ELSO Award for Excellence in Life Support
Equipment and Resource Questionnaire
2016
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Save this questionnaire to your computer as a new word document, using the title:
YourCenterELSOEquipment.docx
(example: MillionDollarBabiesHospitalELSOEquipment.docx)
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Submit the completed questionnaire with your ELSO Award of Excellence Application
We Provide ECLS for the Following
Populations:
Neonate
Pediatric
Adult
Respiratory:
Cardiac:
ECPR (active cardiac arrest):
ECLS Pumps
Check the pump used for each patient population in your institution. Check all that apply, including pumps
used for back-up.
Type
Avecor Affinity
Baxter Century Roller
Biomedicus BP-50 Centrifugal
Biomedicus BP-80 Centrifugal
CardioHelp
Cobe 4" Roller
Cobe 6" Roller
Jostra HL-20 Roller
Jostra Rotaflow Centrifugal
Levitronix CentriMag Centrifugal 3/8
Meta-Plus
Polystan 5" Roller
Sarns Roller
Sarns/3M Delphin II Centrifugal
Sorin Revolution Centrifugal
Stockert S3 Roller
Stockert S5 Roller
Other: Please specify
Other: Please specify
ELSO Award Equipment Survey
Neonate
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Adult
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ECPR
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© 2016 Extracorporeal Life Support Organization
Membrane Lungs
Check the membrane lung used for each patient population in your institution. Check all that apply.
Type
Medos HILITE 1000
Medos HILITE 2400 LT
Medos HILITE 2800
Medos HILITE 7000
Medos HILITE 7000 LT
Medos HILITE 800 LT
Medos HILITE 8000 LT
Medtronic Affinity
Medtronic MiniMax
Medtronic MiniMax Plus
Quadrox-iD Adult
Quadrox-i Small Adult
Quadrox-iD Pediatric
Terumo Baby Fx 05
Terumo Baby Fx 15
Terumo Baby Fx 25
Terumo Baby Rx 05
Terumo Baby Rx 15
Terumo Baby Rx 25
Other: Please Specify
Other: Please Specify
ELSO Award Equipment Survey
Neonate
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Pediatric
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Adult
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© 2016 Extracorporeal Life Support Organization
Hemofilters
Check the hemofilters used for each patient population in your institution. Check all that apply.
Type
Amicon Minifilter+
Baxter CA-50
Baxter Minifilter
Gambro
Hospal 60
MinnTech HF-1200
MinnTech HF-400
MinnTech HF-700
MinnTech Mini+
RenalFlo HF400
RenalFlo HF700
Other: Please Specify
Neonate
Pediatric
Adult
ECPR
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Heat Exchanger
Check the heat exchanger used for each patient population in your institution. Check all that apply,
including heat exchangers used for back-up.
Type
Avecor ECMOtherm
Dideco D720
Gish HE-3
Jostra HEC40
Medtronic BIOtherm
Medtronic ECMOtherm II
Quadrox Integrated
SciMed
SciMed ECMOtherm
SciMed OmniTherm
Other: Please Specify
ELSO Award Equipment Survey
Neonate
Pediatric
Adult
ECPR
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© 2016 Extracorporeal Life Support Organization
Cannula
Check the cannula used for each patient population in your institution. Check all that apply.
Type
Argyle
Avalon Elite Bi Caval DL
Avalon Elite Multi-Port Venous Femoral
Bard
Biomedicus
Cook
DLP
Jostra
Jostra DL
Origen
Pharmaseal UAC
Polystan
Research Medical
Other: Please Specify
Other: Please Specify
Neonate
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ECPR
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Describe the monitoring and/or integrated devices you routinely use for ECLS
cases (inline blood gases or pressure monitors, etc): Click here to enter text.
Describe the anticoagulation equipment used for bedside monitoring: Click here
to enter text.
Describe the disposable equipment used for ECLS: Click here to enter text.
Describe the heater warmer unit used for ECLS: Click here to enter text.
ELSO Award Equipment Survey
© 2016 Extracorporeal Life Support Organization