Global: ^SRT

This is the name of the patient.

1)= S ^SRT("B",$E(X,1,30),DA)=""

2)= K ^SRT("B",$E(X,1,30),DA)

Indicate date organ transplant was completed.

1)= D ADT^SRTPUTL

2)= D KADT^SRTPUTL

The ADT cross reference on the TRANSPLANT DATE field uses the 'inverse' date/time format to sort and to display cases by inverse chronological order.

1)= S ^SRT("AC",X,DA)=$P(^SRT(DA,0),"^")

2)= K ^SRT("AC",X,DA)

The AC cross reference on the DATE OF TRANSPLANT field is used to sort entries by date of transplant for reports.

This is the case in the SURGERY file associated with this file entry.  This field is entered if the transplant was done in a VA medical center. This field will remain blank if the transplant was done in a non-VA facility.

WRITE AUTHORITY:  ^

The VACO ID is a unique identifier provided centrally for each patient undergoing a transplant.  This field is required for creating a Transplant Assessment.

The measurement should be entered in inches (48 to 86) or centimeters (122 to 218). If you are entering the patient's height in centimeters, enter 'C' after the number of centimeters.

Your answer should be in one of the following two formats.

68    (representing inches)

173C  (representing centimeters)

Enter NS for NO STUDY if the patient's height cannot be determined.

The weight should be entered in pounds (50 to 700) or kilograms (23 to 318). If you are entering the patient's weight in kilograms, enter 'K' after the number of kilograms.

Your answer should be in one of the following formats.

178     (weight in pounds)

80K     (weight in Kilograms)

Enter NS for NO STUDY if the patient's weight cannot be determined.

permit ABO incompatible and cross match positive renal transplants.

This is the ABO blood type of the organ recipient.

Indicate date entered on UNOS Waiting List for Transplant.

This is the Recipient CMV status field. The field will capture the cytomegalovirus (CMV) serologic status of the transplant recipient.

between commas can be from 0 to 9999.

NS (No Study) is also an acceptable response for heart transplants assessments.

between commas can be from 0 to 9999.

NS (No Study) is also an acceptable response for heart transplants assessments.

between commas can be from 0 to 9999.

NS (No Study) is also an acceptable response for heart transplants assessments.

between commas can be from 0 to 9999.

NS (No Study) is also an acceptable response for heart transplants assessments.

between commas can be from 0 to 9999.

NS (No Study) is also an acceptable response for heart transplants assessments.

between commas can be from 0 to 9999.

NS (No Study) is also an acceptable response for heart transplants assessments.

The Transplant comments include additional information not available elsewhere on this form. This field has a limit of 130 characters.

physician.

Acute Liver Failure is when a patient develops encephalopathy within 8 weeks of an onset of illness or as documented by an attending physician.

Indicate presence or history of lung cancer with pathology report confirming diagnosis as documented by attending physician.

in medical record.

attending physician.

Bronchiectasis is an abnormal destruction and dilation of the large airways; or a diagnosis of bronchiectasis documented by an attending physician.

Glomerular Sclerosis/Nephritis is kidney disease involving primarily the glomeruli.

For liver transplants, graft failure is failure of transplanted liver caused by the etiologic factor for which the original transplant was performed or the diagnosis of graft failure from recurrent disease documented in

the medical record.

Cirrhosis characterized by hepatitis B surface antibody, hepatitis surface antigen, and hepatitis B core antibody positive and pathology of cirrhosis on liver biopsy.

imaging studies; an alpha-fetoprotein level of >200 ng/ml; an arteriogram confirming a tumor; a biopsy confirming HCC; chemoembolization of lesion, radio frequency, cryo, or chemical ablation of the lesion; or diagnosis of

hepatocellular carcinoma documented in medical record or explant pathology showing hepatocellular carcinoma.

HCV Cirrohosis (Hepatitis C) is characterized by hepatitis C antibody positive and/or PCR positive for HCV RNA and pathology of cirrhosis on liver biopsy.

The measurement should be entered in inches (48 to 86) or centimeters (122 to 218). If you are entering the donor's height in centimeters, enter 'C' after the number of centimeters.

Your answer should be in one of the following two formats.

68    (representing inches)

173C  (representing centimeters)

Enter NS for NO STUDY if the donor's height cannot be determined.

interstitial lung disease documented by an attending physician.

glomerular basement membrane.

