Download Inclusion Criteria:

Institution:
__________________
Enrolling co-investigator:
__________________
Patient #:__________
(sequential for institution)
Demographics / Clinical History:
Age:
_________ Gender: _________
HD# (1st day of admission = 1) of finding of PI: _____
Admission diagnosis:___________________________
Does patient have a history of (check all that apply):
Pulmonary Diseases:
Systemic Diseases:
___Asthma
___ Scleroderma
___Bronchitis
___ Systemic Lupus
___Emphysema
___ AIDS
___Pulmonary Fibrosis
___ Leukemia
___Cystic Fibrosis
___ Chronic Renal Failure
Organ Transplantation:
___ Bone Marrow
___ Kidney
___ Liver
___ Cardiac
___ Lung
___ Graft versus host
Malignancy History:
___Yes
Intestinal:
___ Adynamic ileus
___ Inflammatory bowel dz
___ Pseudoobstruction
___ Ulcerative colitis
___ Crohn’s disease
___ Enteritis
___ Peptic ulcer
___ Intestinal parasites
___ Bowel obstruction
___ Diverticulitis
___ Intestinal Malignancy
___ Recent Endoscopy
___ Recent Laparoscopy
___ Recent open abdominal surgery (Type:_________________________________
Days prior to PI finding: ______)
___ Recent bowel anastamosis (Type:_________________________________
Days prior to PI finding: ______)
Known medications use history (check all that apply):
___ Corticosteroids
___ Chemotherapeutic agents
Patient condition at time of pneumatosis
Patient / Exam Findings (check all that apply):
___ Distension
___ Absent bowel sounds
___ Peritonitis
___ Abdominal Rigidity
___ Diarrhea
___ Constipation
___ High pitched bowel sounds
___ Heme + stool
___ Exam compromised due to sedation, altered mental, distracting injury or other
clinical factors
Active medications at time of pneumatosis:
On pressors? ____Yes _____No
On antibiotics? ____Yes _____No
Current Steroid use? ___Yes ___No
Current Chemotherapy use?___Yes ___No
Mechanical Ventilation at time of pneumatois? ____Yes ____No
PEEP:_____ Max airway pressure 24 hours:_____
Current active infections (check all that apply):
___ Pneumonia (HAP or VAP)
___ Blood stream infection
___ Other Colitis
___ Catheter related UTI
___ Other: ______________
Other active issues (check all that apply):
___ Hypotension (SBP < 90 mm Hg)
___ Hepatic failure
___ ALI or ARDS
___ C Diff Colitis
___ ARF
___ Sepsis
___ Multi-organ failure
Laboratory Values at time of pneumatosis finding:
Approximate time between labs and radiographic findings (in nearest hour): ____ hours
CBC:
WBC________Hgb________ Hct________Plt_________
Basic Chem: Na+________ Cl-_________ K+________ HCO3___________
BUN_______ Cr__________
ABG:
pH_________ paO2________ paCO2_______ Base Deficit_________
Lactate (mmol/L): ________
Coags:
PTT ______ PT_______ INR_______
LFTS:
Direct Bilirubin: _____ Indirect Bili: ______AST: _______ ALT: _______
Radiographic Findings:
Pneumatosis present on (check all that apply):
___ Plain radiography
___ CT
___ MRI
If CT, what was the slice count of the scanner?___________________________
Location of pneumatosis (check all that apply): ___
___ Duodenum
___ Gastric ___ Rectal ___ Duodenum ___ Jejunum
___ Ileum
___ Cecum ___ Ascending colon ___Transverse Colon
___ Descending Colon ___ Sigmoid Colon ___ Appendix
Degree of pneumatosis (check option most descriptive of pattern)
___Local
____ Diffuse
Additonal radiographic findings (check all that apply):
___ Bowel wall thickening
___ Dilated bowel
___Arterial or venous mesenteric occlusion
___ Hepatic portal gas
___ Retroperitoneal Air
___ Portomesenteric venous gas
___ Free Peritoneal Air
___ Ascites
Surgical Evaluation / Intervention:
Did the patient undergo endoscopy? ____ Yes ____ No Type:__________________
Evidence of ischemia on endoscopy? ____ Yes ____ No
Findings of endoscopy:____________________________________________________
Was the patient offered abdominal exploration? (check most appropriate answer)
___ Exploration not offered
___ Exploration offered, but declined with patient moved to withdrawal of care
___ Exploration offered, but declined – No withdrawal of care
___ Exploration offered and performed
Findings of exploration (if not applicable, leave blank)
Was there evidence of transmural ischemia?
___ Yes ___ No
Was a bowel resection performed?
___ Yes ___ No
Other findings of abdominal exploration:_______________________________________
________________________________________________________________________
________________________________________________________________________
___________________________________________________
Hospital Course / Outcomes info:
Was a diagnosis identified as the cause of PI? ___ Yes ___ No
If so, what was the final diagnosis established as?
________________________________________________________________________
________________________________________________________________________
ICU LOS:
_______________
Hospital LOS:
_______________
Ventilator days:
_______________
Mortality:
___ Yes ___ No
HD# (Day # 1 = admission): ______