PHYSIOLOGICAL & TREATMENT PARAMETERS

Complete the questions below and copy paste to the free text box labelled 'HISTORY' in referapatient.



Body weight:     (kg)
Height:     (cm) 
or BMI:     (Kg/ m)

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REASONS FOR REFERRAL (incl. presenting symptoms and date of onset):
Date of Hospital Admission:
Date of Admission to ICU:
 
RESPIRATORY FAILURE RESULTING FROM:
1st diagnosis: (state Suspicion / Proven ? / Reversible)

If appropriate:
2nd diagnosis: (state Suspicion / Proven ? / Reversible)

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UNDERLYING RESPIRATORY FUNCTION:
Known underlying respiratory disease: YES/ NO
If yes, please give details:
 
CURRENT RESPIRATORY STATUS:
Number of days intubated:
Ventilation mode: 
Last ventilation parameters: 
Fi02: 
PEEP:           (cmH2O)
Rate:
Peak airway pressure:      (cmH2O) 
Tidal Volume:               (mls)
Last ABG: 
pH: 
PO2:         (kPa) 
PCO2:         (kPa) 
BE: 
SaO2:
HCO3: 
Lactates:         (mmol/L)
Chest X-Ray / CT scan description or report:

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MURRAY SCORE

Calculate Murray Score and copy paste results here using this online tool:

https://www.mdcalc.com/murray-score-acute-lung-injury 

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ATTEMPTED TREATMENT:
Filters changed and ventilator circuit checked: YES/ NO
Steroids: YES/ NO
Inhaled vasodilators?: YES/ NO
High PEEP: YES/ NO
Lung-recruitment manoeuvres: YES/ NO
Prone positioning: YES/ NO
Oscillatory ventilation?: YES/ NO


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OTHER INFORMATION:
Any known condition or organ dysfunction that would limit the likelihood of overall benefit from ECMO (e.g. severe, irreversible brain injury or untreatable metastatic cancer): YES/NO

Known allergies:
Known or suspected pregnancy: YES/ NO
Severe immunosuppression: YES/ NO
If yes, give reasons:
Blood transfusion limitations (e.g. for religion, antibodies): YES/ NO
Limited vascular access: YES/ NO
Any condition that precludes the use of anticoagulants: (YES/ NO)
 
 
TEMPERATURE:
Highest Temperature:
Barrier nursing status:

If diagnosis unknown:
Recent travel: YES/ NO
If yes details:
Occupation:
Contact with animals: YES/ NO
Contact with other unwell persons: YES/ NO
Bleeding: YES/ NO
If yes details:
Rash: YES/ NO
If yes details:

  
ONGOING MEDICATIONS:

Antibiotics/Antivirals:

Inotropes /vasoactives:
Sedation/muscle relaxants:
Others:
Has sodium bicarbonate been administered: YES/ NO 
If yes, please give details:

BLOOD RESULTS OF INTEREST:
Last WBC:
Neutrophils %:
Peak WBC: 
CRP:
Procalcitonin:
Last haemoglobin:
Last platelet count:
Last creatinine:
Last urea:
Last bilirubin: 
Troponin: (state normal range in referring hospital: 
Vasculitis or auto-immune screen:
Others of interest: 

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ORGAN FUNCTION:
Cardiac function:
Heart rate/ rhythm:
Blood pressure: 
Known previous cardiac pathology?: YES/ NO
If yes details:
TTE/TOE done?: YES/ NO
Main findings:
 
RENAL FUNCTION:
CVVH: YES/ NO
If yes, what is the exchange rate: 
Known previous renal pathology?: YES/ NO
If yes details:
Fluid balance for last 3 days:

HEPATIC FUNCTION:
Known previous hepatic pathology?: YES/ NO
If yes details:
Neurological status:
Known previous neurological pathology?: YES/ NO
If yes details:

CONSENT:
Any known or suspected objection for ECMO from the patient or next of kin: YES/ NO

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INCLUSION CRITERIA:
Potentially reversible respiratory failure: YES/ NO
Severe respiratory failure, defined as a Murray 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
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