Eurotransplant Thoracic Organ Report

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




Date of birth:
:
Sex:




Hospital:
Admission on:
Date of death:
Cause of Death:
Age:
Height:
Weight:
Rhesus:
ABO type:

 HbsAg:
HbcAb:
Malignant tumor:

0
Temperature:
C
Blood pressure:
/
1. Hypotensive Period:
2. Hypotensive Period:
Cardiac Arrest:
Reanimation:
Hypoxemia:
Hypertensive Period:
HCVAb:
Steatosis:
HIVAb:
Diuresis:
ml last
Last hour:
ml
mmHg
Date / duration
/
min.
/
min.
/
min.
/
min.
/
min.
/
min.
hrs
at
at
CMVIgG:
Sepsis:

hrs
hrs
CMVIgM:
 / dosage:
Antibiotics:
Diuretics:
AntiDiuretics:
Dopamine:
Vasopressors:
Dobutamine:
Epinephrine:
Norepinephrine:
(last 24 hrs),
Blood transfusions:
Plasma expanders:
Other drugs:
EBV:
TPHA:
Meningitis:

Toxo:
g / kg BW / min since:
g / kg BW / min since:
g / kg BW / min since:
g / kg BW / min since:
(since admission)
 (most recent data)
Urin sediment:
Urin glucose:
Urea:
AST:
Bili (tot):
Hb:
HbA1c:
erys:
Urin protein:
Crea:
ALT:
Bili (dir):
Leuco’s:
Sputum culture:
leucos:
cyl:
bact:
Urin culture:
Na+:
K+:
Glucose:
LDH:
γGT:
AP:
Amylase:
Lipase:
CRP:
CK:
CKMB:
Blood culture:
Blood gas analysis:
Date/hr
FiO2
PEEP
pH
PaCO2
PaO2
HCO3
BE
EKG:
Echo Heart:
Heart performance:
Remarks:


Heparin:
IU
Cross clamp time:
Cold Perfusion Heart started:
Cardioplegic solution:
Add. To Pres. solution:
Volume of Perfusate:
ml
Storage in:

K09-0-FB-018-3-ex, Stand: 23.01.17

Perfusion:
Coronary Artery Sclerosis:
Reason why not used:
Quality:
Procurement Center:
Surgeon’s name:
SIGNATURE:
Organ(s) transplanted:
Recipient Center:
ET Nr:

at
at
hrs
hrs
hrs
in
min.

100
5
PGE1 (IV / RA / PA ):
PGI2 (IV / RA / PA ):
Other Drugs:
Preservation solution:
Add. To Pres. solution:
Volume of perfusate:
Storage in:
Inflation Status:
Weight of lungs:
Lungs en bloc:

Bronchoscopy findings:
Lung
Right
Secretions:
 clean
 mucoid
 purulent
 hemorrhagic
Aspiration:
Inflammation:

ng/ kg BW
ng/ kg BW
at
at
hrs
hrs
ml
in
min.

With heart:


Additional signature, for Germany only:
Verantwortlicher Entnahmechirurg (leitender Operateur nach Richtlinie der BÄK gemäß § 16 Abs. 1 Satz 1 Nr. 4 a) und b) TPG)
Nachname
K090FB0181ex
Vorname
Unterschrift
Left

Eurotransplant Liver/Pancreas Report

Sepsis sticker