Indicate yes if one of the following diagnoses is recorded in patient's medical record: hemachromatosis, alpha1 antitrypsin deficiency, Wilson's, Banti's, lupoid.

documented in the medical record.

The weight should be entered in pounds (50 to 700) or kilograms (23 to 318). If you are entering the donor's weight in kilograms, enter 'K' after the number of kilograms.

Your answer should be in one of the following formats.

178     (weight in pounds)

80K     (weight in Kilograms)

Enter NS for NO STUDY if the donor's weight cannot be determined.

This is Polycystic Disease status of the organ recipient.  Polycystic Disease is a condition in which multiple cysts on the kidneys cause the kidneys to fail.

Primary Biliary Cholangitis or Cirrhosis is an autoimmune liver disease where over time an antibody created within the body attacks and destroys the bile ducts in the liver.

Indicate whether a diagnosis of Primary Sclerosing Cholangitis is documented in the medical record.

ability to transfer oxygen into the bloodstream. Indicate if patient has diagnosis of pulmonary fibrosis documented in the medical record.

Indicate if patient has diagnosis of pulmonary hypertension with Mean PA pressure > 35 mmHg documented in medical record.

This is the Renal Cancer status of the organ recipient.  Renal Cancer is malignant neoplasm of the kidney.

concurrently with involvement of the lungs or other organs.

Indicate donor's gender as "M" if male, "F" if female.

This is the age of the donor at the time of organ harvest. Field will be automatically calculated and filled if DONOR DATE OF BIRTH entered. Enter NS for NO STUDY if the donor's age cannot be determined.

Narrowing or occlusion of the bile ducts either extrahepatic  (for choledochocholedochostomy or choledochojejunostomy) or intrahepatic, seen on MRCP, ERCP, or PTC or as documented in the medical record.

This is the ABO blood type of the organ donor.

Indicate whether the donor tested positive or negative to Cytomegalovirus.

prospective lung transplants recipients. Indicate patient Lung Allocation Score at Listing with UNOS. Enter a number between 0 and 100.

prospective lung transplants recipients. Indicate patient Lung Allocation Score at Transplant with UNOS. Enter a number between 0 and 100.

documented in the UNOS data base. Enter a number between 6 and 40.

Actual Model of End Stage Liver Disease score using the laboratory values of bilirubin, creatinine, and INR at the time of listing and as documented in the UNOS data base. Enter a number between 6 and 40.

documented in the UNOS data base. Enter a number between 6 and 40.

Actual Model of End Stage Liver Disease score using the laboratory values of bilirubin, creatinine, and INR at the time of transplant and as documented in the UNOS data base. Enter a number between 6 and 40.

In addition, bile leak can be identified  as documented in the medical record.

Indicate the UNOS (United Network for Organ Sharing database) status at the time the transplant procedure was performed.

Indicate the UNOS (United Network for Organ Sharing database) status at the time the heart transplant procedure was listed.

Diabetic Retinopathy is damage to the blood vessels in the retina as a consequence of diabetes mellitus. Enter YES if organ recipient is diagnosed with this condition. Otherwise, enter NO.

autonomic neuropathy (autonomic nervous system) or as defined by the attending physician.

Any documented cardiac abnormality (i.e. EKG abnormality, fixed or reversible defects, cardiac disease on heart catheterization, hypertension, and hyperlipidemia).

Indicate if the patient required an inotropic agent (dobutamine, milrinone, levophed, etc.) to maintain adequate cardiac output while awaiting a donor heart.

This is the name of the institution credited for performing this transplant.

between commas can be from 0 to 9999.

NS (No Study) is also an acceptable response for heart transplants assessments.

between commas can be from 0 to 9999.

NS (No Study) is also an acceptable response for heart transplants assessments.

between commas can be from 0 to 9999.

NS (No Study) is also an acceptable response for heart transplants assessments.

between commas can be from 0 to 9999.

NS (No Study) is also an acceptable response for heart transplants assessments.

the recipient's serum.

Transplanted organ was harvested from a deceased donor. Acceptable answers include DCD (Donor after Cardiac Death), ECD (Extended Criteria Donor), SCD (Standard Criteria Donor), ECD-DCD, and No Study.

Enter the donor's date of birth between December 31, 1870 and today's date.

Short Descr:  Update the Donor Age field

Description:  The AGE cross reference on the DONOR DATE OF BIRTH field stuffs the DONOR AGE field with calculated Donor's Age.

