Form 137 Adult Heart and HeartLung Status 2 Criteria 4 Extension

Adult Heart and HeartLung Status 2 Criteria 4 Extension Justification Form Medical Urgency Data
Fields to be completed by members
Form Section	Field Label	Notes
Status 2 Extension Criteria 4	Percutaneous endovascular mechanical circulatory support device	Display only
Status 2 Extension Criteria 4	Hemodynamic measurements were obtained and within 24 hour period	Display only
Status 2 Extension Criteria 4	Cardiac index	Display only
Status 2 Extension Criteria 4	Cardiac index - Test Date	Display only
Status 2 Extension Criteria 4	Cardiac index - Test Time	Display only
Status 2 Extension Criteria 4	Pulmonary capillary wedge pressure	Display only
Status 2 Extension Criteria 4	Pulmonary capillary wedge pressure - Test Date	Display only
Status 2 Extension Criteria 4	Pulmonary capillary wedge pressure - Test Time	Display only
Status 2 Extension Criteria 4	Systolic blood pressure	Display only
Status 2 Extension Criteria 4	Systolic blood pressure - Test Date	Display only
Status 2 Extension Criteria 4	Systolic blood pressure - Test Time	Display only
Status 2 Extension Criteria 4	Select one of the following, the candidate either	Display only
Status 2 Extension Criteria 4	Was being supported by inotropic therapy according to either of the following qualifying doses	Display only
Status 2 Extension Criteria 4	A continuous infusion of at least one high dose intravenous inotrope	Display only
Status 2 Extension Criteria 4	A continuous infusion of at least two intravenous inotropes	Display only
Status 2 Extension Criteria 4	Developed ventricular tachycardia lasting at least 30 seconds or required cardioversion, defibrillation, or antitachycardia pacing after inotropic therapy was initiated in an attempt to reach the qualifying doses	Display only
Status 2 Extension Criteria 4	Hemodynamic measurements were not obtained. However, within 24 hours prior to percutaneous endovascular mechanical support	Display only
Status 2 Extension Criteria 4	Date of administration of CPR	Display only
Status 2 Extension Criteria 4	Date of administration of CPR - Test Time	Display only
Status 2 Extension Criteria 4	Systolic blood pressure	Display only
Status 2 Extension Criteria 4	Systolic blood pressure - Test Date	Display only
Status 2 Extension Criteria 4	Systolic blood pressure - Test Time	Display only
Status 2 Extension Criteria 4	Arterial lactate	Display only
Status 2 Extension Criteria 4	Arterial lactate - Test Date	Display only
Status 2 Extension Criteria 4	Arterial lactate - Test Time	Display only
Status 2 Extension Criteria 4	Aspartate transaminase	Display only
Status 2 Extension Criteria 4	Aspartate transaminase - Test Date	Display only
Status 2 Extension Criteria 4	Aspartate transaminase - Test Time	Display only
Status 2 Extension Criteria 4	Alanine transaminase	Display only
Status 2 Extension Criteria 4	Alanine transaminase - Test Date	Display only
Status 2 Extension Criteria 4	Alanine transaminase - Test Time	Display only
Status 2 Extension Criteria 4	Clinical Narrative
Status 2 Extension Criteria 4	Select one of the following
Status 2 Extension Criteria 4	Mean arterial pressure
Status 2 Extension Criteria 4	Mean arterial pressure - Test Date
Status 2 Extension Criteria 4	Mean arterial pressure - Test Time
Status 2 Extension Criteria 4	Cardiac index
Status 2 Extension Criteria 4	Cardiac index - Test Date
Status 2 Extension Criteria 4	Cardiac index - Test Time
Status 2 Extension Criteria 4	Pulmonary capillary wedge pressure
Status 2 Extension Criteria 4	Pulmonary capillary wedge pressure - Test Date
Status 2 Extension Criteria 4	Pulmonary capillary wedge pressure - Test Time
Status 2 Extension Criteria 4	SvO2
Status 2 Extension Criteria 4	SvO2 - Test Date
Status 2 Extension Criteria 4	SvO2 - Test Time
Status 2 Extension Criteria 4	Within 48 hours prior to the status expiring, the candidate was being supported by inotropic therapy according to either of the following qualifying doses:
Status 2 Extension Criteria 4	A continuous infusion of at least one high dose intravenous inotrope
Status 2 Extension Criteria 4	A continuous infusion of at least two intravenous inotropes
OMB No. 0915-0157; Expiration Date: XX/XX/20XX
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