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1、NTUHECMODemography病患基本資料：Name：____________ChartNo：___________BH:cm,BW:kg,BSA(m2)，BMISex：Birthdate：--ERadmissiondateandtime：--_______：_______NTUHadmissiondate：--NTUHdischargedate：--ICUadmissiondate：--ICUdischargedate：--Intubationdateandtime：--_______：_______Extubationdatean
2、dtime：--______：_______Expired：(＋,－)if(＋)Expireddateandtime：--_______：_______PatientSource：□ER□Ward□外院□ICU□PedECMOdateandtime：--_______：_______Dialysis：--_______：_______Sepsis：--_______：_______Plasmaexchange：--_______：_______IABP：--_______：_______CPR:--_______：_______DNR：(＋
3、,－)：--_______：_______AAD：(＋,－)：--_______：_______PastHistory：□DM,with(□DM併發Retinopathy,□DMfoot,□Neuropathy,□Nephropathy)□Hypertension，□Provencirrhosis,(Child○A○B○C)□Myocardialinfraction，□CAD，□PAODNYHA(○I,○II,○III,○IV,○Unknown)□COPD，□慢性呼吸衰竭(有用呼吸器或BiPAP)○CKDstageIV，○CKDstageV
4、,○ChronicDialysis,if(＋),(○H/D,○P/D)□Immunecompromisedhosts□CVA，□Hemiplegia，□Dementia□Autoimmunedisease□Gastrointestinalulcerdisease(含GI,GU)□Cancer，□Metastaticcarcinoma□Hematologicmalignancy(含□lymphoma、□leukemia、□MDS)□Smoking□Smokebutquit>6months□LOSbeforeICUadmission□<14da
5、ys，□14~28days，□>28days□BeforeICUVasoactivedruguse□AddICUunplanned□AcuteinfectionatICU：□Nosocomial，□Respiratory□一年內住過院referredVs：,黨中央批准：Set-upsite：OR,5FCV,4A,4B,4C,4Fi,6PE,burn,MICU,Cathroom,PICU,ER,Ward,外院,Others)Ifneonatalpulmonarydisease：Apgar(1min):______Apgar(5min):___
6、___GA:_____WDelivery:(NSD,CS,emergentCS)BBW:_______g,G_____P______A_____ECMOindication:(MCS,ARDS,LTx,NS,PE,NHBD,neonatallungdisease,)Mechanicalcirculatorysupport:Indication:(postcardiotomy,acutemyocarditis,cardiomyopathy,CHD,AMI,Septicshock,PHandRVfailure,Acuterejection,ot
7、her)Note：ARDS分類:Non-infection(Traumarelated,Burn/Inhalation,Toxin/Drug,Non-infectionlungdisease)Infection(Communityacquiredpneumonia,Nosocomialpneumonia,Extra-pulmonaryinfection)Others:Ifpostcardiotomy&set-upatICU:_____hrsaftertheOPOPprocedure:(CABG,valve,CHD,TX,other)Redo
8、(+,－)(elective,emergent)Pacemaker：(+,－)Note:Aorticclamptime:_______min,Totalbypasstime:__
