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 Page 1 of 4 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 Document1 Page 2 of 4 Revised 6/15/2011 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 Document1 Page 3 of 4 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 Page 4 of 4 ______________________________________________________ ______________________________________________________ Revised 6/15/2011