Changes in Ventriculo-arterial Coupling and Myocardial Work During Treatment of Sepsis and Septic Shock: a Prospective Interventional Study
Phase: NA
Conditions: Sepsis, Septic Shock
Sponsor: General and Teaching Hospital Celje

Title:  
Changes in ventriculo-arterial coupling and myocardial work during treatment of sepsis and 
septic shock: a prospective interventional study.   
 
Proposer: prof.dr. Matej Podbregar, specialist in Internal and Intensive Care Medicine  
Department of the study: Internal Intensive Care Medicine (OIIM), General Hospital (SB) 
Celje 
Participating researchers: Andrea D’Angelo, dr.med., Borut Žgavc, dr.med., Roman Parežnik, 
dr.med., Barbara Hudournik, dr.med., as. Janko Vlaovič, dr.med., Anej Skočir, dr.med., as. 
Marko Kurnik, dr.med., Anže Vindišar, dr.med., Mihela Krepek dr.med., Petra Kolar, dr.med, 
Tilen Markelj, dr.med., Ema Ajda Gomezelj, dr.med., Neža Čop, dr. med. 
 
Type of study: Prospective interventional. 
Funding of the study: This is an academic study which is not funded and has no payer. 
Doctor or researcher responsible for the safe conduct of the research: prof.dr. Matej 
Podbregar. 
Estimated duration of the study: 12 months 
Ethical committee approval ID: 70/2025/6-1, 24.01.2025 
NCT number: not yet assigned. 
 
Celje, 25.01.2025 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
Study rationale: 
Patients with septic shock are treated according to the Surviving Sepsis Campaign: 
International Guidelines for Management of Sepsis and Septic Shock. Despite prompt and 
targeted treatment, the mortality of patients with sepsis and septic shock remains very high. 
Current recommendations state that one of the goals is to establish an adequate perfusion 
pressure or Mean Arterial Pressure (MAP). The current recommended target MAP value is 65-
70mmHg. A study (Asfar P. et al. NEJM 2014) looking at two diaerent target MAP values (65-
70mmHg vs. 80-85mmHg) found no diaerence in survival. Patients in the higher target pressure 
group had more atrial ﬁbrillation paroxysms. The group of patients with chronic arterial 
hypertension had statistically fewer treatment alternatives due to renal failure. We hypothesize 
that a modern cardiovascular assessment approach could be used to individually set target 
blood pressures in patients with sepsis and septic shock. 
Ventriculo-arterial coupling (VAC) is the connection between the left ventricle and the arterial 
system. VAC is a key concept in cardiovascular physiology and describes how well the heart 
and the arterial system work together to ensure eaicient blood ﬂow and optimal cardiac 
function. 
Two main variables are needed to assess VAC: ventricular elastance (Ees) and arterial 
elastance (Ea). Ees describes the ability of the left ventricle (LV) to generate pressure and eject 
blood during systole. Ees is related to myocardial contractility and the LV pressure-volume 
ratio. Ea describes the stianess of the arterial system and expresses the resistance of the 
arteries to blood ejection; it is inﬂuenced by factors such as arterial tone and compliance. 
VAC is deﬁned as the ratio of Ees to Ea or as the ratio of LV end-systolic pressure to LV ejection 
volume. VAC is crucial because it tells us how eaiciently the heart and arteries work together 
during the cardiac cycle. Optimal coupling occurs when the ventricle and the arterial system 
are coordinated in their mechanical properties, allowing eaicient energy transfer and 
minimizing the load on the heart. A normal VAC value is between 0.7-1.3. If the ventricle or 
arterial system is too stia, the connection may be suboptimal (VAC >1.3). This can eventually 
lead to increased strain on the heart, ineaicient blood ﬂow and eventual heart failure. 
Myocardial work (MW) is a non-invasive tool in echocardiography that incorporates the average 
left ventricular strain into the Global Longitudinal Strain (GLS) analysis. MW is correlated with 
myocardial oxygen consumption and work eaiciency can be assessed. MW analysis combines 
analysis of apical views from transthoracic echocardiography (synchronized with ECG tracing, 
which is necessary to derive the timing of mitral and aortic valve opening and closure), with 
blood pressure measurement to produce a graph showing myocardial tissue energy 
expenditure. The MW analysis allows us to calculate the Global Work Index (GWI), Global 
Constructive Work (GCW), Global Wasted Work (GWW) and Global Work Eaiciency (GWE). 
The aim of our study is to combine MW assessment with VAC to assess the appropriateness of 
ﬂuid and vasopressor treatment in sepsis. However, the question of whether a patient should 
receive a ﬂuid infusion and when is far from being certainly deﬁned. It is also not clear whether 
VAC and MW analysis can be used to assess the optimal concentration of vasoconstrictor and 
inotropic drugs to use in the treatment of patients with sepsis and septic shock. There is still a 
paucity of knowledge in the literature in this area, and investigators believe that the 
combination they wish to investigate could be a promising and reliable non-invasive method 
that would allow clinicians to identify patients suitable for ﬂuid infusion or treatment with 
vasoactive drugs. 
 
