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Microsoft powerpoint - anzodjan2008.ppt

NZ
A
DATA
AUSTRALIA AND NEW ZEALAND ORGAN DONATION REGISTRY 28. Enrolled with Organ
A=Not Accessed S=Not Applicable
31. Donor Coordinator
1. DONOR NUMBER
6. GENDER
7. HEIGHT (cms) 8. WEIGHT (kg)
14. DIABETES
Contact with
Donor Registry
R=Not Registered Y=Yes
Donor Family
T = Type I (Insulin dependent)P = Type II (Non insulin or insulin requiring) 29. Driver’s Licence
32. Coroner’s Case
2. WAS DONOR
9. RACIAL / ETHNIC ORIGIN
A = ACTUAL
15. PAST HISTORY OF TREATED HYPERTENSION
33. Authority for
B = INTENDED
30. Sought By (Refer Codes)
Research
3. HOSPITAL AND STATE
10. RELIGION
Organs / Tissue
AUTHORITY
16. SMOKING
ORGANS / TISSUES
OTHER REASON
OBTAINED Y/N
4. DATE OF BIRTH
11. OCCUPATION (Write In)
13. HEART
17. PAST HISTORY OF CANCER
5. POSTCODE OF DONOR
12. PRIMARY CAUSE OF DEATH
BEATING Y/N
If Yes, enter the
separate cancer form
18. KEY EVENTS Cardio/Pulmonary
Resuscitation
Admission to Hospital
Ventilation
35. ORGANS / TISSUES RETRIEVED (Refer Codes) Withdrawal (DCD)
SOLUTION IN ORGAN
PRESERVATION
RETRIEVAL
ORGANS / TISSUES
OTHER REASON
AT STORAGE
Brain Death (2nd test)
Cross Clamp or
21. DONOR MAINTENANCE (POST BRAIN DEATH OR PRE-DCD)
HOSPITAL
REGISTRY
Admission
Terminal
ORGANS / TISSUES
AND STATE
RECIPIENT SURNAME
GIVEN NAME
OPERATION
Arterial
Oliguria in last 12 hours <20 mls / hr Blood Gas
Y=Yes
N=No

Updated January 2008
INSTRUCTIONS FOR COMPLETION
If maintenance drugs given post brain death OF DONOR SHEET
Terminal = In Intensive Care Unit (ICU)
4 = Prior family request 9 = Family refusal State prefix, then number (eg. Q00001, N00023, Mean Arterial Blood Pressure (MAP) <50 mm Hg
15 = Other Road Accident (Specify)
21 = Fall
Enter Y=Yes or N=No (If Yes, enter duration) If authority obtained enter Y in box–If not enter N
22 = Other Accident (Specify)
(Specify)
31 = Spontaneous Subarachnoid Haemorrhage Complete only for organs where authority
32 = Other Spontaneous Intracranial Haemorrhage obtained (If not retrieved – enter reason)
23. KIDNEY DONOR Enter Y=Yes or N=No in box A=Actual
10 = No suitable recipient 18 = Inotropic support 34 = Hypoxia (Specify)
If not all information known, enter X in box A person from whom the retrieval operation is 35 = Cerebral Oedema (Specify)
commenced for the purpose of transplantation. Admission = First available result
40 = Cerebral Tumour (Specify benign or malignant)
If malignant–enter cancer sheet with details
Terminal = In Intensive Care Unit (ICU)
medically unsuitable at time of surgery or after 51 = Sudden Infant Death Syndrome (SIDS) B=Intended
A person from whom authority has been given or volunteered, but organ donation did not proceed. 60 = Other (Specify)
Urine Output = last hour in ICU preceding transfer
(eg positive virology, cardiac arrest, further PRESERVATION (Solution in organ at storage)
investigations discovered cancer, infection etc) Oliguria In last 12 hours
Record in order of solutions given
Record reason in Section 20 or 35
If two solutions used (eg Ross followed by UW)
As documented in Medical Records and /or Enter most recent donor values prior to retrieval discussion with the Local Medical Officer 10 = No washout (Ice slush only) 20 = Citrate solution (Ross) If a hospital is not on the list, write on the sheet and ECG Normal Y=Yes or N=No
Do not use code that is used by the tissue typing
Echocardiogram Y=Yes or N=No
laboratory for allocation
Y=Yes N=No U=Unknown If Yes, please enter the separate cancer form Two digits per box = DD.MM.YY (eg 03.04.80) 52 = Albumin based blood cardioplegia (pneumoplegia) Admission to Hospital=Initial admission to hospital
Bronchoscopy
When a patient is transferred record admission time Postal residential address of donor. Enter 9999 if overseas resident temporarily in Australia or NZ Do not use gases taken to determine brain death
Ventilation=Time of Intubation
Chest Trauma
Withdrawal (DCD)=Date and time of withdrawal
1=Pneumothorax 2=Chest Drain 3=Other (Specify) 95 = PFC (Perfluorodecalin)–UW (Islets Storage) Record time of Second Brain Death Test and
Cross Clamp of Aorta in Operating Theatre
Enter to nearest centimetre (eg 160.5 = 161) 27. PANCREAS DONOR Enter Y=Yes or N=No in box If Brain Death NOT CERTIFIED (Donation After
Code as per ANZDATA Hospital List. See Question 3 Cardiac Death (DCD) record time of cardiac death
Enter to nearest kilogram (eg 80.6 = 81) and commencement of adequate cold perfusion
Hospital and State
Code as per ANZDATA hospital list. See Question 3 Blood Group
Enter Transplant Hospital NOT Caring Hospital
(Enter subtypes A1 or A2 if known)
Tissue Typing
20. HEPATITIS HBV sAg, HBV CORE ANTIBODY, HCV Ab, HCV NAT (Nucleic Acid), CMV IgG,
N = Not used (Specify reason in Surname section) U = Unusable (Specify reason in Surname section) OTHER – Any other virology tests performed eg IMPORTANT for all solid organs
Enter 1=Positive 2=Negative 3=Not Done

Source: http://www.anzdata.org.au/forms/ANZOD/ANZODForm2008.pdf

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