Set Logic:  D AGE^SRTPUTL Q

Set Cond:  S X=((X1(1)'=X2(1))&(X2(1)'=""))

Kill Logic:  D KAGE^SRTPUTL Q

Kill Cond:  Q

X(1):  DONOR DATE OF BIRTH  (139.5,70)  (forwards)

catheterization measurement.

between commas can be from 0 to 9999.

NS (No Study) is also an acceptable response for heart transplants assessments.

between commas can be from 0 to 9999.

NS (No Study) is also an acceptable response for heart transplants assessments.

Indicate if the patient has Pulmonary Hypertension or an Elevated PAP not reversible by sodium nitroprusside (Nipride).

Indicate the presence of liver disease such as positive HCV, Hep BsAg, or documented cirrhosis in organ transplant recipient.

predicted.

hallucinogens, marijuana, alcohol or other substances.

The pulmonary arterial vasculopathy associated with elevated pulmonary artery pressure (mean > 35mmHg) and as a consequence of severe hepatic dysfunction or as documented in the medical record.

The presence of upper gastrointestinal bleeding from esophageal or gastric varices any time in the patient's medical history.

This is Pre-transplant Malignancy status of the organ recipient.  Pre-transplant Malignancy is any history of solid organ, blood cell, or lymph node malignancy prior to kidney transplantation.

Indicate if the patient has any neoplasm or tumor of the skin that is biopsy-proven to be malignant prior to organ transplant.

Indicate if patient has history of solid organ, blood cell, or lymph node malignancy (other than skin) prior to organ transplantation.

methamphetamines, cocaine, hallucinogens, marijuana, alcohol or other substances.

The presence of infection related to the diseased biliary tract in the native liver at the time of liver transplantation. The infection would be manifest as cholangitis, bacteremia, or biliary sepsis.

Enter warm ischemia time for organ in minutes as written on transplant data sheet or operative note. This is defined by the time that the donor organ is off ice until the time of reperfusion.

History of new onset of hepatic encephalopathy, recurrent hepatic encephalopathy, or a state of ongoing, continued hepatic encephalopathy as documented in the medical record.

ice.

The presence of ascites fluid (presence of fluid accumulation in the peritoneal cavity noted on physical exam, abdominal ultrasound, or abdominal CT/MRI) at any time in the patient's medical history.

Enter the total ischemia time for organ in minutes which is the sum of warm ischemia time and cold ischemia time.

If both the Warm and Cold Ischemia fields contain values, the "AD" cross reference populates this field with the sum of their values.

scheduled appointments and laboratory draws when requested.

Patient who has had previous substance abuse with opioids and is currently prescribed methadone by a physician or methadone clinic. This patient would be yes for drug abuse variable as well.

This is the Post Transplant Prophylaxis for TB/Antimycobacterial Treatment status of a patient receiving any tuberculosis or antimycobacterial drugs continuously post operatively for at least 30 days.

A diagnosis of acute rejection as made by pathologic evaluation of allograft biopsy or a diagnosis of acute rejection as documented in the medical record.

disorder leads to end-stage renal disease, the patient must go on dialysis or receive a kidney transplant.

hyperkalemia with or without acidosis and progressive chronic renal failure and neurotoxicity manifest primarily as tremors and headache.

toxic manifestations appear to occur in a fairly predictable sequence related to lithium concentrations. Thirst and polyuria may be followed by increased drowsiness, ataxia, tinnitus and blurred vision, indicating early

intoxication. As intoxication progresses the following manifestations may be encountered: confusion, increasing disorientation, muscle twitchings, hyperreflexia, nystagmus, seizures, diarrhea, vomiting, and eventually coma

and death.  Long term lithium use can also cause nephrogenic diabetes insipidus and a chronic tubulointersitial nephritis with progressive chronic kidney disease leading to ESRD.

increasingly larger amounts of residual urine are left behind. Infection is frequently associated with the residual urine. This can be transmitted to the upper urinary tracts, with ensuing hydroureter, hydronephrosis and

progressive renal damage and if untreated to ESRD.

Hepatitis or cirrhosis due to immune cell attack of the liver causing inflammation and or cell death; or diagnosis of autoimmune  hepatitis documented in medical record.

Cryptogenic Cirrhosis is cirrhosis of the liver by biopsy with no specific etiology for the cirrhosis.

The diagnosis of chronic rejection as made by pathologic evaluation or a diagnosis of chronic rejection documented in the medical record.