Patients and methods: 

The study will start after obtaining the approval of the Medical Ethics Committee of SB Celje. 
Patients aged 18 years and older admitted to the Department of Internal Intensive Care 
Medicine (OIIM), SB Celje, due to sepsis or septic shock will be included in the study. Patients 
will be enrolled in the study after obtaining informed consent from the patient or relatives if the 
patient is unable to give consent. 
Will not be enrolled in the study: 
- Patients who do not consent to inclusion 
- under 18 years of age 
- pregnant women 
- patients with more than moderate aortic stenosis (AVA <1.4 cm2, AVAi <0.85, DVI <0.5) 
- patients with more than mild mitral regurgitation (IVC width<=3mm, MR EROA<20, MR RegV 
<30mL) 
- patients with arrhythmic cardiac rhythm disturbances (e.g. atrial ﬁbrillation, frequent 
ventricular and supraventricular nodal activity, atrial ﬂutter) 
- patients for whom renal replacement therapy will be performed 
- patients who will not be artiﬁcially ventilated with continuous modes of ventilation. 
 
Deﬁnition of sepsis/septic shock: 
Sepsis and septic shock will be deﬁned according to current recommendations (Surviving 
Sepsis campaine guidliness 2021). The diagnosis of sepsis will be conﬁrmed in case of 
sequential organ failure (SOFA) ≥ 2. Septic shock will be deﬁned by the need for a vasopressor 
to maintain the patient's mean arterial pressure (MAP) ≥ 65 mmHg and serum lactate level ≥ 2 
mmol/l, despite adequate ﬂuid replacement. 
 
Patient information: 
General data (age, sex, weight and height, underlying cause of admission, previous diseases) 
and speciﬁc data (microbiological ﬁndings, C-reactive protein, procalcitonin, interleukin 6, 
serum lactate, arterial and venous blood gas analysis of the patients) will be obtained from the 
hospital information system (Birpis, Slovenia) and the electronic temperature sheet (Centricity, 
GE HealthCare, USA). Will be obtained data on the amount of ﬂuid added and the peak 
concentration of vasoconstrictors during the ﬁrst 24 hours of treatment, length of artiﬁcial 
ventilation, renal replacement therapy, cardiac rhythm disturbances, ICU treatment outcome 
and 28-day survival. The data will be anonymized in the databases collected. 
 
Clinical examination of the patient: 
On clinical examination, investigators will speciﬁcally look for sacral and pretibial edema.  
 
Ultrasound of the lungs: 
Ultrasound will be used to examine the upper, apical parts of the lungs, in the midclavicular 
line. If the patient has more than 3 B-lines in 2 consecutive intercostal spaces, will be classiﬁed 
as hypervolemic. 
 
Transthoracic ultrasound of the heart:  
All enrolled patients will undergo trans thoracic echocardiography (TTE) (Vivid E95 or Vivid S70, 
GE HealthCare, USA) immediately on admission to the OIIM as part of the routine work-up on 
admission to the ward. Investigators will measure inferior vena cava dimensions in 
inspiration/expiration, cardiac volumes, systolic and diastolic function and ﬁlling (E/E’) of the 
left ventricle (LV), estimate minute cardiac volume from ﬂow to ﬂow (VTI) (10 second recording) 

in the left ventricular outﬂow tract (LVOT). Investigators will assess right ventricular dimension 
and function (TAPSE, PAPs). The LV will be imaged in three planes (apical 2 cavity projection 
(A2C), apical 4 cavity projection (A4C) and apical 3 cavity projection (A3C, APLAX) with an 
image capture of at least 40Hz and 4 heartbeats. During TTE, the ECG signal and respiratory 
waveform will be monitored on ultrasound. Patients with a VTI LVOT >10% diaerence between 
inspiration and expiration will be assessed as ﬂuid responsive.   
           In control TTEs, investigators will measure the minute cardiac volume from VTI to LVOT 
(10-second recording) and make LV recordings in three planes (A2C, A4C, A3C-APLAX) with an 
image capture of at least 40Hz and 4 heartbeats while monitoring the ECG signal for later 
analysis. A control TTE will be performed on admission before speciﬁc treatment (ﬂuid, 
vasopressor) and when the target blood pressure is reached. At that time, investigators will also 
record the invasively measured blood pressure. 
The ultrasound recordings will be stored for analysis using EchoPac (GE Healthcare, USA). 
  
Analysis of TTE images: 
Using the EchoPac computer program (GE Healthcare, USA), investigators will perform an 
additional analysis of cardiac function, measuring LV end-systolic and diastolic volumes in two 
planes, LV ejection fraction and LV VTI LVOT during inspiration/expiration. LV recordings in three 
planes will be used to calculate LV GLS and LV MW.  GWI, GCW, GWW and GWE will be 
calculated.  
 
Ventriculo-arterial coupling (VAC): 
To calculate VAC investigators will use the iElastance app (VACi, by Pietro Bertini, MD, 
Department of Cardiothoracic Anaesthesia and Intensive Care Medicine, University Hospital of 
Pisa) available in the Apple store or Google play store. To calculate VACi, investigators will use 
invasively measured systolic (mmHg) and diastolic blood pressure (mmHg), and data obtained 
from TTE recordings (LV pulse volume (ml), LV ejection fraction, Total Ejection Time (msec), Pre 
Ejection Time (msec)). The formula has been evaluated in previous studies (Chen CH et Al J Am 
Coll Cardiol 2001). VACi will be calculated on admission before speciﬁc treatment (ﬂuid, 
vasopressor) and on reaching the target blood pressure.  
 
Estimation of VAC from GLS and MW data: 
From the TTE analysis data obtained in EchoPac (GE Healthcare, USA) (GLS LV, MW, blood 
pressure and LV systolic/diastolic volume), investigators will calculate the VAC (VACpy) with 
the help of a program written in the Python programming language.           
 
Haemodynamic monitoring of patients: 
Patients admitted to the OIIM for sepsis/septic shock are monitored using the transpulmonary 
thermodilution method (EV1000, Edwards, USA). The pulse volume variation (PVV) will be 
read from the monitor. Patients with SVV >10% and ELWI <12ml/kg will be considered ﬂuid 
responsive. When vasoactive therapy is given, investigators will check the adequacy of ﬂow in 
the blood gas analysis of the central venous blood. 
 
Vasopressor treatment: 
Following the recommendations for the treatment of sepsis/septic shock, investigators will 
start treatment with noradrenaline in a continuous infusion to achieve the target MAP.  All 
patients, once receiving norepinephrine, will additionally receive hydrocortisone 50mg iv/6h. 
Norepinephrine will be escalated when target pressure is not reached up to the dose (0.4 

µg/kg/min). If target pressure is not reached at a norepinephrine dose of 0.4 µg/kg/min, 
vasopressin (Empressin, Amomed, Austria) will be added to the therapy at a dose of 0.03 
i.e./h. Norepinephrine will be escalated to a dose of 0.4 µg/kg/min.  If target pressure is not 
reached with the addition of vasopressin after 2 hours of therapy, the dose of noradrenaline 
will be increased accordingly.  
 
Patient treatment and protocol for MW and VAC measurements: 
Patients will be treated according to the current recommendations for the management of 
sepsis and septic shock (Surviving Sepsis Campaign: International Guidelines for Management 
of Sepsis and Septic Shock 2021). 
On admission to the ward, all patients will undergo a clinical examination, lung ultrasound and 
TTE and VACi will be calculated. 
The exact treatment protocol and measurements are presented graphically (ﬁg. 1). 
Based on clinical examination, absence of B-lines on lung ultrasound, SVV >10% (EVO 1000 or 
VTI LVOT) and inferior vena cava respiratory variability >10%, patients will be divided into 
treatment arm A (ﬂuid responsive patients). The remaining patients will be classiﬁed into 
therapeutic arm B (ﬂuid non-responsive patients-without initial ﬂuid therapy). 
In therapeutic arm A, the patient will receive ﬂuid (8ml/kg/30min of balanced saline) after initial 
evaluation. In case of SVV<10% and MAP<65mmHg after ﬂuid infusion, or at the discretion of 
the treating physician, the patient will be jumped to therapeutic arm B, where he/she will 
receive a vasopressor according to the protocol. 
In case the patient from therapy arm A has SVV>10% and MAP<65mmHg after receiving the ﬁrst 
ﬂuid therapy, he/she will receive additional ﬂuid (8ml/kg/30min of balanced saline). In case 
he/she has SVV<10% and MAP<65mmHg after the second ﬂuid replacement, or at the 
discretion of the attending physician, the patient will continue treatment in therapy arm B, 
where he/she will receive a vasopressor.  If the patient still has SVV>10% and MAP<65mmHg in 
treatment arm A after 2 doses of ﬂuids, the patient will receive additional ﬂuids (14ml/kg/60min 
of balanced saline). If MAP<65mmHg persists after 3 doses of ﬂuids, the patient will receive 
vasopressor according to protocol B. 
In the primary classiﬁcation of the patient in the therapeutic arm B, patients will be treated with 
vasopressor in a stepwise fashion until the ﬁrst target MAP blood pressure of 65-70mmHg for a 
duration of at least 30min with unchanged norepinephrine dose. Investigators will then 
increase the dose of vasopressor according to the protocol until a target MAP blood pressure 
of 80-85 mmHg is achieved over a duration of at least 30 min with unchanged vasopressor dose. 
A control TTE and a bedside VACi assessment will be performed after completion of the ﬂuid 
infusion in therapeutic arm A, or 30 minutes after reaching a stable target blood pressure. 
If VAC > 1.3 at a target MAP of 80-85mmHg, investigators will lower the patient to a target blood 
pressure of 65-70mmHg and potentially initiate inotropic therapy in the setting of insuaicient 
cardiac output (<2.0L/min/m2 and/or central venous hemoglobin saturation (ScvO2) <65%). 
After reaching the ﬁnal target pressure for 30minutes, protocol treatment and measurement 
will be terminated. Treatment will be continued at the discretion of the treating physician. 
A control TTE and a bedside VACi assessment will be performed 24-32hrs after the patient's 
admission to the OIIM. 
       
Estimation of the number of patients included: 
There are no studies evaluating MW with TEE in critically ill patients. Investigators estimate 
that will be included 30 patients (each group of 15 patients) to be able to demonstrate 
changes in MW and VAC with therapy. 

 
Statistics: 
Investigators will use classical statistical methods. Data will be tested for normality of 
distribution (D’Agostino-Pearson test). Presentation of results as mean±standard deviation 
(SD) or median (95% conﬁdence interval, 95%CI) or proportion for uncontinuous variables. 
For group comparisons, investigators will use Student's t-test for paired data or, in the case of 
non-normal distributions, the Wilcoxon test for paired data, and the chi-square test for non-
continuous covariates. Bland-Altman analysis will be performed to compare VACi and VACpy. 
A 10% diaerence between VACi and VACpy measures will be considered clinically 
insigniﬁcant.  With a P value <0.05, the diaerence between the groups will be statistically 
signiﬁcant.  
 
Expected results: 
Investigators expect to be able to categorize ﬂuid-responsive and non-responsive patients 
based on VAC and MW. Investigators also expect to be able to individually determine the 
optimal target MAP based on MW and VAC, which will not be associated with a reduction in 
cardiac output and a reduction in myocardial useful work. Investigators also expect that VACi 
and VACpy values will not diaer in a clinically meaningful way. 
 
