you / family doctor)?
Wer ist Ihr überweisender Arzt / Hausarzt / weiter betreuender Arzt?
Name: [Name]
Name and age of the person picking you up: [Name und Lebensalter des Abholers]
Street, number, postcode, place: [PLZ, Ort , Straße, Hausnummer]
Where will you be able to be reached during the 24 hours after the
medical procedure?
Telephone number: [Telefonnummer]
Wo sind Sie in den nächsten 24 Stunden nach dem Eingriff erreichbar?
Street, number, postcode, place: [PLZ, Ort, Straße, Hausnummer]
Telephone number: [Telefonnummer]
Name and age of person looking after your: [Name und Lebensalter der Aufsichtsperson}
Lizenznummer: 0711_02_AN4_5a
Lizenz-Start: 15.07.2013
EN AS-3
Kaiserswerther Diakonie
Patient:
Med. Documentation of Explanatory Appointment
I hereby refuse all further treatment. Ich lehne jegliche Behandlung ab.
7/7
Ärztl. Dokumentation zum Aufklärungsgespräch
To be filled in by the physician Wird vom Arzt ausgefüllt
During the patient’s explanatory appointment I explained the following subject
matter to the patient in detail (e.g. possible complications that can result from
the risks specific to the patient, details of the alternative methods and possible
consequences if the anaesthesia is postponed or refused):
Über folgende Themen (z.B. mögliche Komplikationen, die sich aus den spezifischen Risiken beim Patienten
ergeben können, nähere Informationen zu den Alternativ-Methoden, mögliche Konsequenzen, wenn der
Eingriff verschoben oder abgelehnt wird) habe ich den Patienten im Gespräch näher aufgeklärt:
Place, date and time [Ort, Datum, Uhrzeit]
Signature of the patient / legal guardians / witness, if any
[Unterschrift der Patientin / des Patienten / der Erziehungsberechtigten / ggf. des Zeugen]
Patient’s Declaration and Consent
Erklärung und Einwilligung des Patienten
Please mark your declaration in the applicable box and then confirm
it with your signature.
Bitte kreuzen Sie Ihre Erklärung im zutreffenden Kästchen an und bestätigen Sie diese anschließend mit
Ihrer Unterschrift:
I hereby confirm that I have understood all the parts of
this explanation for patients. I have read this explanatory document (7 pages) in its entirety and answered the questions about my
medical history to the best of my knowledge. During my explanatory
appointment, Dr.
has given me a comprehensive
explanation of how the anaesthesia procedure scheduled for me is
carried out, its risks, complications and side effects in my specific
case, and the advantages and disadvantages of the alternative
methods.
I have proposed:
Vorgeschlagen habe ich:
Local anaesthesia Femoral block
General anaesthesia Sciatic block
Lokalanästhesie
Femoralisblock
Narkose
Ischiadikus-Block
Other
Sonstiges
Instructions on preoperative eating/drinking/smoking:
Anweisung zum Nüchternheitsgebot:
no solid food after
keine feste Nahrung ab
o’clock on the day before the procedure
Uhr am Vortag des Eingriffes
no food, beverages or alcohol after
o’clock on the day of
the procedure keine Nahrung, Getränke, Alkohol ab
Uhr am Tag des Eingriffes
no clear liquids, after
o’clock on the day of the procedure
keine klare Flüssigkeit ab
Uhr am Tag des Eingriffes
Patient’s ability to take an independent decision on granting consent:
Fähigkeit der eigenständigen Einwilligung:
The patient has the ability to make an independent decision on the
recommended anaesthesia procedure and to grant his or her consent
to this procedure.
Der Patient besitzt die Fähigkeit, eine eigenständige Entscheidung über das empfohlene AnästhesieVerfahren zu treffen und seine Einwilligung in das Verfahren zu erteilen.
The patient was represented by a custodian or other legal guardian
with proof of authority. This person is in a position to make a decision in the interests of the patient.
Der Patient wird von einem Betreuer bzw. Vormund mit einer Betreuungsurkunde vertreten. Dieser ist
in der Lage, eine Entscheidung im Sinne des Patienten zu treffen.
The patient, custodian or other legal guardian has refused the recommended anaesthesia procedure. The possible disadvantages of
refusing were explained to him or her in detail.
Der Patient/Betreuer/Vormund lehnt das empfohlene Anästhesie-Verfahren ab. Er wurde über die
möglichen Nachteile einer Ablehnung umfassend aufgeklärt.
Place, date and time [Ort, Datum, Uhrzeit][
Physician‘s signature
Unterschrift der Ärztin / des Arztes]
Patient‘s Refusal Ablehnung des Patienten
Dr.
has given me a full explanation of the anaesthesia procedure proposed for the medical procedure to be performed
on me and of the disadvantages that will result from my refusal. I have
un-derstood this explanation. I was also able to discuss with this physician my knowledge and understanding of the information given to me.
