Confidential Donor Form
UNOS ID # ________________
OPO #
________________
Pre-Procurement Document Review
Donor Identification
ABO Determination:
#1 ABO sample date/time __________/__________
#2 ABO sample date/time __________/__________
Abdominal/Chest cavities visually inspected for contraindications to donation
Brain Death Declaration
Consent Documentation
Serologies
Date/Time ____________/____________
Signature __________________________________ Signature _____________________________________
OR Personnel
Heart/Tx Code
Heart/Lung/Tx Code
Liver/Tx Code
Credential check date/time__________
Credential check date/time__________
Credential check date/time__________
Right Lung/Tx Code
Left Lung/Tx Code
Kidneys/Tx Code
Credential check date/time__________
Credential check date/time__________
Credential check date/time__________
Pancreas/Tx Code
Intestine/Tx Code
Credential check date/time__________
Credential check date/time__________
Circulator(s)
Scrub(s)
Anesthesia
Guidelines provided
Others
OPC(s)
Document1
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Revised 6/15/2011
Confidential Donor Form
UNOS ID # ________________
OPO #
________________
Intraoperative Timeframe
Enter OR
Team Pause
Incision
Clamp
Exit OR
Date/Time __________/__________ Time Zone (circle): PT MT
Date/Time __________/__________ Time Zone (circle) PT MT
Date/Time __________/__________ Time Zone (circle): PT MT
Date/Time __________/__________ Time Zone (circle): PT MT
Date/Time __________/__________ Time Zone (circle): PT MT
Abdominal Perfusion Data
Warm Ischemia Time:
yes
no
Available Typing Materials
Duration: ___________
Aortic Flush Solution : _________________________
Nodes
Volume: ____________
Spleen
Date/Time: __________________________________
Blood
Aortic Flush Characteristics:
1+
2+
3+
4+
Other _________________
Portal Flush Solution: __________________________
Volume: ____________
Date/Time: __________________________________
Portal Flush Characteristics:
1+
2+
3+
4+
Hemodynamic Documentation
Blood Pressure
Heart Rate
Average
________
Low/Duration ________/________
High/Duration ________/________
Average
________
Low/Duration ________/________
High/Duration ________/________
Total Urine Output in OR: ____________
*See also Anesthesia Record (if brain dead donor)
*See also DCD Flow Sheet (if DCD donor)
Medications / IV Volumes
Heparin
Mannitol
Other_______________
Dose / Time
_________/_______
_________/_______
_________/_______
Type / Volume
Blood products _________________/_______
Blood products _________________/_______
Crystalloids
_________________/_______
SPS-1 Additives: Glutathione .92 grams/1000cc
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Dose at time of cross clamp
Vasodilators:
Nipride _______________________
Other ________________________
Vasopressors:
Dopamine______________________
T-4___________________________
Other _________________________
Other __________________________
Confidential Donor Form
UNOS ID # ________________
OPO #
________________
Cross Clamp date/time _______/_______
Time Kidneys Out:__________________
Right
Hard
Soft
Yes
No
Aortic Plaque
Yes
No
Hard
Soft
Hard
Soft
Yes
No
Arterial Plaque
Yes
No
Hard
Soft
Yes
No
Infarcted Areas(s)
Yes
No
Yes
No
Capsule Tear(s)
Yes
No
Yes
No
Subcapsular Hematoma
Yes
No
Yes
No
Cysts/Discoloration
Yes
No
Yes
No
Fat Cleaned
Yes
No
Yes
No
Biopsy
Yes
No
Yes
No
Pumped
Yes
No
Yes
No
Abnormalities
Yes
No
Yes
No
Surgical Damage
Yes
No
Kidney Length x Width
_______ cm x ________cm
1
2
3
Arteries
________ cm x ________cm
1
2
3
cm
cm
cm
Length
cm
cm
cm
mm
mm
mm
Diameter
mm
mm
mm
mm
Distance Apart
mm
Yes
mm
Yes
No
Aortic Cuff
Yes
No
No
NA
Mult. arteries on common cuff
Yes
No
2
1
3
Veins
1
mm
NA
2
3
cm
cm
cm
Length
cm
cm
cm
mm
mm
mm
Diameter
mm
mm
mm
mm
Distance Apart
mm
Yes
No
1
Full
2
cm
Patch
cm
Ureter
cm
1+
Yes
1
Length
2+
3+
mm
No
Full
Patch
2
cm
Vol
3
cm
cm
Solution
No ______________/______
Flush Characteristics:
mm
On Cava
3
Solution
Yes
Left
Kidney Anatomy
Back Table Flush
4+
Yes
Vol
No _______________/_____
Flush Characteristics:
1+
2+
3+
4+
Comments
*if biopsy performed see 12a Histologic Scoring Form
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Revised 6/15/2011
*Storage solution__________________
Confidential Donor Form
UNOS ID # ________________
OPO #
___________
Cross Clamp date/time _______/_________
Liver Anatomy
Comments
Yes
No Anatomical abnormality
_____________________________________________________
Yes
No Surgical damage
_____________________________________________________
Yes
No Capsule torn
_____________________________________________________
Yes
No Hematoma
_____________________________________________________
Yes
No Vessels sent
_____________________________________________________
Yes
No Gall bladder incised/flushed _____________________________________________________
Yes
No Aberrant vasculature
_____________________________________________________
Yes
No Back table flush
Solution:___________________Amount:____________________
Yes
No Biopsy
% Macro Steatosis _________ % Micro Steatosis ____________
Yes
No Percutaneous Biopsy
% Macro Steatosis _________ % Micro Steatosis ____________
Other disease process ________________________________________________________________________
If no biopsy, estimate % visualized fat content ____________________________________________________
Pathologist (Biopsy) _____________________________ Date / Time ___________ / ___________
Pathologist (Percutaneous) ________________________ Date / Time ___________ / ___________
Yes
No Slide sent with liver
Time liver out:________________
______________________________________________________
Heart Anatomy
Flush Solution ______________ Volume ________
Storage Solution _____________ Volume ________
Comments
Yes
No Anatomical abnormality
Yes
No Surgical damage
Yes
No Evidence of CV disease
Time heart out:_______________
_____________________________________________________
_____________________________________________________
_____________________________________________________
Lung Anatomy
Flush Solution ______________ Volume ________ Storage Solution _____________ Volume ________
Comments
Yes
No Anatomical abnormality
Yes
No Surgical damage
Time lungs out: ______________
_____________________________________________________
_____________________________________________________
Pancreas Anatomy
Flush Solution ______________ Volume ________ Storage Solution _____________ Volume ________
Yes
No Bowel Prep
(Gentamycin 100mg/Ancef 1gm/Polymixin 1 million units)
Yes
No Vessels sent
Yes
No Anatomical abnormality
Yes
No Surgical damage
Yes
No Spleen attached
Time pancreas out: _____________
Other ________________
Comments
______________________________________________________
______________________________________________________
______________________________________________________
Intestine Anatomy
Flush Solution ______________ Volume ________
Yes
No Bowel Prep
Storage Solution _____________ Volume ________
(Gentamycin 100mg/Ancef 1gm/Polymixin 1 million units)
Other ________________
Comments
Yes
No Anatomical abnormality
Yes
No Surgical damage
Time intestine out: ______________
Document1
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______________________________________________________
______________________________________________________
Revised 6/15/2011
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Confidential Donor Form