Eurotransplant Liver/Pancreas Report

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Date of birth:
Sex:


Age:
Height:
Weight:
Rhesus:
ABO type:

 HbsAg:
HbcAb:
Malignant tumor:

0
Temperature:
C
Blood pressure:
/
1. Hypotensive Period:
2. Hypotensive Period:
Cardiac Arrest:
Reanimation:
HCVAb:
Steatosis:
Diuresis:
hrs
Last hour:
HIVAb:
ml last
ml
CMVIgG:
Sepsis:

at
at

hrs
hrs
CMVIgM:
Toxo:
EBV:
TPHA:
Meningitis:

 / dosage
Antibiotics:
Diuretics:
AntiDiuretics:
Vasopressors:
Dopamine:
Dobutamine:
Epinephrine:
Norepinephrine:
(last 24 hrs),
Blood transfusions:
Plasma expanders:
Other drugs:
mmHg
Date / duration
/
min.
/
min.
/
min.
/
min.
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:
Crea:
ALT:
Bili (dir):
Leuco’s:
Sputum culture:
Na+:
K+:
Glucose:
LDH:
γGT:
AP:
Amylase:
Lipase:
CRP:
CK:
CKMB:
Blood culture:
Urin protein:
Urin culture:
leucos:
cyl:
bact:

Heparin:
Cold Perfusion Aorta started:
Kind and Volume of perfusate:


Normal arterial anatomy:
If no, specify:
IU at
at
hrs
hrs
Volume:


Perfusion:
Hepatectomy at:
Reason why liver not used:
Quality of liver:
Procurement Center:
Surgeon’s name:
SIGNATURE:
Liver transplanted:
Recipient Center:
ET Nr.:
Cross clamp time:
Cold perfusion Portal Vein or SMV started:
hrs
hrs
ml

Whole pancreas:
With duodenum:
Remarks:
Gallbladder flushed:
Bile duct flushed:
Coeliac axis:
Common hepatic artery:
SMA:
Aortic patch:
Portal vein:
Cholecystectomie
Iliac arteries:
Iliac veins:
K09-0-FB-019-3-ex, Stand: 23.01.17

Hospital:
Admission on:
Date of death:
Cause of Death:

Coeliac axis:
Common hepatic artery:
SMA:
Aortic patch:
Portal vein:
Iliac arteries:
Iliac veins:


Perfusion:
Pancreatectomy at:
Reason why pancreas not used:
Quality of pancreas:
Procurement Center:
Surgeon’s name:
SIGNATURE:
Pancreas transplanted:
Recipient Center:
ET Nr.:

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0191ex
Vorname
Unterschrift

Page 1 K09-0-FB-018-3-ex, Stand: 23.01.17 Eurotransplant

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