This document contains a checklist for organ transplant surgery. It lists donor information, the recipient's medical status and lab values, equipment, drugs, infusions, and spaces to record vital signs, urine output, blood loss, fluid administration, and blood product transfusions over a 24 hour period. The checklist aims to ensure all necessary information, equipment, medications and support services are available for a safe organ transplant procedure.

1. MY CHECK LIST FOR OLTx
DONOR DATA:
Age: yrs Sex: M / F weight: kgs Height: cms Blood Group:
CVS: Ionotropes: Dopamine / dobutamine / adrenaline / N adrenaline / vasopressin
mcg / kg / min:
RS: PaO2 / FiO2: PEEP FiO2
UOP: ml / hr
Serology: HBsAg HCV CMV
SUPPORT SERVICES:
Blood products available: ______ PRBCs ______ FFPs ______ RDPs _______ SDPs _____ Cryoppt
Novoseven
Antifibrinolytics: can be used yes / no
EQUIPEMENTS NEEDED:
Warming devices: Fluid Forced air Theatre temp control
Cell saver: Indicated / Contraindicated
Lab services: ABGs / TEG
CO monitoring available: yes / no
SCD device / TED stockings

2. THEATRE DRUGS:
Induction Others Resuscitation drugs
Fentanyl 50 mcg /cc in 10 ml syringe Phenylephrine: 100 mcg / cc in 10 ml Adrenaline: 1 in 10 diluted in 10 ml
Midazolam 1mg / cc in 5 ml syringe syringe x 2 syringe
Propofol 10mg / cc in 10 ml syringe Mephentermine: 6 mg / cc in 5 ml Adrenaline: 1 mg / cc in 2 ml syringe x 1
Rocuronium 10mg / cc in 5 ml syringe or syringe Sodium bicarbonate: 20 /25 ml
Atracurium 10 mg / cc in 5 ml syringe Atropine 0.6 mg / cc in 2 ml syringe x 2 Calcium gluconate: 10 ml
Glycopyrolate 0.2 mg / cc in 2 ml syringe
Xylocard 20mg /cc in 5 ml syringe
Infusions ALL IN 50 ML LUER LOCK SYRINGES WITH 200 CM EXTENSION LINES
Anaesthetic / Relaxant :
Fentanyl 50mcg / cc, Atracurium 10 mg / cc, Midazolam 1mg/ cc
Ionotropes:
N. Adrenaline 4mg / 50 cc, Dopamine: 200 mg / 50cc, Adrenaline: 4mg / 50 cc Dobutamine: 250 mg / 50 cc
NAC : g/ 50cc
Calcium 100 mg / cc Sodabicarb 7.5% Glucose: 10 % / 25% Insulin 40 U / 40ml
Tranexamic acid: 100 mg / cc
IV infusion lines: all prepared in blood transfusion sets with luer lock ends
2 lines with gelofusine via a warming device
Blood products to be made available in theatre fridge ______ PRBCs & ____ platelets

3. NAME: WEIGHT: kg
AGE / SEX: HEIGHT: cms
IP No:
Hb WCC Platelet INR Fib FDP Lac Glucose Na K Mg Ca2 Urea Creatinine Bilirubin Al AST ALT GGT ALP
+ b
06:00
07:00
08:00
09:00
10:00
11:00
12:00
13:00
14:00
15:00
16:00
17:00
18:00
19:00
20:00
21:00
22:00
23:00
24:00

4. NAME: WEIGHT: kg
AGE / SEX: HEIGHT: cms
IP No:
Urine Output Blood Loss Fluids Blood products
NS 500 ml ½ NS Gelofusine Albumin 20% PRBC FFP Cryo Plt
06:00
07:00
08:00
09:00
10:00
11:00
12:00
13:00
14:00
15:00
16:00
17:00
18:00
19:00
20:00
Fluids:
Crystalloids: Platelets: RDPs SDPs
Colloids: Albumin 20%: Cryoppt:
PRBCs:
FFPs: