Intensive Care Unit
ExtraCorporeal Membrane Oxygenation (ECMO)
Referral FORM
Fax 01480 364898
Please contact ECMO Coordinator at Papworth (01480 830541) to inform of fax being sent
Date: ______ Time: ______
Patient demographics:
Patient’s first name: ______Patient’s last name: ______
Date of birth: ___ / ___ / _____ NHS Number: ______
Gender: M / F
Body weight: ___ kg and Height: _____ cm or BMI: _____ Kg/ m2
ECMO requested by:
Doctor’s name: ______Grade: ______
Hospital:______
Unit: ______
Direct Tel: ______Bleep: ______
Mobile Tel: ______
Reasons for referral (in brief): ______
______
______
ECMO inclusion/exclusion checks (any deviation from criteria will be discussed and clinical sense will prevail).
Inclusion criteria:
Potentially reversible respiratory failure Yes/ No
Severe respiratory failure, defined as a Murray score score ≥ 3 Yes / No
Or
Uncompensated hypercapnoea with a pH < 7.20 Yes / No
Relative exclusion criteria:
High-pressure ventilation (plateau pressure > 30 cm H2O) for > 10 days Yes / No
High FIO2 requirements (>0.8) for > 10 days Yes / No
Limited vascular access Yes / No
Any condition or organ dysfunction that would limit the likelihood of overall benefit from ECMO (e.g. such as severe, irreversible brain injury or untreatable metastatic cancer) Yes / No
Any condition that precludes the use of anticoagulants Yes / No
Other elements relative to patient’s general status:
Infection and barrier nursing status (e.g. MRSA, C. Diff): ______
Known allergies: ______
Known or suspected pregnancy Yes / No
Blood transfusion limitations (e.g. for religion, antibodies reasons) Yes / No
Severe immunosuppression Yes / No If yes, give reasons: ______
Respiratory failure resulting of:
1st diagnosis: ______Suspicion Proven Reversible
If appropriate:
2nd diagnosis: ______Suspicion Proven Reversible
3rd diagnosis: ______Suspicion Proven Reversible
Underlying respiratory function:
Known underlying respiratory disease: Yes / No -- If yes, please give details:______
______
Current respiratory status:
Number of days intubated: ______
Last ventilation parameters: Fi02 ____% Peep ____ cmH2O Plateau pressure ____cmH2O Last ABG: pH ____ PO2 ____ kPa PCO2 _____ kPa Lactates ______mmol/L
Treatment tried: Steroids Inhaled vasodilatators higher levels of PEEP Lung-recruitment manoeuvres Prone position Oscillatory ventilation
Organ function “check-list”:
Ongoing drugs:______
______
Cardiac function:
Known previous cardiac pathology? Yes / No -- If yes, please details:______
______
TTE/TOE done? Main findings: ______
Renal function:
Last creatinine: ______CVVH: Yes / No
Known previous renal pathology? Yes / No -- If yes, please details:______
______
Hepatic function:
Known previous hepatic pathology? Yes / No -- If yes, please details:______
______
Neurological status:
Known previous neurological pathology? Yes / No -- If yes, please details:______
______
Consent:
Any known or suspected objection for ECMO from the patient or next of kin: Yes / No
If our team is coming:
When is most convenient for our team to arrive? ___ / ___ / ____time: ___ h ___ min
Is access possible to the theatre with anaesthetic support? Yes / No
Can we have access to a C-arm and radiographer in ICU or theatre? Yes / No
Can you have 2 units of RBC cross-matched for our arrival? Yes / No
Can you order 1 unit of platelets if platelet count < 100,000 Yes / No
Fax 01480 364898 - Papworth Hospital ECMO referral form 2.0 – Page 1 of 5
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