CDH Data Form V3



CONGENITAL DIAPHRAGMATIC HERNIA FORM(To be used for patients born on or after 1/1/2007)Year of Birth: FORMTEXT ????? Center #: FORMTEXT ????? Patient #: FORMTEXT ?????Date of Birth: FORMTEXT ????? Time of Birth: FORMTEXT ????? FORMCHECKBOX Inborn FORMCHECKBOX Outborn: Admission Date: FORMTEXT ????? Time: FORMTEXT ?????Sex: FORMCHECKBOX M FORMCHECKBOX F Race: FORMCHECKBOX Asian FORMCHECKBOX Black FORMCHECKBOX Hispanic FORMCHECKBOX Native American FORMCHECKBOX White FORMCHECKBOX Other: FORMTEXT ?????Birthweight: FORMTEXT ????? kg EGA (at birth): FORMTEXT ????? weeks APGARs (1/5/10): FORMTEXT ?????/ FORMTEXT ?????/ FORMTEXT ?????CPR in Delivery Room: FORMCHECKBOX Yes FORMCHECKBOX NoMethod of Delivery: FORMCHECKBOX Vaginal (Spontaneous) FORMCHECKBOX Vaginal (Induced) FORMCHECKBOX C-section (Elective) FORMCHECKBOX C-section (Urgent/Non-elective)If C-Section, reason: FORMTEXT ?????If urgent/non-elective C-Section, what was intended method of delivery: FORMCHECKBOX Vaginal (Spontaneous) FORMCHECKBOX Vaginal (Induced) FORMCHECKBOX C-section (Elective)Prenatal diagnosis of CDH: FORMCHECKBOX Yes FORMCHECKBOX No If Yes, diagnosis made at FORMTEXT ????? weeks gestationPrenatal steroids given: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnknownIf Yes, steroids given at gestational ages (in wks): FORMTEXT ?????/ FORMTEXT ?????/ FORMTEXT ?????/ FORMTEXT ?????Associated Non-Cardiac Anomalies (Check all that apply and please provide DX if known): FORMCHECKBOX Chromosomal – If Yes, please describe: FORMTEXT ????? FORMCHECKBOX Other Anomalies – If Yes, please describe: FORMTEXT ?????Associated Structural Cardiac Anomalies (Check all that apply): FORMCHECKBOX ASD FORMCHECKBOX VSD FORMCHECKBOX AVSD (AV Canal) FORMCHECKBOX Pulmonic Stenosis FORMCHECKBOX Pulmonary Atresia FORMCHECKBOX TOF (Tetralogy of Fallot) FORMCHECKBOX Coarctation of Aorta FORMCHECKBOX TOGV (Transposition of Great Vessels or Transposition of Great Arteries) FORMCHECKBOX Truncus Arteriosus FORMCHECKBOX Complex biventricular anatomy (i.e. heterotaxy syndrome) FORMCHECKBOX Anomalous Pulmonary Venous Return FORMCHECKBOX Single Ventricle Variant (hypoplastic left heart syndrome) FORMCHECKBOX Other (provide details in Comments)(You may explain or elaborate on cardiac diagnosis and /or treatment in the Comments section at the end of the form)Pharmacologic Data:Surfactant given: FORMCHECKBOX Yes FORMCHECKBOX No If Yes, 1st dose given at date: FORMTEXT ????? time: FORMTEXT ????? # doses of surfactant given: FORMTEXT ?????Pulmonary Hypertension (PHTN):First ECHO done on date: FORMTEXT ?????PHTN: FORMCHECKBOX None FORMCHECKBOX < 2/3 systemic FORMCHECKBOX between 2/3 and systemic FORMCHECKBOX > systemicDuctus: FORMCHECKBOX Open FORMCHECKBOX ClosedDuctal shunt: FORMCHECKBOX L to R FORMCHECKBOX Bidirectional FORMCHECKBOX R to LAtrial shunt: FORMCHECKBOX Yes FORMCHECKBOX NoTricuspid regurgitation: FORMCHECKBOX Yes FORMCHECKBOX NoLast ECHO done on date: FORMTEXT ?????PHTN: FORMCHECKBOX None FORMCHECKBOX < 2/3 systemic FORMCHECKBOX between 2/3 and systemic