MEDEX

Description of Event or Problem

MULTIPLE STAFF AT PATIENT'S BEDSIDE IN THE SETTING OF ELEVATED DELTA PS ON ECMO [EXTRACORPOREAL MEMBRANE OXYGENATION]. TEAM WAS INSPECTING THE PIGTAIL TUBING FOR CLOTS/FIBRINS AND TUBE SNAPED OFF AT THE LEUR LOCK OF THE ECMO CIRCUIT. THE ECMO CIRCUIT WAS BRIEFLY CLAPPED OFF TO REPLACE TUBING. THE PATIENT LOST BLOOD AND LATER HAD TO BE TRANSFUSED ONE UNIT TO REPLACE BLOOD LOST DURING INCIDENT. ATTENDING ICU PHYSICIAN AT BEDSIDE AS WELL AS MULTIPLE ECMO SPECIALIST AT TIME OF CLAMPING OFF ECMO. PATIENT WAS HYPOTENSIVE AND BEING SUPPORTED ON VASOPRESSORS. BOTH INFLOW AND RETURN CANNULAS WERE CLAMPED OFF <10 SECONDS IN ORDER TO REPLACE PIGTAIL TUBING. FLOWS ON ECMO REESTABLISHED WITHIN 30 SECONDS AND ABLE TO COME OFF OF VASOPRESSORS.