<p> Patient Addressograph Label (minimum of Patient Name, Date of Birth, Hospital No., NHS No.)</p><p>Intensive Care Unit EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO) REFERRAL FORM</p><p>Fax 01480 364898</p><p>Please contact ECMO Coordinator at Papworth (01480 830541) to inform of fax being sent</p><p>Date: ______Time: ______</p><p>Patient demographics:</p><p>Patient’s first name: ______Patient’s last name: ______</p><p>Date of birth: ___ / ___ / _____ NHS Number: ______</p><p>Gender: M / F </p><p>Body weight: ___ kg and Height: _____ cm or BMI: _____ Kg/ m2</p><p>ECMO requested by:</p><p>Doctor’s name: ______Grade: ______</p><p>Hospital:______</p><p>Unit: ______</p><p>Direct Tel: ______Bleep: ______</p><p>Mobile Tel: ______</p><p>Reasons for referral (in brief): </p><p>______</p><p>______</p><p>______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.)</p><p>______</p><p>______</p><p>ECMO inclusion/exclusion checks (any deviation from criteria will be discussed and clinical sense will prevail).</p><p>Inclusion criteria:</p><p>Potentially reversible respiratory failure Yes/ No</p><p>Severe respiratory failure, defined as a Murray score score ≥ 3 Yes / No</p><p>Or </p><p>Uncompensated hypercapnoea with a pH < 7.20 Yes / No</p><p>Relative exclusion criteria:</p><p>High-pressure ventilation (plateau pressure > 30 cm H2O) for > 10 days Yes / No</p><p>High FIO2 requirements (>0.8) for > 10 days Yes / No</p><p>Limited vascular access Yes / No</p><p>Any condition or organ dysfunction that would limit the likelihood of overall benefit from ECMO</p><p>(e.g. such as severe, irreversible brain injury or untreatable metastatic cancer) Yes / No</p><p>Any condition that precludes the use of anticoagulants Yes / No</p><p>Other elements relative to patient’s general status:</p><p>Infection and barrier nursing status (e.g. MRSA, C. Diff): ______</p><p>Known allergies: </p><p>______</p><p>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.)</p><p>Known or suspected pregnancy Yes / No</p><p>Blood transfusion limitations (e.g. for religion, antibodies reasons) Yes / No </p><p>Severe immunosuppression Yes / No </p><p>If yes, give reasons: ______</p><p>Respiratory failure resulting of:</p><p>1st diagnosis: ______Suspicion Proven Reversible </p><p>If appropriate:</p><p>2nd diagnosis: ______Suspicion Proven Reversible </p><p>3rd diagnosis: ______Suspicion Proven Reversible </p><p>Underlying respiratory function:</p><p>Known underlying respiratory disease: Yes / No -- If yes, please give details:______</p><p>______</p><p>Current respiratory status:</p><p>Number of days intubated: ______</p><p>Last ventilation parameters: Fi02 ____% Peep ____ cmH2O Plateau pressure ____cmH2O</p><p>Last ABG: pH ____ PO2 ____ kPa PCO2 _____ kPa Lactates ______mmol/L</p><p>Treatment tried: Steroids Inhaled vasodilatators higher levels of PEEP </p><p>Lung-recruitment manoeuvres Prone position Oscillatory ventilation </p><p>Fax 01480 364898 - Papworth Hospital ECMO referral form 2.0 – Page 3 of 5 CN123 File Section: 1 Patient Addressograph Label (minimum of Patient Name, Date of Birth, Hospital No., NHS No.) </p><p>Organ function “check-list”:</p><p>Ongoing drugs:______</p><p>______</p><p>______</p><p>______</p><p>Cardiac function:</p><p>Known previous cardiac pathology? Yes / No -- If yes, please details:______</p><p>______</p><p>TTE/TOE done? Main findings: ______</p><p>Renal function: </p><p>Last creatinine: ______CVVH: Yes / No</p><p>Known previous renal pathology? Yes / No -- If yes, please details:______</p><p>______</p><p>Hepatic function: </p><p>Known previous hepatic pathology? Yes / No -- If yes, please details:______</p><p>______</p><p>Neurological status:</p><p>Known previous neurological pathology? Yes / No -- If yes, please details:______</p><p>______</p><p>Fax 01480 364898 - Papworth Hospital ECMO referral form 2.0 – Page 4 of 5 CN123 File Section: 1 Patient Addressograph Label (minimum of Patient Name, Date of Birth, Hospital No., NHS No.)</p><p>Consent:</p><p>Any known or suspected objection for ECMO from the patient or next of kin: Yes / No</p><p>If our team is coming:</p><p>When is most convenient for our team to arrive? ___ / ___ / ____time: ___ h ___ min</p><p>Is access possible to the theatre with anaesthetic support? Yes / No</p><p>Can we have access to a C-arm and radiographer in ICU or theatre? Yes / No</p><p>Can you have 2 units of RBC cross-matched for our arrival? Yes / No</p><p>Can you order 1 unit of platelets if platelet count < 100,000 Yes / No</p><p>Fax 01480 364898 - Papworth Hospital ECMO referral form 2.0 – Page 5 of 5 CN123 File Section: 1</p>