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ICU TREATMENT FORM
Gender
M
F
Other
Age
Site
Date of inclusion
Visit
Page
Date of data entry
Date of ICU admission
Date of ICU discharge
Severity scores
SAPS II score upon ICU admission :
SOFA score upon ICU admission (day 1):
SOFA score day 2 :
SOFA score day 3 :
SOFA score day 7 :
SOFA score day 14 :
Invasive mechanical ventilation?
Yes
No
Date of intubation :
Date of successful extubation :
Was a bronchoscopy performed?
Yes
No
Date bronchoscopy :
Specific tracheobronchial involvement :
Yes
No
Acute Respiratory Distress Syndrome :
Yes
No
Renal replacement therapy (RRT) ?
Yes
No
Date of RRT initiation :
Date of RRT end :
Fluid resuscitation :
Yes
No
Was fluid volume estimated using a dedicated formula?
Yes
No
Which formula was used?
Parkland formula?
Yes
No
Other :
Type of fluids used:
Crystalloids only :
Yes
No
Crystalloids and albumin :
Yes
No
Crystalloids and synthetic colloid fluids :
Yes
No
Vasopressor use:
Yes
No
Date vasopressor initiated :
Date vasopressor stopped :
Outcomes
For all patients:
Did the patient develop bacteraemia ?
Yes
No
Catheter-related bacteraemia ?
Yes
No
Number of positive blood cultures :
Date first positive blood culture :
Microorganism(s) isolated :
Meti-S Staphylococcus aureus
Other gram positive pathogen
Enterobacteriaceae
Pseudomonas aeruginosa
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