Thrombosis of the liver allograft hepatic artery documented by ultrasound duplex, angiogram, or another vascular imaging study; or a diagnosis of hepatic artery thrombosis documented in the medical record.

Transplanted organ was harvested from a living donor.

for 'No Study/Unknown' is also allowed.

1) AST > 4999 and one or both of the following: an INR >2.4, acidosis,

defined as having an arterial pH < 7.31 or venous pH of 7.25 and/or

lactate  > 3.9 mMol/L;

2) anhepatic candidate; or diagnosis of primary non-function

documented in the medical record.

A diagnosis of secondary sclerosing cholangitis in medical record.

Hepatitis and or necrosis of the liver due to a known hepatotoxic agent or diagnosis of toxic exposure causing liver failure as documented in medical record.

Enter YES if organ recipient is HIV positive on laboratory test or HIV positive as documented in the medical record. Otherwise, enter NO.

This is the Post Transplant Prophylaxis for CMV/Antiviral Treatment status of a patient who is receiving ganciclovir, valganciclovir, or acyclovir continuously post operatively for at least 30 days.

This is the Post Transplant Prophylaxis for PCP/Antibacterial Treatment status of a patient receiving septra/bactrim, pentamidine, or dapsone continuously post operatively for at least 30 days.

Thrombosis of the liver allograft portal vein documented by ultrasound duplex, angiogram, or CT angiogram or MRI; or a diagnosis of portal vein thrombosis as documented in the medical record.

If the patient was diagnosed with any other form of cardiomyopathy that is not listed elsewhere on this form, specify details into the comment field.

Indicate the presence of lung disease such as documented COPD, pulmonary hypertension, or interstitial disease in organ transplant recipient.

Renal dysfunction is evidenced by a serum creatinine results over 1.5 mg/dl.

Indicate the presence of infection in recipient of the target organ or system requiring antibiotic treatment.

more units of packed red blood cell in the postoperative period including hanging blood from the OR that is finished outside of the OR. If the patient receives shed blood, autologous blood, cell saver blood or pleurovac

postoperatively, this is counted if greater than four units. The blood may be given for any reason.

Criterion 1.  Rales or dullness to percussion on physical examination of chest AND any of the following: a. New onset of purulent sputum or change in character of sputum b. Organism isolate from blood culture c. Isolation

of pathogen from specimen obtained by transtracheal aspirate, bronchial brushing, or biopsy

OR

Criterion 2.  Chest radiographic examination shows new or progressive infiltrate, consolidation, cavitation, or pleural effusion AND any of the following:

a. New onset of purulent sputum or change in character of sputum b. Organism isolated from blood culture c. Isolation of pathogen from specimen obtained by transtracheal

aspirate, bronchial brushing, or biopsy d. Isolation of virus or detection of viral antigen in respiratory

secretions e. Diagnostic single antibody titer (IgM) or fourfold increase in

paired serum samples (IgG) for pathogen f. Histopathologic evidence of pneumonia

CUMULATIVE, not necessarily consecutive.  Ventilator-assisted respirations can be via endotracheal tube, nasotracheal tube, or tracheostomy tube.

CICSP Definition (2007): Indicate if the total duration of ventilator-assisted respiration within 30 days post-operatively was greater than or equal to 48 hours.

completely closed and within 30 days of surgery.  (YES/NO) If patient had cardiac arrest requiring CPR, indicate

whether the arrest occurred intraoperatively or postoperatively. Indicate the one appropriate response:

- intraoperatively: occurring while patient was in the operating room - postoperatively:  occurring after patient left the operating room

NSQIP Definition (2006): The absence of cardiac rhythm or presence of chaotic cardiac rhythm that results in loss of consciousness requiring the initiation of any component of basic and/or advanced cardiac life support.

Patients with AICDs that fire but the patient does not lose consciousness should be excluded.

record.

Indicate if there was any new objective neurologic deficit lasting > 72 hours with onset immediately post-operatively or occurring within the 30 days after surgery.

hospitalization. Do not include drug-induced coma (e.g. Propofol drips, etc.)

CICSP Definition (2006): Indicate if postoperatively within 30 days of surgery there was a significantly decreased level of consciousness (exclude transient disorientation or psychosis) for greater than or equal to 24

hours as evidenced by lack of response to deep, painful stimuli.

- Purulent drainage, with or without laboratory confirmation, from the

superficial incision.