FORMCHECKBOX > systemicDuctus: FORMCHECKBOX Open FORMCHECKBOX ClosedDuctal shunt: FORMCHECKBOX L to R FORMCHECKBOX Bidirectional FORMCHECKBOX R to LAtrial shunt: FORMCHECKBOX Yes FORMCHECKBOX NoTricuspid regurgitation: FORMCHECKBOX Yes FORMCHECKBOX NoTreatment of Pulmonary Hypertension (PHTN):Check if UsedDate StartedDate Ended FORMCHECKBOX Inhaled Nitric Oxide – Maximum dose: FORMTEXT ????? ppm FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Sildenafil FORMCHECKBOX Oral FORMCHECKBOX iv FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Endothelial Receptor Blockade FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Prostacyclin FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Alprostadil (PGE1) FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Milrinone FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Other (specify): FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Ventilation:Intubated at: Date: FORMTEXT ????? Time: FORMTEXT ????? Extubated at: Date: FORMTEXT ????? FORMCHECKBOX Never extubatedActual Values in the first 24 hours of life (pre-ECMO):Highest pre-ductal PaO2: FORMTEXT ????? mm Hg O2 sat: FORMTEXT ????? % FORMCHECKBOX Not availableHighest post-ductal PaO2: FORMTEXT ????? mm HgO2 sat: FORMTEXT ????? % FORMCHECKBOX Not availableHighest PaCO2: FORMTEXT ????? mm Hg FORMCHECKBOX Not availableLowest PaCO2: FORMTEXT ????? mm Hg FORMCHECKBOX Not availableHighest Lactate in first 24 hours: FORMTEXT ????? mmol/L)Highest Lactate in first 72 hours: FORMTEXT ?????mmol/L)Side of Diaphragmatic Hernia: FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Bilateral/Central FORMCHECKBOX No Repair: Reasons repair not done (select best): FORMCHECKBOX Unable to stabilize patient FORMCHECKBOX Patient felt to be non-survivable / not candidate for ECMO: FORMCHECKBOX PaO2 never greater than FORMTEXT ????? mm Hg FORMCHECKBOX PaCO2 never lower than FORMTEXT ????? mm Hg FORMCHECKBOX Anomaly: Cardiac / Chromosomal / Other FORMCHECKBOX Parents requested no further therapy FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Patient felt to be survivable / not candidate for ECMO: FORMCHECKBOX Prematurity / low birth weight FORMCHECKBOX IVH or cerebral hemorrhage pre-ECMO FORMCHECKBOX Parents requested no further therapy FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Patient felt to be survivable / placed on ECMO but no repair done: FORMCHECKBOX IVH or cerebral hemorrhage on ECMO FORMCHECKBOX Other ECMO complication: FORMTEXT ????? FORMCHECKBOX Parents requested no further therapy FORMCHECKBOX Unable to wean off ECMO FORMCHECKBOX Late diagnosis of anomaly: Cardiac / Chromosomal / Other FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Patient came off ECMO but was not repaired: FORMCHECKBOX Refractory hypoxia FORMCHECKBOX Refractory hypercarbia FORMCHECKBOX Anomaly: Cardiac / Chromosomal / Other FORMCHECKBOX Parents requested no further therapy FORMCHECKBOX Multisystem organ failure FORMCHECKBOX Sepsis FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Repair Done:Repair done on done on date: