34, 5, 12, 21, 35, 36
Cannula events are the commonest and among the most lethal ECMO accidents that reach an incident system. Use real-time imaging (ideally combined) for femoral cannulation; treat a flow that will not rise at initiation as possible extravascular cannula; assign one person to the cannulas whenever another procedure is performed on an ECMO patient; secure and keep insertion sites in view.
None
DOI 10.1007/s10047-023-01386-z; PMID 36795227; PMC9933024
Not applicable (descriptive analysis of reported accidents)
No denominator; authors state incidence cannot be calculated. Voluntary reporting dependent on individuals; system designed around errors, so bleeding likely under-reported. About 20% of hospitals. Categorisation subjective. 12-year window spanning equipment change. Japanese-language database, free-text search.
Cannula malposition 28% (50), accidental decannulation 19% (34), bleeding 15% (26), air in circuit 7% (12), thromboembolism 5% (9), limb ischaemia, gas supply and power supply 4% each, foreign body 3%. Harm: death 23%, high potential residual disability 26%. Malposition fatal in 44% (22/50), thromboembolism 56% (5/9). MALPOSITION: ECPR 46%, VA 28%, VV 26%; 74% over 60 years; retroperitoneal or intraperitoneal injury 63% (27/50), all via femoral vessels; right internal jugular commonest single insertion site (20%) with mediastinal/thoracic injury; 38% (19/50) had neither fluoroscopic nor ultrasound guidance and combined guidance was used in none; some malpositions despite fluoroscopic wire confirmation; surgery 54%, trans-arterial embolisation 18%, death before treatment 26%. DECANNULATION: all 34 complete removals requiring reinsertion; arterial cannula 85% (29/34); during another procedure (surgery, PCI) 41% (14/34); insufficient fixing reported as 44% with numerator 23/34 (internal inconsistency); blinded insertion position 41%; inadequate communication 21%. BLEEDING: 9/26 due to circuit damage including fissure at arterial cannula-circuit connection; 11/26 needed surgical repair. AIR: incorrect clamp release 33%, stopcock error 33%, machine breakage 17%. Authors cite Kim et al for a 1.3% decannulation rate.
178 ECMO-related accidents reported to the Japan Council for Quality Health Care patient-safety accident database, January 2010 to December 2021 (reporting mandatory for tertiary teaching hospitals, voluntary for others; about 20% of Japanese hospitals). Free-text narratives reviewed by two authors. Events limited to intraoperative cardiopulmonary support excluded.