Department of Anaesthesia & Intensive Care

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): ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________

_______________________________________________________________________________

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

Or 

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: __________________________________________________________________

Known or suspected pregnancy Yes / No

Blood transfusion limitations (e.g. for religion, antibodies reasons) Yes / No 

Severe immunosuppression Yes / No If yes, reasons: _______________________________

Respiratory failure resulting of:

1^st diagnosis: ________________________________ Suspicion Proven   Reversible 

If appropriate:

 2^nd diagnosis:  ________________________________ Suspicion Proven   Reversible 

3^rd diagnosis (if appropriate): _______________________ Suspicion Proven   Reversible 

Underlying respiratory function:

Known underlying respiratory disease: Yes / No   --  If yes, please 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