- Organisms isolated from an aseptically obtained culture of fluid or

tissue from the superficial incision.

- At least one of the following signs or symptoms of infection:  pain

or tenderness, localized swelling, redness, or heat and superficial

incision is deliberately opened by the surgeon, unless incision is

culture-negative.

- Diagnosis of superficial incisional SSI by the surgeon or attending

physician.

Do not report the following conditions as SSI:

- Stitch abscess (minimal inflammation and discharge confined to the

points of suture penetration).

- Infected burn wound.

- Incisional SSI that extends into the fascial and muscle layers (see

deep incisional SSI).

muscle layers) of the incision and at least one of the following:

- Purulent drainage from the deep incision but not from the

organ/space component of the surgical site.

- A deep incision spontaneously dehisces or is deliberately opened by

a surgeon when the patient has at least one of the following signs

or symptoms: fever (>38 C), localized pain, or tenderness, unless

site is culture-negative.

- An abscess or other evidence of infection involving the deep

incision is found on direct examination, during reoperation, or by

histopathologic or radiologic examination.

- Diagnosis of a deep incision SSI by a surgeon or attending

physician.

Note:

- Report infection that involves both superficial and deep incision

sites as deep incisional SSI.

- Report an organ/space SSI that drains through the incision as a deep

incisional SSI.

level using the criteria below:

1. Sepsis: Sepsis is the systemic response to infection. Report this variable if the patient has clinical signs and symptoms of SIRS. SIRS is a widespread inflammatory response to a variety of severe clinical insults. This

syndrome is clinically recognized by the presence of two or more of the following:

- Temp >38 degrees C or <36 degrees C

- HR >90 bpm

- RR >20 breaths/min or PaCO2 <32 mmHg(<4.3 kPa)

- WBC >12,000 cell/mm3, <4000 cells/mm3, or >10% immature (band)

forms

- Anion gap acidosis: this is defined by either:

[Na + K] - [Cl + HCO3 (or serum CO2)]. If this number is

greater than 16, then an anion gap acidosis is present.

or

Na - [Cl + HCO3 (or serum CO2)]. If this number is greater

than 12, then an anion gap acidosis is present.

and one of the following:

- positive blood culture

- clinical documentation of purulence or positive culture from any

site thought to be causative

2. Severe Sepsis/Septic Shock: Sepsis is considered severe when it is associated with organ and/or circulatory dysfunction. Report this variable if the patient has the clinical signs and symptoms of SIRS or sepsis AND

documented organ and/or circulatory dysfunction. Examples of organ dysfunction include: oliguria, acute alteration in mental status, acute respiratory distress. Examples of circulatory dysfunction include: hypotension,

requirement of inotropic or vasopressor agents.

* For the patient that had sepsis preoperatively, worsening of any of the above signs postoperatively would be reported as a postoperative Examples:

A patient comes into the emergency room with signs of sepsis - WBC 31, Temperature 104. CT shows an abdominal abscess. He is given antibiotics and is then taken emergently to the OR to drain the abscess. He receives

antibiotics intraoperatively. Postoperatively his WBC and Temperature are trending down.

POD#1 WBC 24, Temp 102

POD#2 WBC 14, Temp 100

POD#3 WBC 10, Temp 99 This patient does not have postoperative sepsis as his WBC and Temperature are improving each postoperative day.

Patient comes into the ER with s/s of sepsis - WBC 31, Temp 104. CT shows an abdominal abscess. He is given antibiotics and is taken emergently to the OR to drain the abscess. He receives antibiotics intraoperatively.

Postoperatively his WBC and Temp are as follows:

POD#1 WBC 28, Temp 103

POD#2 WBC 24, Temp 102.6

POD#3 WBC 22, Temp 102

POD#4 WBC 21, Temp 101.6

POD#5 WBC 30, Temp 104 This patient does have postoperative sepsis because on postoperative day #5, his WBC and Temperature increase. The patient is having worsening of the defined signs of sepsis.

This field documents returns to the operating room including all surgical procedures that required the patient to be taken to the surgical operating room for intervention of any kind.

Documentation of a sudden change in behavior due to an excessive electrical activity in the brain or the diagnosis of seizure in the medical record.

often results in shortness of breath. Indicate if the patient has a diagnosis of emphysema documented by an attending physician.

