ECMO Datasheet
Patient name – ___________________________________________ Age/Sex – __________
ID no – __________ Date & time of admission – _______________
Date & time of discharge ____________
Hospital Referred from ________________________________________________________
Referring consultant __________________________________________________________
Ht – ______cms, Wt – ______kgs, BSA – ______sq m, Blood group – _________
Diagnosis –
____________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Intervention or procedure – ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Date & Time on Ventilator – ____________________________________________________
Date & Time off Ventilator –_____________________________________________________
Date & Time on IABP – _______________________________________________________
Date & Time off IABP – _______________________________________________________
Indication for ECMO – _________________________________________________________
Date & Time on ECMO – _______________________________________________________
Date & Time off ECMO – _______________________________________________________
Patient History –
___________________________________________________________________________
___________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Stratergy –
- Type of ECMO – ________________________________________________________
- Cannulation –
Site Size/type
- Arterial – _________________________________________________________
- Venous –_________________________________________________________
- Technic – open/seldinger/semi open
- Circuit Priming – ________________________________________________________
- Pump – Centrifugal (BP80/BP50) –__________________________________________
- Oxygenator – __________________________________________________________
- Flow rate – after 4 hrs____________ after 24 hrs___________________ ________
- Antibiotics – __________________________________________________________
Pre ECMO Clinical parameter (worst in last 6 hrs) –
- Iontropic score – preparation
- Dopamine – µg/kg/min
- Nor adrenaline – µg/kg/min
- Adrenaline – µg/kg/min
- Dobutamine – µg/kg/min
- Vasoprin – u/hr
CLINICAL PARAMETRES
Parameters | Pre ECMO (worst in last 6 hrs before ECMO) | Post ECMO (Best in 24 hrs after ECMO) | Weaning started | Before trial off (at the time of successful trial off) |
Pulse | ||||
Mean arterial pressure | ||||
Rhythm | ||||
Temperature | ||||
Glassglow coma scale | ||||
PaO2 | ||||
PCO2 | ||||
HCO3 | ||||
pH | ||||
Mode | ||||
RR | ||||
TV | ||||
Peak Inspiratory pressure | ||||
Mean airway pressure | ||||
FiO2 | ||||
PEEP | ||||
Amplitude (HFOV) | ||||
PaO2/FiO2 ratio | ||||
Oxygenation Index | ||||
LVEF | ||||
Chamber size | ||||
VTI | ||||
Mitral regurgitation | ||||
Inotropic score | ||||
SVO2 | ||||
Lactate | ||||
Haemoglobin | ||||
WBC | ||||
Platelet | ||||
Creatinine | ||||
Sodium | ||||
Potassium |
Culture reports –
Date | Material | Organism | Sensitivity | Antibiotics on |
Complications –
Mechanical –
(Pump, oxygenator, etc related, also spcify whether you need to change the circuit or any component)
Bleeding –
(if any, specify the site)
Cardiovascular –
(like HT, Hypotension, cardiac stun)
Renal –
(specify whether required dialysis or not, if require then which type eg SLEED, CRRT)
Infection –
(Nosocomial infection after initiating ECMO, specify if culture proved)
Miscellaneous –
Vascular –
(during cannulation or decannulation)
Weaning trial – 1st –
2nd –
Trial off –
Decannulation –
Outcome –
Cause of mortality –
(like DNR, Sepsis or Bleeding, etc)
Transport – Intra or Inter hospital
Filled by ___________________________________________, contact no – ______________________
Instructions –
- Kindly fill up the preliminary data with date & time
- For inotropic score, if you don’t want to calculate just mention the mcg/kg/min or just write down your preparation of inotropes & how much ml/hr it is going
- For pre ECMO support fill up the parameters which were worst in last 6 hrs before starting ECMO
- For Post ECMO parameters, include those which are found best in 24 hrs after initiating ECMO
- Weaning parameters to be included when you decide to wean the patient from moderate support of ECMO
- Trial off parameters should be taken after 30 mins of off ECMO parameters
- Write down complications as per classification, in case of any doubts you can put it in miscellaneous
- For Mechanical complication, kindly also include whether you required to change the circuit or any part
- If there is a mortality kindly mention the probable cause of mortality
- Kindly mention the antibiotics on which patient was on before initiation of ecmo
- In culture table just mention only positive resport, negative culture not required to be mentioned
- Kindly fill up the name & contact no so that we can speak to you in case of any queries
- Please feel free to call on 9821214971, if you have any queries in filling up the form.
- If patient required transport then briefly describe the purpose of transport, distance & any issues during transport