ECMO referral | Te Whatu Ora

Respiratory Details

Intubation Date

Time

Ventilation

Mode

PEEP (cmH2O)

PIP (cmH2O)

PLAT (cmH2O)

RR

TV

FiO2

Sats

Current ABG

pH

pCO2 (kpa)

pO2 (kpa)

BE

HCO3 (mmol/L)

Lactate (mmol/L)

Duration Fio2 > 80%

CXR and/or CT findings

Chest Drains/Pneumothoraces

Known Underlying Respiratory Disease

Radiology sent Electronically to ADHB PACS

Cardiovascular Details

Vitals

HR (bpm)

MAP (mmHg)

CVP (cm H2O)

CO (L/min)

Inotropes

Adrenaline (mcg/kg/min)

Noradrenalin (mcg/kg/min)

Dopamine (mcg/kg/min)

Other (mcg/kg/min)

Cumulative fluid balance since admission (ml)

Fluid balance last 24 hr period (ml)

Feeding

Feeding rate (ml/hr)

Echo Findings

Cardiac Arrest

Duration of arrest

neurological function post arrest

ROSC

CNS function post arrest

Vascular access/sites

Neurology Details

Neurology Status Pre-sedation

Pupil size & reactivity

Current sedation/Paralysis

Infection Details

Infective organisms and site

Current Antibiotic / Antifungal / Antiviral

Blood results

Haematology

Hb

WCC

Plts

INR

APTT

Fib

Biochemistry

Na

K

Creat

Urea

Bilirubin

ALT or AST

Albumin

Negative Serology

Referral Details

Mode of transport

Team Departure Time

Additional Notes

Adult ECMO Referral Form

Once submitted, please call the ECMO referral number on 0800ADULTECMO (0800 238 583)

Referring Hospital Details

Patient Details

Clinical Details

Additional Information