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Patient ID Patient code F/L name Section B: CABG procedure form Date of operation : dd/mm/yyyy CABG priority CBP use CBP time Yes Elective Emergency resuscitation No Cross clamp time Urgent min min Total number of distal anastomoses with arterial grafts GRAFT #1 Type of graft: Proximal origin: Target Vessel: LIMA RIMA Aortic In-situ LAD D1 D2 RCA PDA SVG Radial Composite Intermediate M1 PLB GRAFT #2 Type of graft: LIMA RIMA SVG Radial M2 M3 Proximal origin: Target Vessel: Aortic In-situ LAD D1 D2 RCA PDA Composite Intermediate M1 M2 M3 M2 M3 M2 M3 M2 M3 PLB GRAFT #3 Type of graft: Proximal origin: Target Vessel: LIMA RIMA Aortic In-situ LAD D1 D2 RCA PDA SVG Radial Composite Intermediate M1 PLB GRAFT #4 Type of graft: Proximal origin: Target Vessel: LIMA RIMA Aortic In-situ LAD D1 D2 RCA PDA SVG Radial Composite Intermediate M1 PLB GRAFT #5 Type of graft: Proximal origin: Target Vessel: LIMA RIMA Aortic In-situ LAD D1 RCA PDA D2 PLB SVG Radial Composite Intermediate M1 Myocardial protection technique: Antegrade Blood Warm Retrograde Both Crystalloid Cold Tepid Single aortic clamping Yes No Two-clamp technique CABG Medications ASA Yes No Heparin Yes No Angiomax Yes No CABGCABG post-Operative event Postoperative Event Yes No Re-operation due to Bleeding/ Tamponade Yes No Re-operation due to valvular dysfunction Yes No Re-operation due to other cardiac reason Yes No Re-operation due to other non-cardiac reason Yes No Yes No Re-operation due to graft occlusion Yes No If yes, treated by: Other Yes No PCI Re-do Conservative Specify_____________________ Section C: In-Hospital Post procedure Complication and Discharged Status. Any complication during hospitalization If yes: Yes NO Yes CHF mild-moderate (Killip-2)* Sustained VT (>125 bpm) Pulmonary edema (Killip-3)* VF Cardiogenic Shock (Killip-4)* A. Fib (requiring treatment) Hemodynamically significant RVI Asystole MI/ Re MI Acute renal failure Stent thrombosis Dialysis Free wall rapture Local Infection Pericarditis Systematic Infection Tamponade Stroke VSD MR Moderate- severe High degree (2-3°) AVB Permanent pacemaker *Specify worst Killip Class orrhgic NO Bleeding events Significant Bleeding Event Intracranial bleed Retroperitoneal bleed Intraocular bleed Access site hemorrhage requiring surgical intervention Hematoma 5 cm Drop in Hgb 4 g/dL without an overt bleeding source Drop in Hgb 3 g/dL with an overt source of bleeding Operation for bleeding Any blood product transfusion. If Yes, specify number of units:__________ RBC transfusion. If Yes, specify number of units:__________ Platelets transfusion. If Yes, specify number of units:__________ Medications On admission/ during Hosp: At discharge: Aspirin Unknown B Blockers Unknown Clopidogrel Unknown Ca Antagonists Unknown Prasugrel Unknown ACE Inhibitors Unknown Aggrastat Unknown ARB Unknown Intergrillin Unknown Nitrates Unknown Ticagrelor Unknown Coumadin Unknown Nitrates Unknown Pradaxa Unknown Reopro Unknown Xarelto Unknown Fusid Unknown Fusid Unknown Aldactone/ Inspra Unknown Oral antihyperglycemic Unknown Insulin Aspirin Unknown Unknown Clopidogrel Unknown Prasugrel Unknown Ticagrelor Unknown Statin Unknown Ezetimibe Unknown Amiodarone Unknown Other anti-arrhythmic Unknown Smoking cessation therapy Unknown Referral to Rehabilitation Program Yes No Status at Discharged from last department: Alive Discharged Date: dd/mm/yyyy Discharged to: Other Ward Other Hospital Home Deceased Date of Death: dd/mm/yyyy Cause of Death: Cardiac Non-cardiac Unknown Comments: _______________________________________________________________________________ Name of Coordinator/ Physician:__________ Date: dd/mm/yyyy END of Procedure CRF
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