FORMTEXT ????? time: FORMTEXT ?????Diaphragm Defect: FORMCHECKBOX A FORMCHECKBOX B FORMCHECKBOX C FORMCHECKBOX D (Have surgeon identify which diagram (A, B, C, D) most closely approximates defect noted intra-operatively. Orientation: diagram is drawn with the diaphragm (defect) on the patient’s left and you are looking up from the abdomen towards the chest)Type of Diaphragm Repair: FORMCHECKBOX Primary FORMCHECKBOX PatchIf Patch, type patch: FORMCHECKBOX PTFE FORMCHECKBOX Alloderm FORMCHECKBOX Dacron FORMCHECKBOX Mesh plug FORMCHECKBOX Muscle flap FORMCHECKBOX Surgisis FORMCHECKBOX Other: FORMTEXT ?????Hernia Sac: FORMCHECKBOX Yes FORMCHECKBOX NoLiver: FORMCHECKBOX Chest FORMCHECKBOX AbdomenApproach: FORMCHECKBOX Subcostal FORMCHECKBOX Thoracic FORMCHECKBOX Thoracoscopic FORMCHECKBOX Laparoscopic FORMCHECKBOX Both subcostal and Thoracic FORMCHECKBOX Other: FORMTEXT ????? Abdominal Closure: FORMCHECKBOX Primary FORMCHECKBOX Ventral hernia FORMCHECKBOX Silo FORMCHECKBOX Patch FORMCHECKBOX Other: FORMTEXT ????? Chest Tube: FORMCHECKBOX Yes FORMCHECKBOX No ECMO Data: FORMCHECKBOX Placed on ECMOStarted ECMO: date: FORMTEXT ????? time: FORMTEXT ?????Ended ECMO: date: FORMTEXT ????? time: FORMTEXT ?????ECMO Mode: FORMCHECKBOX VA FORMCHECKBOX VA (+V) FORMCHECKBOX VV (DL) FORMCHECKBOX VV to VAMain reason for starting ECMO: FORMCHECKBOX Poor oxygenation FORMCHECKBOX Poor ventilation FORMCHECKBOX Hemodynamic instabilityData supporting decision:FiO2: FORMTEXT ????? %PaCO2: FORMTEXT ????? mm HgPaO2: FORMTEXT ????? mm Hg FORMCHECKBOX Preductal FORMCHECKBOX PostductalMAP: FORMTEXT ?????O2 sat: FORMTEXT ?????% FORMCHECKBOX Preductal FORMCHECKBOX PostductalPIP: FORMTEXT ????? FORMCHECKBOX Second ECMO run: started at date: FORMTEXT ????? time: FORMTEXT ????? ended at date: FORMTEXT ????? time: FORMTEXT ?????Mode: FORMCHECKBOX VA FORMCHECKBOX VA (+V) FORMCHECKBOX VV (DL) FORMCHECKBOX VV to VA FORMCHECKBOX Chylothorax: If Yes, Date of Dx: FORMTEXT ?????Method of Dx- check all that apply: FORMCHECKBOX Xray FORMCHECKBOX Ultrasound FORMCHECKBOX Examination of pleural fluid FORMCHECKBOX Other: FORMTEXT ?????Intervention (feeding) - check all that apply: FORMCHECKBOX Special feeds started: Date: FORMTEXT ????? and type feeds: FORMTEXT ????? FORMCHECKBOX TPN started: Date: FORMTEXT ????? FORMCHECKBOX CT placed: Date: FORMTEXT ????? FORMCHECKBOX Ligation of thoracic duct: Date: FORMTEXT ????? FORMCHECKBOX Pleurodesis: Date: FORMTEXT ?????Resolution (check all that apply): FORMCHECKBOX CXR: Date: FORMTEXT ????? FORMCHECKBOX CT removed: Date: FORMTEXT ????? FORMCHECKBOX TPN stopped: Date: FORMTEXT ?????Other Surgical Procedures (Check all that apply and provide dates): FORMCHECKBOX Repair of recurrent CDH Date: FORMTEXT ????? FORMCHECKBOX Gastrostomy tube (no fundoplication) Date: FORMTEXT ????? FORMCHECKBOX Fundoplication (with or without G-tube) Date: FORMTEXT ????? FORMCHECKBOX Lysis of adhesions/ surgery for SBO Date: FORMTEXT ????? FORMCHECKBOX Closure of ventral hernia Date: FORMTEXT ????? FORMCHECKBOX Cardiac surgery Date: FORMTEXT ?????Details