Form 133 Adult Heart and HeartLung Status 1 Criteria 1 Extension

Adult Heart and HeartLung Status 1 Criteria 1 Extension Justification Form Medical Urgency Data
Fields to be completed by members
Form Section	Field Label	Notes
Status 1 Extension Criteria 1	Veno-Arterial Extracorporeal Membrane Oxygenation (VA ECMO)
Status 1 Extension Criteria 1	Hemodynamic measurements
Status 1 Extension Criteria 1	Was the candidate on inotropes at the time cardiac index was obtained?
Status 1 Extension Criteria 1	Cardiac index
Status 1 Extension Criteria 1	Cardiac index - Test Date
Status 1 Extension Criteria 1	Cardiac index - Test Time
Status 1 Extension Criteria 1	Pulmonary capillary wedge pressure
Status 1 Extension Criteria 1	Pulmonary capillary wedge pressure - Test Date
Status 1 Extension Criteria 1	Pulmonary capillary wedge pressure - Test Time
Status 1 Extension Criteria 1	Systolic blood pressure
Status 1 Extension Criteria 1	Systolic blood pressure - Test Date
Status 1 Extension Criteria 1	Systolic blood pressure - Test Time
Status 1 Extension Criteria 1	Date of administration of CPR
Status 1 Extension Criteria 1	Date of administration of CPR - Test Time
Status 1 Extension Criteria 1	Systolic blood pressure
Status 1 Extension Criteria 1	Systolic blood pressure - Test Date
Status 1 Extension Criteria 1	Systolic blood pressure - Test Time
Status 1 Extension Criteria 1	Arterial lactate
Status 1 Extension Criteria 1	Arterial lactate - Test Date
Status 1 Extension Criteria 1	Arterial lactate - Test Time
Status 1 Extension Criteria 1	Aspartate transaminase
Status 1 Extension Criteria 1	Aspartate transaminase - Test Date
Status 1 Extension Criteria 1	Aspartate transaminase - Test Time
Status 1 Extension Criteria 1	Alanine transaminase
Status 1 Extension Criteria 1	Alanine transaminase - Test Date
Status 1 Extension Criteria 1	Alanine transaminase - Test Time
Status 1 Extension Criteria 1	Clinical Narrative
Status 1 Extension Criteria 1	Mean arterial pressure (MAP)
Status 1 Extension Criteria 1	Mean arterial pressure (MAP) - Test Date
Status 1 Extension Criteria 1	Mean arterial pressure (MAP) - Test Time
Status 1 Extension Criteria 1	Cardiac index
Status 1 Extension Criteria 1	Cardiac index - Test Date
Status 1 Extension Criteria 1	Cardiac index - Test Time
Status 1 Extension Criteria 1	Pulmonary capillary wedge pressure
Status 1 Extension Criteria 1	Pulmonary capillary wedge pressure - Test Date
Status 1 Extension Criteria 1	Pulmonary capillary wedge pressure - Test Time
Status 1 Extension Criteria 1	SvO2
Status 1 Extension Criteria 1	SvO2 - Test Date
Status 1 Extension Criteria 1	SvO2 - Test Time
OMB No. 0915-0157; Expiration Date: XX/XX/20XX
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