捐贈者查核表 Cadaveric donor checklist

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捐贈者查核表

Cadaveric donor checklist

器官組織

*捐贈者基本資料

醫院: 通報日期/時間姓名: 分享代碼:

身份証號: 性別: 年齡(yr): 血型:

身高(cm): 體重(kg): 胸圍(cm): 回覆時間:

*聯絡方式

通報者/身份: / 電話: (白) (晚)

家屬/電話: (1) / (2) / 同意書是否完整( )

疾病狀況

*診斷: *住院日期: / /

*主治醫師: *過去病史:

手術術式: 手術日期: / /

入院T/P/R/BP: 現在T/P/R/BP:

抽煙: 喝酒: 2T 時間: / /

呼吸器設定 Mode: TV: PC level: RR: FiO2: PEEP:

特殊治療 Dopamine ___________ Dobutamine ___________ Epinephrine ___________ Norepinephrine __ __

*住院過程:

實驗室檢查

HLA typing: A_______-_______ B_______-_______ C_______-_______ DR_______-_______ DQ_______-_______

*Hepatitis markers: HBsAg _______ Anti-HBs _______ Anti-HBc _______ HBeAg _______ Anti-HBe _______

Anti-HCV _______ Anti-HDV _______ Others ________________________________________

Other serology: *Anti-HIV _______*RPR _______ *Anti-HTLV _______ HSV-IgG _______ HSV-IgM _______

CMV-IgG _______ CMV-IgM _______ EB VCA-IgG _______ EB VCA-IgM _______

Toxoplasma IgG _______ Toxoplasma IgM _______ Others ________________________________________

影像學檢查

(組織免填) CXR (____/____/____): ____________________________

EKG (____/____/____): ____________________________

ABD sonogram (____/____/____): ___________________________________

Cardiac echo (____/____/____): EF _____% __________________________

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血液檢查生化檢查(組織免填)

入院時最近入院時最近

*WBC (/mm³⁾ GOT (U/L)

Seg (%) GPT (U/L)

Band (%) ALK-P (U/L)

Mono (%) Bil-T/D (mg/dl)

Lym (%) Alb (g/dl)

Hb (/mm³) CRP (g/dl)

Hct (%) BUN (mg/dl)

PLT (x10³/mm³) Cr (mg/dl)/eGFR

PT (sec) Glucose/HbA1C

INR CPK/MB (U/L)

APTT (sec) Troponin (ng/ml)

尿液檢查(組織免填) Amylase (U/L)

WBC ______/HPF RBC ______/HPF Epi ______/HPF Protein ______ Nitrite ______ Glu ______ Other ____________

Lipase (U/L)

Lactate (mg/dl)

*病原菌培養 Na (ng/ml) Blood culture (____/____/____): _________________________

Sputum culture (____/____/____): ________________________

Urine culture (____/____/____): __________________________

K (mmol/l) Cl (mmol/l) Ca(mg/dl) 血液氣體分析(組織免填)

入院時 (____/____/____- ____:____): pH _____ PaO2 _____ PaCO2 _____ HCO3 _____ BE _____; FiO2 _____ PEEP _____

最近 (____/____/____- ____:____): pH _____ PaO2 _____ PaCO2 _____ HCO3 _____ BE _____; FiO2 _____ PEEP _____

1^st腦判 (____/____/____- ____:____): pH _____ PaO2 _____ PaCO2 _____ HCO3 _____ BE _____; FiO2 _____ PEEP _____

2^st腦判 (____/____/____- ____:____): pH _____ PaO2 _____ PaCO2 _____ HCO3 _____ BE _____; FiO2 _____ PEEP _____

死後捐贈死亡時間：年月日時分

確認完成簽名/蓋章

腎臟科總醫師_______________協調師(他院通報)__________________

摘取醫師____________________摘取醫師____________________摘取醫師____________________摘取醫師____________________

其它/備註:

注：「*」為必填項目