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SHOCK TRIAL

CARDIAC SURGERY

Form S1

INSTRUCTIONS:	COMPLETE FOR ALL TRIAL AND REGISTRY PATIENTS WHO 									UNDERGO ANY TYPE OF CARDIAC SURGERY.
		
						TO BE COMPLETED BY PERFUSIONIST OR SURGEON
			

A.	IDENTIFICATION

A1.		Clinic Site Code and Patient I.D.
ID LABEL HERE
Sample Listing of Eight Patients
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗   
A2.		Date Form Completed									___ ___ / ___ ___ / ___ __
            (COMP_D is character and COMPD is numeric)	    MO		DAY	   YEAR
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗    
A3.		Person Completing Form								___________________________________
																		(NAME - PLEASE PRINT)

A4.		Date of Cardiac Surgery								___ ___ / ___ ___ / ___ ___
            (CSURG_D is character and	    		   MO		DAY	   YEAR
            CSURGDTE is numeric)
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
A5.		a.  (Version 2 only) Date of Completion of	           ___ ___ / ___ ___ / ___ ___           Not Done
		     Coronary Angiography						               MO		DAY	   YEAR            (Q.A6)
		     (CANG_DT is character and CANGDTE is numeric)
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		b.  (Version 2 only) Time of Completion of Coronary Angiography	___ ___:___ ___ 
																					   HRS      MINS

						   (circle one):  						1.  AM       2.  PM       3.  24-hour clock	

A6.		a.  Date Started on Total Vented Bypass				___ ___ / ___ ___ / ___ ___
												   				    MO		DAY	   YEAR
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		b.  Time Started on Total Vented Bypass				___ ___:___ ___ 
																   HRS      MINS

						   (circle one):  						1.  AM       2.  PM       3.  24-hour clock	

B.  TREATMENT

B1.		Cardioplegia Used										1.  No (Q.B5)		2.  Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗	
		a.  Antegrade Delivery								1.  No				2.  Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		b.  Retrograde Delivery								1.  No				2.  Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗

B2.		Type of Cardioplegia or Cardioprotection

		a.  Crystalloid											1.  No				2.  Yes	
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		b.  Blood												1.  No				2.  Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		c.  Additives											1.  No (Q.B3)		2.  Yes
		    (e.g., Aspartate, glutamate, pyruvate, 
		     adenosine, lidoflazine, etc.)

				IF YES, Specify:	c1.________________________
									c2.________________________
									c3.________________________
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
B3.  	Temperature

		a.  Cardioplegia Induction								1.  Warm 			2.  Cold
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		b.  Cardioplegia Maintenance							1.  Warm			2.  Cold
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		c.  Cardioplegia Maintenance Mode					1.  Intermittent		2.  Continuous
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
B4.  	Cardioplegia Final Dose								1. Warm			2.  Cold
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
B5.	(Version 2 only) Comments (explain special technique, no cardioplegia, problems, etc.) 
		
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
B6.		Topical Hypothermia									1.  No 				2.  Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
B7.		Systemic Hypothermia								1.  No  (Q.C1)		2.  Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		B7.1  IF YES, Core temperature (lowest)  				 ___ ___ ___.___SYMBOL 176 \f "Symbol"

							B7.1a.  Units  							1.  Fahrenheit		2.  Celsius
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
C.  (Version 2 only) SURGERY

C1.		CABG													1.  No (Q.C8)		2.  Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
C2.		Vessels Bypassed

		a.	RCA (including PDA)							1.  No 				2.  Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		b.	LCF (including OM)								1.  No 				2.  Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		c.	LAD (including diagonal)							1.  No 				2.  Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
C3.		Were the following conduits used? (answer all items)

		a.  Left Internal Mammary Artery						1.  No				2.  Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		b.  Right Internal Mammary Artery					1.  No				2.  Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		c.  Saphenous Veins									1.  No (Q.C4)		2.  Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
			 c1.  Number of Veins used in surgery							___ ___
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
C4.		Proximal anastomoses done with:						1.  Partial aortic occlusion clamp
																2.  Single total aortic cross clamp
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
C5.		Total perfusion time (Time on C-P bypass)			a.  ___ ___ hrs		b.  ___ ___ min
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
C6.		Total cross clamp time 								a.  ___ ___ hrs 	b. ___ ___ min
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
C7.		Conduit used on infarct-related artery				1.  None
																2.  SVG 
																3.  IMA
																4.  Other 

		a.  IF OTHER, specify  ______________________________________________
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗

C8.Valve procedure1.  No (Q.C9) 2.  Yes (Complete 
  Form S3 if 
  applicable)  MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗

		C8.1.	Mitral valve replacement or repair					1.  No (Q.C8.2)	2.  Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
			a.	Preserved leaflet chordae/papillary muscle			1.  No 				2.  Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		C8.2.	Aortic valve replacement								1.  No 				2.  Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
C9.Myocardial rupture repair1.  No (Q.C10) 2.  Yes (Complete 
               Form S4) MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		C9.1.	Ventricular Septum				  1.  No				     2.  Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		C9.2.	LV free wall						  1.  No 			     2.  Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		C9.3.	RV free wall						  1.  No 			     2.  Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
C10.  	Aneurysmectomy							  1.  No 			     2.  Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
C11.	In the opinion of the surgeon, 
		was revascularization complete?			  1.  No				     2.  Yes				-1. No CABG
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗








 Patient ID Number   ___ ___ - ___ ___ ___ ___ - ___

Quality of Life - OLS  9/21/92  Page page1



SHOCK TRIAL - Form S1 - Version 2.0 Date 9/23/96  Page PAGE4

SHOCK TRIAL - Form S1 - Version 2.0 Date 9/23/96  Page PAGE1




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