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Department of Critical Care Medicine ECMO Referral Form Please email this completed form to [email protected] and contact MMUH Duty Critical Care Consultant on 01-8032000 REFERRAL Date of referral: Time of referral: Referring hospital: Referring Doctor: Contact number: PATIENT DETAILS Name: Date of birth: Age: Gender: Height: Weight: BMI: Allergies: Pregnancy test result: Smoking history: Alcohol history: Hospital admission date: ICU admission date: Working diagnosis: Other significant background: Brief clinical summary: RESPIRATORY Intubation date: Number of days intubated: Oxygenation FiO 2 : PEEP: Ventilation Tidal volume: P peak : P plat : Resp rate: Findings On Imaging CXR: CT thorax: Adjuncts Prone positioning: Neuromuscular blockade: Pulmonary vasodilators: Chest drains: ABG pH: P a CO 2 : P a O 2 : SaO 2 : P/F ratio: Base Excess: Lactate: J McNamara & I Conrick-Martin, April 2020

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Page 1: 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

Page 2: ECMO Referral Form - mater.ie

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


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