TRANSONIC

Description of Event or Problem

NO LOW FLOW ALARMS TRIGGERED BY R IJ ECMO FLOW PROBE. ALARM ISSUES: ALARM SET INCORRECTLY. PRIOR TO EVENT, STABLE R IJ ECMO FLOWS >1.3 AND STABLE L GROIN ECMO > 4.4 NOTED DURING MORNING HANDOFF REPORT WITH PM RN AND DURING "PRE-ROUNDS" WITH ALD RESIDENT. AROUND 0845 - NO FLOW ON R IJ ECMO CANNULA VISUALLY NOTICED WITH ANESTHESIOLOGIST DURING ICU ROUNDS, NO ALARMS AT THIS TIME. PERFUSIONIST ASSESSED AND REPORTED SEEING SEPARATION OF BLOOD/CLOT IN R IJ CANNULA. PATIENT HAS A KNOWN ATRIAL SEPTAL DEFECT (ASD). THROUGHOUT THE EVENT PATIENT WAS HEMODYNAMICALLY STABLE AND INTACT MENTAL STATUS. EMERGENT REMOVAL OF R IJ CANNULA PERFORMED BEDSIDE BY MD. PATIENT RECEIVED 30MCG EPINEPHRINE IV PUSH FOR CARDIAC SUPPORT AND 125MCG OF FENTANYL. PATIENT HEMODYNAMICALLY TOLERATED THE DECANNULATION. LOW FLOW ALARM OR NO FLOW ALARM WOULD HAVE BEEN USEFUL IN THIS SITUATION.