Bibliography: 
1. Rehn M, Chew MS, Olkkola KT, Ingi Sigurðsson M, Yli-Hankala A, Hylander Møller M. 
Surviving sepsis campaign: International guidelines for management of sepsis and 
septic shock in adults 2021 - endorsement by the Scandinavian society of 
anaesthesiology and intensive care medicine. Acta Anaesthesiol Scand. 2022 
May;66(5):634-635. doi: 10.1111/aas.14045. Epub 2022 Mar 6. PMID: 35170043; 
PMCID: PMC9310818.- 
2. Asfar, P., Meziani, F., Hamel, J.-F., Grelon, F., Megarbane, B., Anguel, N., Mira, J.-P., et al. 
2014. High versus Low Blood-Pressure Target in Patients with Septic Shock. New 
England Journal of Medicine 370, 1583–1593.. https://doi.org/10.1056/nejmoa1312173 
3. Demailly Z, Besnier E, Tamion F, Lesur O. Ventriculo-arterial (un)coupling in septic 
shock: Impact of current and upcoming hemodynamic drugs. Front Cardiovasc Med. 
2023 May 30;10:1172703. doi: 10.3389/fcvm.2023.1172703. PMID: 37324631; PMCID: 
PMC10266274. 
4. Bischoa AR, Stanford AH, McNamara PJ. Short-term ventriculo-arterial coupling and 
myocardial work eaiciency in preterm infants undergoing percutaneous patent ductus 
arteriosus closure. Physiol Rep. 2021 Nov;9(22):e15108. doi: 10.14814/phy2.15108. 
PMID: 34806325; PMCID: PMC8606853. 
5. Antonini-Canterin F, Poli S, Vriz O, Pavan D, Bello VD, Nicolosi GL. The ventricular- 
arterial coupling: from basic pathophysiology to clinical application in the 
echocardiography laboratory. J Cardiovasc Echogr. (2013) 23:91––5. doi: 
10.4103/2211-4122.127408  
6. Zhou X, Zhang Y, Pan J, et al. Optimizing left ventricular-arterial coupling during the 
initial resuscitation in septic shock—a pilot prospective randomized study. BMC 
Anesthesiol. (2022) 22:31. doi: 10.1186/s12871-021-01553-w  
7. Chen CH, Fetics B, Nevo E, et al. Noninvasive single-beat determination of left 
ventricular end-systolic elastance in humans. J Am Coll Cardiol. (2001) 38:2028–34. 
doi: 10.1016/S0735-1097(01)01651-5  

8. Zhou X, Pan J, Wang Y, Wang H, Xu Z, Zhuo W. Left ventricular-arterial coupling as a 
predictor of stroke volume response to norepinephrine in septic shock—a prospective 
cohort study. BMC Anesthesiol. (2021) 21:56. doi: 10.1186/s12871-021-01276-y  
9. Nasrollahi-Shirazi S, Sucic S, Yang Q, Freissmuth M, Nanoa C. Comparison of the β-
adrenergic receptor antagonists landiolol and esmolol: receptor selectivity, partial 
agonism, and pharmacochaperoning actions. J Pharmacol Exp Ther. (2016) 359:73–81. 
doi: 10.1124/jpet.116.232884  
10. Morelli A, Ertmer C, Westphal M, et al. Eaect of heart rate control with esmolol on 
hemodynamic and clinical outcomes in patients with septic shock: a randomized 
clinical trial. J Am Med Assoc. (2013) 310:1683–91. doi: 10.1001/ jama.2013.278477  
11. Kakihana Y, Nishida O, Taniguchi T, et al. Eaicacy and safety of landiolol, an ultra-short-
acting β1-selective antagonist, for treatment of sepsis-related tachyarrhythmia (J-land 
3S): a multicentre, open-label, randomised controlled trial. Lancet Respir Med. (2020) 
8:863–72. doi: 10.1016/S2213-2600(20)30037-0  
12. Sunagawa K, Sagawa K, Maughan WL. Ventricular interaction with the loading system. 
Ann Biomed Eng. (1984) 12:163–89. doi: 10.1007/BF02584229  
13. Evans L,  et al. Surviving Sepsis Campaign: International Guidelines for Management of 
Sepsis and Septic Shock 2021. Critical Care Medicine 49(11):p e1063-e1143, 
November 2021. | DOI: 10.1097/CCM.0000000000005337 
14. Andrei S, Bahr PA, Berthoud V, Popescu BA, Nguyen M, Bouhemad B, Guinot PG. 
Diuretics depletion improves cardiac output and ventriculo-arterial coupling in 
congestive ICU patients during hemodynamic de-escalation. J Clin Monit Comput. 
2023 Aug;37(4):1035-1043. doi: 10.1007/s10877-023-01011-7. Epub 2023 Apr 25. 
PMID: 37097337 
 
