Medication:	Dopamine Dobutamine Epinephrine Levophed Neosynephrine Isoproterenol (Isuprel) Other, specify
Medication:	Dopamine Dobutamine Epinephrine Levophed Neosynephrine Isoproterenol (Isuprel) Other, specify
Medication:	Dopamine Dobutamine Epinephrine Levophed Neosynephrine Isoproterenol (Isuprel) Other, specify
	Specify:
	Specify:
	Specify:

	Culture:
Blood:	YES NO
Lung:	YES NO
Urine:	YES NO
Other:	YES NO
Other, specify:

Diet:	YES NO UNK
Diuretics:	YES NO UNK
Other Hypertensive Medication:	YES NO UNK

If Yes, Date and time of withdrawal of support:	Date: Time: (military time)
If Yes, Date and time agonal phase begins (systolic BP < 80 or O2 sat. < 80%):	Date: Time: (military time)
If Yes, Total urine output during OR recovery phase:
Measures Between Withdrawal of Support and Cardiac Death. Provide Serial Data Every 15 Minutes Between Withdrawal of Support and Start of Agonal Phase, and Every 5 Minutes Between Start of Agonal Phase and Cardiac Death.
Date:	Time:	Systolic blood pressure:
Diastolic blood pressure:	Mean arterial pressure:	O2 saturation:
If Yes, Core Cooling Used:	YES NO

If Yes, Date and time of abdominal aorta cannulation:
Date:	Time: (military time) ST= Missing Unknown N/A Not Done
If Yes, Date and time of thoracic aorta cannulation:
Date:	Time: (military time) ST= Missing Unknown N/A Not Done
If Yes, Date and time of portal vein cannulation:
Date:	Time: (military time) ST= Missing Unknown N/A Not Done
If Yes, Date and time of pulmonary artery cannulation:
Date:	Time: (military time) ST= Missing Unknown N/A Not Done
If Yes, Estimated Warm Ischemic Time:	min	ST= Missing Unknown N/A Not Done
If DCD, date and time heart recovered/removed from donor:	Date: Time: (military time)
If DCD, date and time right lung recovered/removed from donor:	Date: Time: (military time)
If DCD, date and time left lung recovered/removed from donor:	Date: Time: (military time)
If DCD, date and time double/en-bloc lung recovered/removed from donor:	Date: Time: (military time)

If No, Was this a consented DCD donor that progressed to brain death?

YES NO

	Initial:	Final:
Map: (mm/Hg)
CVP: (mm/Hg)
PCWP: (mm/Hg)
SVR: (dynes/sec/cm)^5)
PA Systolic (initial)
PA Diastolic: (mm/Hg)
CO: (L/min)
Cardiac Index: (L/min/sq.m)