If the patient was diagnosed with any other condition that is not listed elsewhere on this form, specify details into the comment field. Free text field will have a limit of 50 characters.

appropriate even if the pump is only used for a short time perioperatively. A "yes" response, however, is only correct if the patient did not enter the operating room with this same mechanical circulatory support, and the

device insertion occurred AFTER the induction of  anesthesia.

If patient had/required new mechanical circulatory support, indicate whether the placement occurred intraoperatively or postoperatively.  Indicate the one appropriate response:

- intraoperatively: occurring while patient was in the operating room.  - postoperatively:  occurring after patient left the operating room.

A "no" response is appropriate if the circulatory support device was placed as a prophylaxis before the induction of anesthesia; however, if it was placed for any reason after the induction of anesthesia, then a "yes"

response is appropriate. A "no" response is also appropriate if the primary operation is to insert a ventricular assist device.

usually performed in the course of a normal day in a person's life'. ADLs include: bathing, feeding, dressing, toileting, and mobility. Report the corresponding level of self-care for activities of daily living

demonstrated by this patient at the time the patient is being considered as a candidate for surgery (which should be no longer than 30 days prior to surgery). If the patient's status changes prior to surgery, that change

should be reflected in your assessment. For this time point, report the level of functional health status as defined by the following criteria.

(1) Independent: The patient does not require assistance from another

person for any activities of daily living. This includes a person

who is able to function independently with prosthetics, equipment,

or devices.

(2) Partially dependent: The patient requires some assistance from

another person for activities of daily living. This includes a

person who utilizes prosthetics, equipment, or devices but still

requires some assistance from another person for ADLs.

(3) Totally dependent: The patient requires total assistance for all

activities of daily living.

(4) Unknown: If unable to ascertain the functional status for the time

point of 'prior to the current illness' only, report as unknown.

All patients with psychiatric illnesses should be evaluated for their ability to function with or without assistance with ADLs just as the non-psychiatric patient. For instance, if a patient with schizophrenia is able to

care for him/herself without the assistance of nursing care, he/she is considered independent.

revascularization procedure(s) on vessels to legs, and/or absent or diminished pulses in legs, and/or angiographic evidence of noniatrogenic peripheral arterial obstruction greater than or equal to 50% of luminal diameter.

This is the date of Graft Failure and return to maintenance dialysis after successful kidney transplant. System will also accept an entry for NS (No Study)

transplant.

information is not available.

this information is not available.

(enteric).

Glucose is blood sugar. Blood glucose helps measure pancreas function. Enter the blood glucose level of the organ recipient after transplant.

information is not available.

Lipase is a fat digesting enzyme. It is primarily made in the pancreas. Enter the blood lipase level of the organ recipient after transplant.  Enter NS to represent "No Study" if this information is not available.

Insulin is a hormone made by the islet cells in the pancreas. It controls sugar in the blood by moving it into the cells where it can be used for energy. Indicate if insulin treatment was necessary after the transplant.

Oral hypoglycemics are oral medications taken to lower blood glucose levels. Indicate if oral hypoglycemics were administered to lower blood glucose levels after the transplant.

Indicate the Panel Reactive Antibody of organ recipient at time of listing with UNOS. PRA represents the percent of the U.S. population that the anti-human antibody in the organ recipient's blood reacts with.

Indicate the Panel Reactive Antibody of organ recipient at time of transplant. PRA represents the percent of the U.S. population that the anti-human antibody in the organ recipient's blood reacts with.

For heart transplant assessments, indicate if the patient has a documented history of hypertension with or without current treatment of antihypertensive medication(s).

Preoperative loss of blood necessitating a minimum of 5 units of whole blood/packed red cells transfused during the 72 hours prior to surgery including any blood transfused in the emergency room.

insulin or an oral hypoglycemic agent to prevent a hyperglycemic/metabolic acidosis. If the patient is on both Oral and Insulin therapy, indicate Insulin therapy. Indicate the one most appropriate response.

No - no diagnosis of diabetes.

Diet - a diagnosis of diabetes that is controlled by diet alone in the

two weeks preceding surgery (the only prescribed treatment has

been diabetic relief).

Oral - a diagnosis of diabetes requiring therapy with an oral

hypoglycemic agent in the two weeks preceding surgery.

Insulin - a diagnosis of diabetes requiring daily insulin therapy in

the two weeks preceding surgery.

CICSP Definition (2004): Indicate if there was any re-exploration of the thorax for suspected bleeding within 30 days of surgery.