Assessment of the ethical aspects of the research, the potential beneﬁts, risks and 
burdens for those involved: 
The proposed research is not ethically controversial. The patients included will be treated 
according to current recommendations. Apart from routine collection of biological samples or 
blood from the patient, no other procedures will be performed for the purpose of the study. 
For more accurate monitoring, investigators anticipate that they will be able to treat patients 
with an individualized target blood pressure, which could reduce the incidence of arrhythmias 
(e.g. atrial ﬁbrillation) and the need for renal treatment and increase the chance of survival. 
There will be no additional risk of participation in the study. 
 
Information on monetary and any other compensation to study subjects: 
Patients will not receive any monetary or other compensation for participation in the study. 
 
Illustration of the costs of the study: 
There are no costs associated with the study. 
 
Information on monetary and any other compensation to researchers: 
No monetary or other compensation will be paid to the investigators. 
 
Description of the safety concerns and beneﬁts of the people involved in the study: 
Patients will be treated according to current recommendations for the treatment of 
sepsis/septic shock. Patients will be hemodynamically monitored with methods routinely 
used in the management of OIIM (semi-invasive monitoring, EVO 1000, Edwards, USA). They 

will be treated with respiratory support and possibly renal replacement therapy. For more 
accurate monitoring, investigators anticipate that they will be able to treat patients with an 
individualized target blood pressure, which could reduce the incidence of arrhythmias (e.g. 
atrial ﬁbrillation) and the need for renal therapy and increase the chance of survival. The 
protection of patients' personal data will be ensured. Data collected electronically will be 
anonymized and will not include any identiﬁable patient data. 
 
Explanatory notes on the study for participants and declarations of informed and free 
consent: 
Attached. 
 
Speciﬁc explanations for persons invited to participate in the study: 
Not required. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Informed Consent for Data Collection and Research 
 
Research Title:  
Changes in the ventricular-arterial coupling and myocardial function during the treatment of 
sepsis and septic shock: a prospective interventional study. 
 
Principal Investigator:  
Prof. Dr. Matej Podbregar, Specialist in Internal and Intensive Medicine   
Research Department: Department of Internal Intensive Medicine, SB Celje, Tel. 03 321 3418 
 
Dear Patient, 
At the Department of Internal Intensive Medicine (OIIM) of SB Celje, we are conducting a 
research study to improve our understanding of sepsis and enhance our knowledge and 
treatment methods for sepsis/septic shock, which could potentially improve patient survival. 
Your participation in this study is entirely voluntary, and you have the right to withdraw at any 
time without any consequences for your care. Your non-participation in the study will not 
aaect the treatment of your condition. 
Sepsis/septic shock treatment at OIIM follows international guidelines (Surviving Sepsis 
Campaign: International Guidelines for Management of Sepsis and Septic Shock), which 
currently do not allow for an individual assessment of optimal cardiovascular function using 
the new ultrasound methods available for evaluating heart and vascular function. These 
methods will form the basis of our study. 
In the study, we will collect data such as your medical history (disease progression and 
previous illnesses), laboratory results, and other relevant health data during treatment. Your 
personal data will be anonymized (without the use of your personal information or date of 
birth) and will be used exclusively for research purposes. Your participation in this study will 
not harm you in any way. Advanced ultrasound assessment of heart function and the 
calculation of the relationship between heart and vascular function will be performed during 
your treatment in the ﬁrst few hours until the target blood pressure is reached, as per 
international treatment guidelines. If we detect a worsening relationship between heart 
function and the vascular system, we will adjust the target blood pressure, which could help 
improve the performance of your cardiovascular system during treatment. 
Your privacy and conﬁdentiality will be fully protected. All collected data will be strictly 
conﬁdential and securely stored. Only authorized members of the research team will have 
access to your data. The results of the study will be used for scientiﬁc purposes only, and no 
personal data will be publicly disclosed. 
 
Patient (Printed name and signature):_________________________________________ Date: 
_________ 
 
Patient’s Representative (Printed name and signature): _________________________ Date: 
_________ 
 
Researcher (Printed name and signature):_____________________________________ Date: 
___________