Stay Prepared: Preventing and Managing Accidental ECMO Decannulations

October 10, 2024

Accidental decannulation is a rare but serious complication during ECMO that requires immediate attention. The risks are significant, including hemorrhage, loss of ECMO support, and air embolism. Below, I summarize what the Extracorporeal Life Support Organization (ELSO) materials say about accidental decannulation, focusing on preventive measures and immediate management.

As a novice ECMO specialist, I’ve heard of accidental decannulations, but thankfully, they have never happened to me. Every specialist always thinks about this, and it’s a constant part of my emergency planning at the beginning of every shift. We also practice similar situations in simulations, which helps us be more prepared in case it ever becomes a reality.

The seriousness of an accidental decannulation cannot be overstated. In the event of a complete decannulation, you could pump anywhere from three to five liters per minute directly out of the patient. Losing that much volume so quickly can have an immediate and devastating impact on the patient’s condition. The rapid exsanguination requires swift and decisive action to minimize the risk of death.

Preventive Measures

Secure Cannulas Properly: Always secure cannulas to a fixed object like the mattress or bed frame, rather than relying solely on sutures or tape, which can loosen.
Monitor Cannula Placement: Regularly check and document the depth of each cannula to quickly detect any changes in placement.
Use Specialized Equipment: Utilize equipment such as towel clamps or tubing holders to provide additional security for ECMO tubing, minimizing the chance of dislodgement.
Create Awareness: Ensure parents, staff, and visitors are informed about cannula placement and understand how to avoid accidental contact with the tubing and circuitry.
Brake Everything: Keep the ECMO pump and patient bed braked to prevent accidental separation during movement.
Appropriate Patient Restraints: Use appropriate patient restraints to prevent self-harm or movements that could lead to dislodgement.

Immediate Management

Clamp the Circuit: Immediately clamp the circuit to prevent further blood loss and reduce the risk of air entering the system.
Apply Pressure: Apply firm pressure at the cannulation site to control bleeding.
Alert the ECLS Surgeon: Inform the ECLS surgeon immediately for intervention, as their expertise is crucial to resolving the decannulation.
Prepare for Low Cardiac Output: Be ready to support the patient in case of low cardiac output or cardiac arrest, with appropriate personnel and equipment prepared for resuscitation.
Stabilize the Patient: Increase ventilator support, administer blood products, and initiate vasopressor and inotropic agents as needed to stabilize the patient.
Reinsert the Cannula If Possible: If the cannula is only partially removed and the patient is fully dependent on ECLS, attempt reinsertion. This high-risk intervention should only be carried out by experienced personnel.

ELSO emphasizes that every ECMO program must have a clear policy for managing accidental decannulation. This policy includes comprehensive prevention strategies, clear, immediate actions, and defined team roles to ensure a rapid and effective response.

If you found this article helpful, please share it with your colleagues and leave a comment below. I’d love to hear your thoughts and experiences on managing accidental decannulation!

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Note: This article is based on information sourced from the ELSO Red Book (6th Edition) and the ECMO Specialist Training Manual (4th Edition). ELSO has not reviewed or officially endorsed this article. This article reflects my learning journey in ECMO and is intended for educational purposes only. It should not be used as a substitute for professional medical advice or guidance. Always consult with qualified healthcare professionals for clinical decisions and patient care.

References:

MacLaren, G., Brodie, D., Lorusso, R., Peek, G., Thiagarajan, R., & Vercaemst, L. (Eds.). (2022). Extracorporeal Life Support: The ELSO Red Book (6th ed.). Extracorporeal Life Support Organization.
Brogan, T. V., Annich, G., Ellis, W. C., Haney, B., Heard, M., & Lorusso, R. (Eds.). (2018). ECMO Specialist Training Manual (4th ed.). Extracorporeal Life Support Organization.

Acknowledgments:

I want to express my gratitude for the tools and resources that assisted in creating this article and others. I developed three custom GPTs—

OpenEvidence
GPT-4o/o1, Claude 3.5 Sonnet/Opus, Perplexity
Grammarly for editorial and proofreading assistance
Leonardo AI, DALL-E3 AI Image Generator, Microsoft Designer, and Adobe Express for generating images and visual content