Extracorporeal Membrane Oxygenation (ECMO)

Patient Addressograph Label (minimum of Patient Name, Date of Birth, Hospital No., NHS No.)

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):

______

______Fax 01480 364898 - Papworth Hospital ECMO referral form 2.0 – Page 1 of 5 CN123 File Section: 1 Patient Addressograph Label (minimum of Patient Name, Date of Birth, Hospital No., NHS No.)

______

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

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:

______

Fax 01480 364898 - Papworth Hospital ECMO referral form 2.0 – Page 2 of 5 CN123 File Section: 1 Patient Addressograph Label (minimum of Patient Name, Date of Birth, Hospital No., NHS No.)

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 5 of 5 CN123 File Section: 1