CAR T-Cell Therapy Cytokine Release Syndrome Assessment
Use this form to assess and grade Cytokine Release Syndrome (CRS) in patients receiving CAR T-Cell Therapy.
Patient Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Medical Record Number
*
Date of CAR T-Cell Infusion
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time Since Infusion (in days)
*
CRS Symptom Assessment
*
Rows
Present
Severity (1-5)
Fever (>38°C)
1
1
2
3
4
5
Hypotension
2
1
2
3
4
5
Hypoxia
3
1
2
3
4
5
Tachycardia
4
1
2
3
4
5
Organ Dysfunction
5
1
2
3
4
5
CRS Severity Grade (per ASTCT Consensus)
*
Grade 1: Fever only
Grade 2: Fever with hypotension responsive to fluids or low-flow oxygen requirement
Grade 3: Hypotension requiring vasopressors or high-flow oxygen
Grade 4: Life-threatening symptoms (ventilatory or multiple vasopressors)
Interventions Required
Antipyretics
IV fluids
Vasopressors
Oxygen supplementation
Mechanical ventilation
Tocilizumab
Steroids
Other
Laboratory Findings (select all abnormal results)
Elevated C-reactive protein (CRP)
Elevated ferritin
Elevated IL-6
Elevated liver enzymes
Other
Additional Comments / Notes
Assessor's Signature
*
Submit Assessment
Submit Assessment
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