ECMO referral

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ECMO referral

REFERRING HOSPITAL DETAILS

Date

Time

Referring Doctor

Referring Hospital

Cellphone number

Patient Details

First Name

Family Name

NHI

Date of Birth

Age

Gender

Blood transfusion limitations (eg religion, antibodies etc)

Weight

Height

Next of kin + contact number

CLINICAL DETAILS

Working Diagnosis

Clinical Summary

Allergies

Alcohol

Smoking

Pregnancy Test

Research Studies Enrolled in/screened for

RESPIRATORY DETAILS

Intubation Date

Intubation Time

Ventilation

Mode

PEEP

PIP

PLAT

RR

TV

FiO2

Sats

Adjuncts

Steroids

Proned

iNO

Current ABG

pH

pCO2

pO2

BE

HCO3

Lactate

Duration FiO2 > 80% (Days)

CXR/CT Findings

Chest Drains/Pneumothoraces

Known Underlying Respiratory Disease

Radiology sent Electronically to ADHB PACS

CARDIOVASCULAR DETAILS

Vitals

HR

MAP

CVP

CO

Inotropes

Adr

Norad

Dopamine

Other

Fluid balance daily/Cumulative

Feeding

Urine Output

RRT

Ischaemia/mottling

Echo findings

Cardiac Arrest

ROSC

CNS function post arrest

Vascular access/sites

NEUROLOGY DETAILS

Neurology status pre-sedation

Pupil size & reactivity

Current sedation/Paralysis

INFECTION DETAILS

Confirmed Infection

Current Antibiotic/Anitfungal Anitviral

BLOOD RESULTS

Haematology

Hb

WCC

Plts

INR

APTT

Fib

Biochemistry

Na

K

Creat

Urea

Bili

ALT/AST

Albumin

Attach images (if required)