Formato de Entrega de Paciente en ECMO Tras El Transporte
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afmchile2017Formato de Entrega de Paciente en ECMO Tras El Transporte
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afmchile2017Patient Information Form (ECMO Referral)
• Patient location (Hospital, City, State, Unit/Bed #): Date/Time:
Patient Name:
• Requesting provider:
Patient Health Number:
• Call back phone number: DOB:
Admission date:
• Is family aware of potential for ECMO? Yes/No (circle one)
Flu positive? Yes/No (circle one)
• Consent/assent obtained, by whom?
Viral panel:
• Admission diagnosis: COVID-19? Yes/No (circle one)
• Mode of ECMO Support:
• Brief patient history (working diagnosis, past medical history, reason for ECMO, etc.):
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Current and admission weight:
Height: Cardiac arrest this admission? Yes/No (circle one)
Chronic renal failure? Yes/No (circle one)
Trauma? Yes/No (circle one)
Dialysis? Yes/No (circle one)
Acute renal failure? Yes/No (circle one) Surgery/type/date:
Active bleeding? Yes/No (circle one) If yes, where?
Requiring transfusion Yes/No (circle one)
Current continuous medications:
Current neurological status:
Latest laboratory results
WBC: Na: ALT: INR:
HGB: K: AST: PT:
Platelets: Urea Total bilirubin: APTT:
Fibrinogen: Creatinine: Albumin: Glucose:
Lactate: HCO3: LDH: Pregnancy test:
Procalcitonin: Blood type: (please have 2 units PRBC available.)
Latest ABG
pH:
Latest Vitals Ventilator settings I/O status
pCO2:
pO2: HR: Date of intubation:
ABP: Mode: Last 24 hours
Base excess:
Resp: FiO2: Since admission:
Chest X-Ray SpO2: PEEP:
Findings: Temp: When was the FiO2 last < 60%? Nutrition:
ECHO
Ejection fraction:
Aortic Valve status: Mitral Valve status: Pericardial effusion? Yes/No (circle one)
CT Head: CT Chest/Abdomen:
