REPORT
039
DATE
Dec 2019
TITLE
Dual Lumen Cannula Movement
DETAILS OF INCIDENT

A neonatal patient was placed on VV ECMO for acute hypoxic respiratory failure.  The patient was unstable and cannulated bedside on the PICU under echo guidance.  X-ray confirmed correct placement of the cannula.  The cannula was secured in the standard method for neck cannulation.  

After 3 days of therapy, it was noticed the recirculation increased significantly from 1-3% to 45%.  

During physiotherapy sessions, which included proning the patient, the cannula slipped out of the IVC and was free in the RA.  After discussions with an MDT, the balance of risk was discussed about recannulating.

There are case studies of repositioning the cannula with a “lasso” from the IVC but in this case it was decided to leave the cannula as the patient was improving and it was anticipated that they would be weaned the following day.  

The patient failed to wean from ECMO and was kept on ECMO.  1 day later the cannula pierced the RA causing a tamponade and required surgery and conversion to VA ECMO.  The patient was successfully weaned 3 days later.  

DETAILS OF INJURY TO PATIENT

None

TYPE OF DEVICE/MANUFACTURER

Maquet Avalon Elite Bi-Caval Dual Lumen Cannula

Product Code: 10016-CE

Lot/Batch: 246799

ACTION TAKEN

Reported to the company.

A discussion was had with a peer centre to ask if they would have had the same response. The peer centre has had similar translocations. They would observe in a similar situation. They did have a puncture in one of their migrated cannula too.

RESPONSE FROM MANUFACTURER

n/a

ADDTIONAL INFORMATION

Upon reflection whatdo you think went well?

The junior team provided excellent support whilst the senior on-call team came in.  This included a pericardiocentesis.  

New action plans/changes as a result of the event?

The team are very aware of the risks with the cannula for VV and so may have taken a more positive look at VA ECMO.  Although a more risky procedure for respiratory ECMO, the exposure to VA means that is managed with better experience than VV.  

SUPPORTING VISUALS/VIDEO
SUPPORTING DOCUMENT

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