ECMO Referral Form - mater.ie
Transcript of 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