Adult Heart and HeartLung Status 3 Criteria 2 Extension Justification Form Medical Urgency Data

OMB No. 0915-0157; Expiration Date: XX/XX/20XX

Adult Heart and HeartLung Status 3 Criteria 2 Extension Justification Form Medical Urgency Data

You will be informed of any downgrades that are pending in the Critical Data section of Secure Enterprise. You may also view the Candidates Pending Downgrade Report section of Waitlist^SM. The “Extend” button will be available 2 days prior to expiration of the status.

All required data must be submitted in order to list a candidate at status 3, or extend their listing at status 3, in accordance with criteria that are specified in OPTN Policy. Use the search feature to locate specific policy information concerning adult heart status requirements.

Status 3 Extension Criteria 2

If status 3, criteria 2: Multiple inotropes or a single high dose inotrope and hemodynamic monitoring, is selected, enter the following information: 

Multiple inotropes or a single high dose inotrope and hemodynamic monitoring: Candidate is admitted to the transplant hospital that registered the candidate on the waiting list. Within 7 days prior to inotrope administration or while on inotropes, all of the following are true:

Select one of the following:

• Candidate has an invasive pulmonary artery catheter

• Candidate has daily hemodynamic monitoring to measure cardiac output and left ventricular filling pressures

Candidate is supported by either:

A continuous infusion of at least one high dose intravenous inotrope

• Dobutamine greater than or equal to 7.5 mcg/kg/min

• Milrinone greater than or equal to 0.50 mcg/kg/min

• Epinephrine greater than or equal to 0.02 mcg/kg/min

A continuous infusion of at least two intravenous inotropes

• Dobutamine greater than or equal to 3mcg/kg/min

• Milrinone greater than or equal to 0.25 mcg/kg/min

• Epinephrine greater than or equal to 0.01 mcg/kg/min

• Dopamine greater than or equal to 3 mcg/kg/min  

Was the candidate on inotropic or mechanical support at the time cardiac index was obtained?: If the candidate was on inotropic or mechanical support at the time of cardiac arrest, select Yes. If not, select No. This is a required field.

Cardiac index: Enter the candidate’s cardiac index in L/min/m². The entry must fall between 0 and 1.79 L/min/m² if the candidate was not on inotropic or mechanical support and must be less than 2.2 L/min/m² if the candidate was on inotropic or mechanical support. Enter the Test Date of when the cardiac index value was obtained. The date must be in the following format: MM/DD/YYYY. A calendar link is available. Enter the Test Time. The time must be in the following 24-hour format: HH:MM. Time must be in military format. This is a required field.

Pulmonary capillary wedge pressure: Enter the candidate’s pulmonary capillary wedge pressure in mmHg. The entry must fall between 16 and 100 mmHg. Enter the Test Date of when the PCWP value was obtained. The date must be in the following format: MM/DD/YYYY. A calendar link is available. Enter the Test Time. The time must be in the following 24-hour format: HH:MM. Time must be in military format. This is a required field.

Systolic blood pressure: Enter the candidate’s systolic blood pressure in mmHg. The entry must fall between 50 and 89 mmHg. Enter the Test Date of when the systolic blood pressure was obtained. The date must be in the following format: MM/DD/YYYY. A calendar link is available. Enter the Test Time. The time must be in the following 24-hour format: HH:MM. Time must be in military format. This is a required field.

Extending the candidate’s status under criteria 2
The candidate qualifies for an extension if the candidate remains admitted to the hospital that registered the candidate on the waiting list, and meets all of the following criteria:

Select one of the following:

• Candidate has an invasive pulmonary artery catheter

• Candidate has daily homodynamic monitoring to measure cardiac output and left ventricular filling pressures

Candidate continues to be supported by either:

A continuous infusion of at least one high does intravenous inotrope:

• Dobutamine greater than or equal to 7.5 mcg/kg/min

• Milrinone greater than or equal to 0.50 mcg/kg/min

• Epinephrine greater than or equal to 0.02 mcg/kg/min

A continuous infusion of at least two intravenous inotropes:

• Dobutamine greater than or equal to 3 mcg/kg/min

• Milrinone greater than or equal to 0.25 mcg/kg/min

• Epinephrine greater than or equal to 0.02 mcg/kg/min

• Dopamine greater than or equal to 0.02 mcg/kg/min

Within 48 hours prior to the status expiring, either of the following are true:

• Cardiac index is less than 2.2 L/min/m² on the current medical regimen

• Failed attempt to wean the inotrope support documented by at least one of the following:

  • Cardiac index less than 2.2 L/min/m² during dose reduction

  • Increase in serum creatinine by 20 percent over the value immediately prior to, and within 24 hours of inotrope dose reduction

  • Increase in arterial lactate to greater than 2.5 mmol/L

  • SvO² less than 50 percent measured by central venous catheter

 

Public Burden Statement: The private, non-profit Organ Procurement and Transplantation Network (OPTN) collects this information in order to perform the following OPTN functions: to assess whether applicants meet OPTN Bylaw requirements for membership in the OPTN; and to monitor compliance of member organizations with OPTN Obligations. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915-0157 and it is valid until XX/XX/202X. This information collection is required to obtain or retain a benefit per 42 CFR §121.11(b)(2). All data collected will be subject to Privacy Act protection (Privacy Act System of Records #09-15-0055). Data collected by the private non-profit OPTN also are well protected by a number of the Contractor’s security features. The Contractor’s security system meets or exceeds the requirements as prescribed by OMB Circular A-130, Appendix III, Security of Federal Automated Information Systems, and the Departments Automated Information Systems Security Program Handbook. The public reporting burden for this collection of information is estimated to average 0.27 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857 or paperwork@hrsa.gov.   

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