Amiodarone is an antiarrhythmic agent used for various types of tachyarrhythmias, both ventricular and supraventricular arrhythmias. Indicate if the patient has a history of current or past use of Amiodarone.

Indicate if the patient has heparin sensitivity.

elevated cholesterol levels.

Indicate if the patient had rapid beating of the heart-paroxysmal tachycardia originating in an ectopic focus in the ventricle.

Indicate if the patient has ever received a transfusion of blood and/or blood products.

Indicate the patient's Serum Creatinine result (mg/dl) preoperatively evaluated closest to transplant surgery but not greater than 72 hours before surgery.

Indicate whether the patient was diagnosed with dilated cardiomyopathy (DCM) as characterized by dilation and impaired contraction of one or both ventricles - generally with an ejection fraction < 40%

Indicate if patient was diagnosed with coronary plaque formation or endothelial inflammation of the lining of the coronary arteries.

Indicate if the patient was diagnosed with ischemic cardiomyopathy, primarily due to fixed or non-fixed ischemic damage of the myocardium.

Indicate if the patient was diagnosed with myocardial disease due to chronic alcoholism.

Indicate if the patient was diagnosed with valvular cardiomyopathy thought to be secondary to valvular disease, usually of the aortic or mitral valve.

Indicate if the patient was diagnosed with idiopathic cardiomyopathy.

Coxsackievirus, Influenza virus, Adenovirus, Echovirus, Cytomegalovirus, and Human Immunodeficiency Virus.

Indicate if the patient was diagnosed with cardiac failure in the period before, during, or after pregnancy and delivery.

after Vasodilation is obtained.

obtained.

Indicate the most recent pre-transplant Left Ventricular Ejection Fraction as measured by MUGA scan or Echocardiogram.

Indicate the most recent T-cell and B-cell pre-transplant Percent Reactive Antibodies as measured by flow cyometry.

surgery are acceptable if they are obtained prior to anesthesia induction. If no right heart catheterization performed, entering "NS" for "No Study/Unknown" is also allowed.

prior to surgery. PAW pressures obtained in the operating room prior to surgery are acceptable if they are obtained prior to anesthesia induction. If no right heart or transseptal catheterization performed, entering "NS"

for "No Study/Unknown" is also allowed.

Indicate the amount of forced expiratory volume in one second from the most recent pulmonary function test prior to surgery. Enter 'NS' for No Study if there has been no FEV1 measured in the year preceding surgery.

If the patient has died, this is the date of death.  Enter NA if DATE OF DEATH is not applicable.

is found, please record according to the most conservative (most recent) quit date:

1 = Never a Smoker

2 = Smoking w/i 2 weeks prior to surgery

3 = Smoking w/i 2 weeks to 3 months prior to surgery

4 = Remote Smoker (more than 3 months prior to surgery)

typical rise and fall in biochemical markers, 2) cardiac pain, 3) typical ECG changes (new Q-waves, ST segment elevation or depression). In the absence of the above supporting data, a clear statement or diagnosis of prior

myocardial infarction in the chart will suffice; however, the patient's statement, "I've had a heart attack" is insufficient evidence. Indicate the one appropriate response:

None - The patient has never had a previous Myocardial Infarction.

<=7 days of surg - The patient had a previous Myocardial Infarction

within 7 days prior to surgery.

>7 days prior to surg - The patient had a Myocardial Infarction more

than 7 days prior to surgery."

The field for PRIOR MI shall be added to the data entry option for Non-VA heart transplant assessments.

30 days prior to current surgery).  Both on and off-pump cardiac surgical procedures should be considered.  Count all surgical procedures performed during separate hospital admissions (not the number of grafts, and not

additional procedures performed during the same admission due to a postoperative occurrence). Indicate the one appropriate response: 0, 1, 2, 3, >3.

surgical repair (e.g., carotid endarterectomy), and/or greater than or equal to 50% obstruction of luminal diameter documented by contrast angiography or duplex ultrasound examination.  (NOTE: Stroke should be broadly

interpreted to include intracerebral or subarachnoid bleeding.)

as the inability of the heart to pump a sufficient quantity of blood to meet the metabolic needs of the body or can do so only at increased ventricular filling pressure. Common manifestations are identified:

From the history: 1) Abnormal limitation in exercise tolerance due to dyspnea, fatigue

or angina.

2) Orthopnea (dyspnea on lying supine).

3) Paroxysmal nocturnal dyspnea (PND) - awakening from sleep with

dyspnea which is relieved by assuming an upright posture).

