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