Frau/Herr Dr.
hat mich umfassend über die mir für den bevorstehenden
Eingriff vorgeschlagene Betäubungsart und über die sich aus meiner Ablehnung ergebenden Nachteile
aufgeklärt. Ich habe die diesbezügliche Aufklärung verstanden und konnte meine Erkenntnisse über die mir
erteilten Informationen mit dem Arzt diskutieren.
I hereby refuse the anaesthesia procedure that has been proposed
for me.
Ich bestätige hiermit, dass ich alle Bestandteile der Patientenaufklärung verstanden habe.
Diesen Aufklärungsbogen (7 Seiten) habe ich vollständig gelesen und die Fragen zu meiner Krankengeschichte (Anamnese) nach bestem Wissen beantwortet. Im Aufklärungsgespräch mit Frau/Herrn
Dr.
wurde ich über den Ablauf des geplanten Betäubungsverfahrens, dessen Risiken, Komplikationen und Nebenwirkungen in meinem speziellen Fall und über die Vor- und Nachteile der Alternativmethoden umfassend informiert.
I have seen and understood the film about the anaesthesia
procedure that has been scheduled for me.
Den Informationsfilm über die bei mir geplante Betäubung habe ich gesehen und verstanden.
I decided not to watch the film.
Ich habe auf den Informationsfilm verzichtet.
I hereby deliberately waive my rights to more detailed
explanations. However, I hereby confirm that I have been informed
by the attending physician of the necessity of anaesthesia, of its type
and extent, and of the circumstance that all anaesthesia procedures
have their risks. I have answered the questions about my medical
history in full and to the best of my knowledge.
Ich verzichte bewusst auf eine ausführliche Aufklärung. Ich bestätige hiermit allerdings, dass ich
von dem behandelnden Arzt über die Erforderlichkeit der Betäubung, deren Art und Umfang sowie über
den Umstand, dass alle Betäubungsverfahren Risiken bergen, informiert wurde. Die Fragen zu meiner
Krankengeschichte (Anamnese) habe ich nach bestem Wissen vollständig beantwortet.
I affirm that I have no further questions and do not need any
more time in which to think the matter over. I consent to the
proposed anaesthesia procedure. I also consent to all required
auxiliary and follow-up measures (e.g. injections, monitoring).
Ich versichere, dass ich keine weiteren Fragen habe und keine zusätzliche Bedenkzeit benötige.
Ich stimme dem vorgeschlagenen Betäubungsverfahren zu. Ich willige ebenfalls in alle notwendigen
Neben- und Folgemaßnahmen (z.B. Einspritzungen, Überwachungsmaßnahmen) ein.
My approval also covers any required changes or extensions of the
procedure, e.g. continuation under general anaesthesia, combination
with another local anaesthesia procedure.
Meine Einwilligung bezieht sich auch auf die erforderlichen Änderungen oder Erweiterungen des Verfahrens, z.B. Fortführung in Narkose, Kombination mit einem anderen örtlichen Betäubungsverfahren.
In the event that the local anaesthetisation achieved is not sufficient,
I request that I not be given general anaesthesia but that another
attempt at local anaesthetisation be made at some later time.
Falls die örtliche Betäubung nicht ausreichen sollte, wünsche ich keine Narkose, sondern einen erneuten
Versuch zur örtlichen Betäubung zu einem späteren Zeitpunkt.
In the event of a further medical procedure that requires a repetition
of the same local anaesthesia method,
Falls ein weiterer Eingriff eine Wiederholung derselben Betäubungsmethode erfordert,
I consent to the repetition as well. stimme ich der Wiederholung ebenfalls zu.
I do not consent to the repetition, but prefer to discuss the matter with
my physician. stimme ich der Wiederholung nicht zu und wünsche ein erneutes Gespräch mit dem Arzt.
I affirm that I am in a position to follow the medical instructions I have
received in regard to what is expected of me. Ich versichere, dass ich in der Lage
bin, die ärztlichen Verhaltenshinweise zu befolgen.
Place, date and time [Ort, Datum, Uhrzeit]
Hiermit lehne ich das mir vorgeschlagene Betäubungsverfahren ab.
While I refuse the proposed anaesthesia procedure, I would like to
learn more about the possible alternatives. Ich lehne zwar das mir vorgeschlagene
Betäubungsverfahren ab, jedoch möchte ich mehr über die möglichen Alternativen erfahren.
Lizenznummer: 0711_02_AN4_5a
Lizenz-Start: 15.07.2013
Signature of the patient / the legal guardians
[Unterschrift der Patientin / des Patienten / der Erziehungsberechtigten]
EN AS-3