From the physical examination: 4) Increased jugular venous pressure.

5) Pulmonary rales on physical examination.

From the chest x-ray: 6) Cardiomegaly, and

7) Pulmonary vascular engorgement.

The New York Heart Association functional classification is commonly used as a subjective assessment of the severity of congestive heart failure. If none of the above manifestations have been present or congestive heart

failure is not mentioned as an active problem in the 30 days before surgery, indicate Class I.  Any mention of above manifestations requires the indication of a stage other than Class I.  Indicate the one most appropriate

response:

Class I - cardiac disease, no symptoms of abnormal fatigue, dyspnea,

or angina.

Class II - slight limitation of physical activity by fatigue, dyspnea

, or angina. The patient gets unusual fatigue, dyspnea, and/or

angina only upon performing more strenuous activities, such as

climbing two or more flights of stairs without stopping.

Class III - marked limitation of physical activity by fatigue,

dyspnea, or angina. The patient gets unusual fatigue, dyspnea,

and/or angina upon performing ordinary activities, such as

walking several blocks or climbing a flight of stairs.

Class IV - symptoms at rest and/or inability to carry out any

physical activity without symptoms of fatigue, dyspnea or

angina. The patient has symptoms of unusual fatigue, dyspnea,

and/or angina at rest or when performing minimal activity,

such as walking across the room.

Indicate if the patient was administered nitroglycerin intravenously within 48 hours prior to surgery.

Indicate if the patient has used a digitalis preparation (digoxin, Lanoxin, digitoxin, etc.) within the two weeks prior to surgery.

Indicate if the patient has used any diuretic preparation within the two weeks prior to surgery.

None - No New Mechanical Circulatory Device was placed.

IABP - An intra-aortic balloon pump was placed to assist ventricular

function.

VAD - A ventricular assist device (e.g., LVAD, BIVAD) was placed to

assist ventricular function.

Artificial Heart - An artificial heart was placed to assist ventricular

function.

Other - Another type of Mechanical Circulatory Device was placed.

'COMPLETED'.  After the assessment is transmitted, this field will be automatically updated to 'TRANSMITTED'.

The Transplant Type is the name of the organ transplanted. This field only allows selection of KIDNEY, LIVER, LUNG, or HEART.

This determines whether the assessment will be  re-transmitted.  It will automatically be set to '1' when a transmitted assessment is updated to an INCOMPLETE status to edit and re-transmit.

This is the date (or date/time) that this surgery risk assessment was transmitted.

This field indicates whether the transplant was performed in VA facility or Non-VA facility.

Indicate date that patient began renal replacement therapy due to renal failure. System will also accept an entry for NS (No Study).

This is the date of the retransmission if this assessment has been retransmitted to the national database. If there was no retransmission of this assessment, this is the date of the original transmission.

1)= D AT^SRTPUTL

2)= D KAT^SRTPUTL

This MUMPS type cross-reference is used for sorting transmitted assessed cases and excluded cases by the DATE OF LAST TRANSMISSION field.

Indicate if a procedure to cut into the trachea and insert a tube to overcome tracheal obstruction or to facilitate extended mechanical ventilation was performed within 30 days postoperatively.

Indicate if the patient developed a bacterial infection involving the sternum or deep to the sternum requiring drainage and anti-microbial therapy diagnosed within 30 days after surgery.

ultrafiltration.

TIP: If the patient refuses dialysis the answer is YES to this variable, because he/she did require dialysis.

CICSP Definition (2004): Indicate if the patient developed new renal failure requiring dialysis or experienced an exacerbation of preoperative renal failure requiring initiation of dialysis (not on dialysis preoperatively)

within 30 days postoperatively. (Dialysis includes continuous venous to venous hemodialysis [CVVHD], continuous venous to arterial hemodialysis [CVAHD], and peritoneal.  It does not include ultrafiltration.)

'OTHER.'

CICSP Definition (2007): Indicate the presence of a peri-operative MI if at least one of the following criteria occurs either intraoperatively or postoperatively within 30 days: 1. Evolutionary ST-segment elevations 2.

Development of new Q-waves in two or more contiguous ECG leads 3. New or presumably new LBBB pattern on the ECG.

of a perioperative occurrence of the surgery (e.g., mediastinitis).

Plasmapheresis is the procedure of removing, treating, and returning of plasma from blood circulation. It is an extracorporeal therapy.