ecmo referral form - mater.ie

Department of Critical Care Medicine ECMO Referral Form

Pleaseemailthiscompletedformtoecmo@mater.ieandcontactMMUHDutyCriticalCareConsultanton01-8032000REFERRAL

Dateofreferral: Timeofreferral: Referringhospital:

ReferringDoctor: Contactnumber:

PATIENTDETAILS

Name: Dateofbirth: Age:

Gender: Height: Weight: BMI:

Allergies: Pregnancytestresult:

Smokinghistory: Alcoholhistory:

Hospitaladmissiondate: ICUadmissiondate:

Workingdiagnosis:

Othersignificantbackground:

Briefclinicalsummary:

RESPIRATORY

Intubationdate: Numberofdaysintubated:

Oxygenation FiO2: PEEP:

Ventilation Tidalvolume: Ppeak: Pplat: Resprate:

FindingsOnImaging CXR: CTthorax:

Adjuncts Pronepositioning: Neuromuscularblockade:

Pulmonaryvasodilators: Chestdrains:

ABG pH: PaCO2: PaO2: SaO2:

P/Fratio: BaseExcess: Lactate:

J McNamara & I Conrick-Martin, April 2020

CARDIOVASCULAR

HR: BP: CVP: Cardiacoutput:

Urineoutput: Fluidbalance:

Vasoactivemedicationsanddoses:

Peripheralperfusion:

Detailsofanycardiacarrest:

IABP: Impella:

Angiographyfindings+/-interventions:

Echofindings:

Microbiology

Positivefindings:

Currentantimicrobialregime:

Temp: WCC: Neutrophils: Lymphocytes: CRP:

Infectioncontrolissues:

Other

Pupilarylightreflexes: Immunosuppression:

RelevantCTbrainimaging:

Bloodresults:

Hb: Plt: INR: APTT: Fibrinogen:

Urea: Creatinine: Na: K:

Renalreplacementtherapy:

Bilirubin: Albumin: ALT: AST: GGT: Alkphos:

Anyotherrelevantinformation

ForMMUHuseonly:

MMUHIntensivisttakingreferral:

Accepted: RequirementforECMOretrieval:

Declined: Reason(s):

Deferredpendingfurtherdiscussion:

Additionalnotes:

J McNamara & I Conrick-Martin, April 2020