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European Surgical Outcomes Study (EuSOS) Critical Care case record form Data describing first hour of admission to critical care yr Gender M F Height Age cm Weight kg Time (24h) & date of hospital admission: h h : m m d d m m 2 0 1 1 Time (24h) & date of Critical care admit: h h : m m d d m m 2 0 1 1 Location before critical care admission (or surgery if admitted directly after procedure): Emergency Department General Ward Critical care admission (tick one): Critical Care Planned Other Unplanned Chronic co-morbid disease (tick all that apply): Non-haematological malignancy Haematological malignancy Hypertension Chronic renal failure Chronic excessive alcohol intake Intra-venous drug user HIV/AIDS Cirrhosis Chronic respiratory failure Steroid therapy Radiotherapy Chemotherapy Reason(s) for critical care admission: Coma/delirium Y N Acute abdomen Y N Severe pancreatitis Y N Liver failure Y N Arrhythmia Y N Hypovolaemic shock Y N Septic shock Y N Routine care Y N Respiratory arrest in 24 hours prior to critical care admission Y N Cardiac arrest in 24 hours prior to critical care admission Y N EuSOS unique patient ID EuSOS Critical Care case record form v1.4 Page 1 of 6 Patient name: ___________________________________ DOB d d m m y y y y Airway at end of first hour in critical care (tick one): Own Endotracheal tube Tracheostomy Other Ventilation at end of first hour in critical care (tick one): Invasive (via tracheal tube or tracheostomy) Non-invasive None Plan made at critical care admission for renal replacement therapy Y N Confirmed / strongly suspected infection at critical care admission Y N If yes, was this a nosocomial (hospital acquired) infection Y N Site of infection: Wound Lung Urinary Abdominal Other Surgical site (tick all that apply) Lower gastro-intestinal Upper gastro-intestinal Biliary tract Liver Pancreas Head and Neck Gynaecological surgery Endocrine surgery Upper limb surgery Hip and lower limb surgery Kidney Other urology Thoracic surgery: Vascular surgery: Pneumonectomy Aortic surgery Lobectomy Carotid endarterectomy Pleural surgery Peripheral vascular Other thoracic Other vascular Spine Lung Transplant Cutaneous & burns Trauma Breast OR All other procedures EuSOS unique patient ID EuSOS Critical Care case record form v1.4 Page 2 of 6 Patient name: ___________________________________ DOB d d m m y y y y Heart rate (highest value) beats/minute Systolic arterial pressure (lowest value) mmHg Mean arterial pressure (lowest value) mmHg Lowest GCS (even if sedated) Core temperature (highest value) . Arterial PaO2 (lowest value) °C . FiO2 at the time of this PaO2 . Serum pH (lowest value) . Serum bicarbonate (lowest value) . Leucocytes (highest value) kPa or mmHg # mmol/l x109/L . Platelets (lowest value) x109/L Bilirubin (highest value) . µmol/L or mg/dl # Creatinine (highest value) . µmol/L or mg/dl # # indicate units used for PaO2, creatinine and bilirubin Highest vasoactive drug dose in the first hour following admission: Dobutamine Y N Dose: . µg/kg/min Dopamine Y N Dose: . µg/kg/min Norepinephrine Y N Dose: . µg/kg/min Epinephrine Y N Dose: . µg/kg/min Dopexamine Y N Dose: . µg/kg/min EuSOS unique patient ID EuSOS Critical Care case record form v1.4 Page 3 of 6 Patient name: ___________________________________ DOB d d m m y y y y Physiological data following 24 hours in critical care Enter most severe physiological data / highest drug dose in previous 24 hours Arterial PaO2 (lowest value) . FiO2 at the time of this PaO2 kPa or mmHg # . Actual Glasgow coma score (lowest value) Serum Creatinine (highest value) . µmol/L or mg/dl # Serum Bilirubin (highest value) . µmol/L or mg/dl # Platelets (lowest value) x109/L Mean arterial pressure (lowest value) mmHg # indicate units used for PaO2, creatinine and bilirubin Dobutamine Y N Dose: . µg/kg/min Dopamine Y N Dose: . µg/kg/min Norepinephrine Y N Dose: . µg/kg/min Epinephrine Y N Dose: . µg/kg/min Dopexamine Y N Dose: . µg/kg/min Airway: Own Endotracheal tube Tracheostomy Other Ventilation: Invasive ventilation Non-invasive ventilation Renal replacement therapy Y None N EuSOS unique patient ID EuSOS Critical Care case record form v1.4 Page 4 of 6 Patient name: ___________________________________ DOB d d m m y y y y Physiological data following 48 hours in critical care Enter most severe physiological data / highest drug dose in previous 24 hours Arterial PaO2 (lowest value) . FiO2 at the time of this PaO2 kPa or mmHg # . Actual Glasgow coma score (lowest value) Serum Creatinine (highest value) . µmol/L or mg/dl # Serum Bilirubin (highest value) . µmol/L or mg/dl # Platelets (lowest value) x109/L Mean arterial pressure (lowest value) mmHg # indicate units used for PaO2, creatinine and bilirubin Dobutamine Y N Dose: . µg/kg/min Dopamine Y N Dose: . µg/kg/min Norepinephrine Y N Dose: . µg/kg/min Epinephrine Y N Dose: . µg/kg/min Dopexamine Y N Dose: . µg/kg/min Airway: Own Endotracheal tube Tracheostomy Other Ventilation: Invasive ventilation Non-invasive ventilation Renal replacement therapy Y None N EuSOS unique patient ID EuSOS Critical Care case record form v1.4 Page 5 of 6 Patient name: ___________________________________ DOB d d m m y y y y Critical care discharge data Time of Critical care discharge (or death): h h Date of Critical care discharge (or death): d d : m m (24 hr clock) m m 2 0 1 1 Critical care discharge (tick one): Planned Unplanned Major therapeutic limitation during critical care stay? Y N Status at critical care discharge: Alive Dead Status at Hospital discharge: Alive Dead Still in hospital 60 days after surgery? Y N EuSOS unique patient ID EuSOS Critical Care case record form v1.4 Page 6 of 6 Patient name: ___________________________________ DOB d d m m y y y y
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