of cardiac surgery: FORMTEXT ?????Outcome: FORMCHECKBOX Death at date: FORMTEXT ?????, time: FORMTEXT ?????Cause(s) of death (check all that apply): FORMCHECKBOX PPHN FORMCHECKBOX Sepsis/Infection FORMCHECKBOX Hemorrhage FORMCHECKBOX Multisystem organ failure FORMCHECKBOX Chronic lung disease FORMCHECKBOX Iatrogenic FORMCHECKBOX Associated anomalies FORMCHECKBOX Other FORMTEXT ????? FORMCHECKBOX Survived to discharge home or transfer FORMCHECKBOX Discharge home at date: FORMTEXT ????? FORMCHECKBOX Transfer to another hospital at date: FORMTEXT ????? FORMCHECKBOX Transfer to in-hospital service for long-term care at date: FORMTEXT ?????Pulmonary Status at 30 Days of Age: FORMCHECKBOX Extubated and on room air FORMCHECKBOX Extubated and on nasal cannula FORMTEXT ????? l O2 and FORMTEXT ????? % FiO2 FORMCHECKBOX Nasal CPAP FORMTEXT ????? cm H2O and FORMTEXT ????? % FiO2 FORMCHECKBOX On mechanical ventilation: FiO2 FORMTEXT ????? %, Rate FORMTEXT ?????, PIP FORMTEXT ?????, PEEP FORMTEXT ????? FORMCHECKBOX On ECMOPulmonary status at time of discharge/transfer: FORMCHECKBOX Extubated and on room air FORMCHECKBOX Extubated and on nasal cannula FORMTEXT ????? l O2 and FORMTEXT ????? % FiO2 FORMCHECKBOX Nasal CPAP FORMTEXT ????? cm H2O and FORMTEXT ????? % FiO2 FORMCHECKBOX On mechanical ventilation: FiO2 FORMTEXT ????? % Rate FORMTEXT ????? PIP FORMTEXT ????? PEEP FORMTEXT ?????Eye exam: FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Not doneHead U/S: FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Not done Head CT: FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Not doneCranial MRI: FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Not doneHearing eval: FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Not doneDischarge weight: FORMTEXT ????? kgFeeding at time of discharge/transfer: FORMCHECKBOX po (primarily oral feeds) FORMCHECKBOX ng (primarily gavage feeds) FORMCHECKBOX GT (primarily G-tube feeds)Date on full enteral feeds: FORMTEXT ?????GER (Gastro-esophageal reflux) diagnosed: FORMCHECKBOX Yes FORMCHECKBOX No If Yes, method of diagnosis: FORMCHECKBOX Clinical FORMCHECKBOX UGI FORMCHECKBOX pH Probe FORMCHECKBOX NuclearIf Yes, method of treatment: FORMCHECKBOX Medical FORMCHECKBOX Surgical Discharge medications (Check all that apply):Respiratory: FORMCHECKBOX Diuretics FORMCHECKBOX Inhaled bronchodilators FORMCHECKBOX Inhaled steroids FORMCHECKBOX iNO FORMCHECKBOX Prostacyclin FORMCHECKBOX Sildenafil FORMCHECKBOX Oxygen FORMCHECKBOX Theophylline FORMCHECKBOX Antibiotics FORMCHECKBOX Seizure medications FORMCHECKBOX Sedatives/analgesicsGastrointestinal: FORMCHECKBOX Prokinetic agents FORMCHECKBOX Antacids(ranitidine, proton pump inhibitors, etc.) FORMCHECKBOX Erythromycin (used to increase motility) FORMCHECKBOX HyperalimentationCardiac: FORMCHECKBOX Digoxin FORMCHECKBOX Captopril FORMCHECKBOX Aspirin(Any medications not listed here, please list in comments section below)Additional Comments about this Patient: FORMTEXT ????? ................
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