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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


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