Sign In
CPSI Share                                                                      
​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​ ​​
Back to Search
Publication Type: Risk Alert
Single or Multiple Incident: Single
Date: 7/1/2021 12:00:00 AM
Country: Hong Kong
This alert describes a case where venous arterial extracorporeal membrane oxygenation (VA-ECMO) to the left femoral artery and vein was planned for a patient, who was successfully resuscitated from a cardiac arrest. During ECMO preparation, the patient became agitated and struggled. The cannula connection to the ECMO machine was put aside during stabilization of the patient. After reconnection to the ECMO machine, the patient experienced low blood pressure and the VA cannulas were found reversed. Recommendations to prevent similar incidents are provided.

Additional Details

Device:
veno-arterial cannulas, extracorporeal membrane oxygenation (ECMO), drainage tubings, return tubings

Rules / Policies / Procedures
  1. Remove the blue cap of the venous sheath and the red cap of the arterial sheath only during the last step of connection to the drainage and return tubings of the ECMO machine respectively.
  2. Enhance checking for correct anatomical sites of cannula􀆟on and correct blood flow direction, immediately after connection to the ECMO machine, with independent checking by the doctors responsible for the cannulation procedure.
  3. Remove the blue/red caps ONLY immediately before connecting to drainage/return tubings.

Veno-arterial (VA) cannulas reversely connected to extracorporeal membrane oxygenation (ECMO) system