ECMO preparation checklist

ECMO Centrum
Karolinska University Hospital 4.4.2012
ECMO preparation checklist
ECMO entails the oxygenation of blood by an artificial lung aided by a modified heart-lung machine. The
surgical procedure takes about 20 to 60 minutes and is carried out on the ward. The patient’s bed should be in
a private room if possible. After allowing one to three hours for stabilization the patient is transported to
Stockholm.
We would appreciate it if the following preparations were made before our arrival (please check):
Order blood; should be available on the ward
Children up to 10 kg: 6 units SAG 2 units fresh plasma O
Children 10 to 30 kg: 8 units SAG 4 units fresh plasma O
Children 30 to 50 kg: 12 units SAG 5 units fresh plasma O
Over 50 kg: 15 units SAG 6 units fresh plasma O
√ here
Investigations to be made:
Cranial ultrasound on children (if fontanelle is open)
Echocardiogram
Chest x-ray
CT of cranium and thorax if possible
O
O
O
O
Recent lab tests:
Hgb, Hct, Platelets, CRP, PCT, Na, K, Cl, Alb, ionized Ca, Cr, Urea, ASAT, ALAT, Bilirubine, LactateO
APTT, prothrombin complex, Fibrinogen, D-dimer, Antithrombin
O
Arterial blood gas
O
Cardiac enzymes
O
Note last GCS-score before sedation/intubation
O
Note body temperature, actual blood pressures and heart frequenzy
O
IF utilized with a PICCO- or EV1000-system, calibrate again to note ELWI etc
O
HIV and Hepatitis serology
O
EDTA tube, two serum tubes and two sodium-heparin tubes that we will take care of
O
Blood typing and basic antibody screening in the mother where neonatal patients are involved O
PKU should be taken before ECMO. Record that the test has been done before ECMO treatment and O
the age of the child. A new PKU should be drawn one week after completed ECMO treatment
Patient preparation:
Surgical table or adjustable height outpatient incubator without water mattress
No pumps or similar apparatus on the patient’s right side
Indwelling catheter
CVC, if possible
A-line, if possible
Securely fixed endotracheal tube
Misc:
Surgical personnel, anesthesiologist, diathermia, instrument table, accessory table, suction,
illumination, ultrasound
Fluids: Sodium chloride for infusion, chlorhexidine for sterile preparation, sterile infusion set
Space to set up the ECMO system with access to air, oxygen, and electricity.
Two empty tables or trolleys
CXR immediately after procedure
Copies of chart notes and x-rays
Relatives should be available to receive information from ECMO doctor
O
O
O
O
O
O
O
O
O
O
O
O
O
URL/home page: www.ecmo.se
Phone ECMO doctor on call: +46-8-517 78 050 Telefax: +46-8-517 78 060

Date: _______________ Name: __________________________ Birth date: ________________
Samples taken 60-30 minutes BEFORE our planned arrival.
Fill in the results here, please
Hgb _____ AST _____
EVF _____ ALT _____
WBC _____ Bilirubine _____
CRP _____ Lactate _____
PCT
_____
Na _____ Platelets _____
K _____ APTT _____
Cl _____ PK /INR _____
Alb _____ Fibrinogen _____
Ca++ _____ D-dimer _____
Creatinine _____ Antitrhombin_____
Urea
_____
TnT/TnI _____
CK
_____
CK-MB _____
(please circle)
aBlood gas: pH ____; pO2____; pCO2____; SaO2____; BE____; HCO3-____; kPa or mmHg
FiO2____; Mean Airway Pressure____;
PKU sampled before ECMO YES / no (please circle)
Latest GCS before sedation/intubationb ____;
New SAPS 3- _____________; PIM 2 ___________ scoring
Body temp ____
Blood pressure ____/____; MAP____
Heart rate ____
PiCCO/PiCCO2, EV1000/Volu trac ELWI ____; SVI ____; CI ____; SVRI ____;
This form should be submitted with the other papers to be taken with us when leaving
for transport.
Thanks for your cooperation!