The document discusses the complexities and challenges associated with ECMO (extracorporeal membrane oxygenation), emphasizing the importance of proper patient selection, cannulation techniques, and maintenance to avoid complications. It outlines potential pitfalls during the initiation and maintenance phases, including vascular access issues, circuit complications, and the necessity for thorough training and simulation for healthcare teams. Additionally, the document stresses the importance of effective communication and knowledge sharing to enhance decision-making and minimize risks in high-stakes scenarios.

1. ECMO: WHAT CAN GO
WRONG
DEIRDRE MURPHY ALFRED ICU

2. “what can go wrong will go wrong
at the worst possible moment”
– MURPHY

3. HOW TO BEAT MURPHY’S LAW
Know what can go wrong
Avoid it
Tell others!- share “the knowledge”
Troubleshoot new problems

4. WHAT IS ECMO?
• VV ECMO #1 (Vin

5. KNOWING WHAT CAN GO WRONG
Stages of ECMO support
Initiation
Cannulation
Maintenance
Weaning
What next?

6. INITIATION
Choose right patient
Right type of ECMO (VV vs VA)
Right configuration (site/set up/possible
complications)

7. RIGHT PATIENT
Will benefit from ECMO
Not too sick to benefit (duration of organ failure)
Has an “out” clause

8. RIGHT PATIENT
Decision support
Indications and exclusions
Many relative- requires experience - 2nd opinion
Often very limited time
Can get it wrong
Review all decisions
Share cases/ Registry

9. RIGHT CONFIGURATION
Provides best support for that patient
e.g. VV in setting of severe hypoxaemia
VA in setting of cardiac failure

10. CANNULATION
Cannulas ranging from 15F to 31F in major
vascular structures..
!
What could possibly go wrong …..

11. !
Not simply same as arterial line and venous line only bigger…..

12. FEMORAL ARTERIAL ACCESS
How good are landmarks?
Not Very!
0-11 cm (6.5 cm mean) between inguinal ligament
and groin crease
Maximal femoral pulse less variable ..if there is a pulse..
Bifiurcation of CFA above groin crease in 75%

13. PROBLEMS WITH LANDMARK BASED
FEMORAL APPROACH
Too high- retroperitoneal haematoma
!
Too low- pseudoaneuysms

14. WHY IS SITE SO IMPORTANT
prevent complications
access superficial femoral for
leg perfusion to avoid
ischaemia

15. PLACING “BACKFLOW” CANNULAE

16. Backflow Cannula No Backflow Cannula

17. SOLUTION
Ultrasound guided vascular access
Size vessels (avoid cannulas that
are too big)
Put right sized cannula in the right
part of the vessel
size = 3 xD

19. KINKED/ EXTRAVASCULAR

20. SOLUTION

22. DEEP PELVIC OBSTRUCTION KIT

23. DEEP PELVIC OBSTRUCTION KIT
Stiff guidewire (e.g. Amplatz)
Long exchange catheter to get around
tortuosity in the pelvic vessels

24. ANGIOGRAPHIC DO’S AND DONT’S
Never underestimate the amount of damage you can
do with a needle and guidewire
!
Always visualise the guide wire (unless it is soft tipped
and an experienced operator) (I- I)
!
Always try and visualise what is happening to the tip of
the guide wire even when it is not visible

25. CANNULA IN RIGHT VESSEL BUT WRONG SPOT

26. TROUBLESHOOTING CANNULA
PROBLEMS
Not always easy
Percutaneous cannulation in shocked patient
Cardiogenic shock complicating cardiac surgery
necessitating return to OR

27. CANNULATION
Complicated by presence of IABP
V shocked patient
Seemed to go smoothly

28. POST CANNULATION
High pressures in ECMO circuit
limiting support
Ultrasound of cannulas- in vessels
Venous cannula appropriately
placed

29. FURTHER TESTS?
abdo X ray

31. ALWAYS DO FRESH PUNCTURE
Re-wiring existing lines problematic
May be high entry point to vessel/near inguinal ligament
etc

32. CANNULATION DURING ARREST

33. CANNULATION DURING ARREST
Identify vessels anatomically
(guidewire in aorta/ guidewire in
IVC)
Don’t cut corners
Entire team needs to be co-ordinated-
simulation training

34. MAINTENANCE
Patient complications
Bleeding, bleeding , bleeding
Clotting including HITT
Pump thrombosis
(Murphy’s law of mechanical devices)
Infection

35. MAINTENANCE PHASE..AT THE WORST
POSSIBLE MOMENT. .
Circuit complications
disruption of circuit
venous (pre-pump)
arterial (Post pump)
All life threatening
emergencies

36. Day 1 Day 12 Day 14

37. Day 1 Day 12 Day 14

38. PREVENTION

39. MANAGEMENT OF CIRCUIT
DISRUPTION

40. Cannula disruption
!
Arterial cannula
!
3-4 l/min

41. AIR EMBOLISM
Prevention- No taps on venous (low pressure) side of
circuit
Training to deal with- simulation

42. PUMP FAILURE..AT THE WORST
POSSIBLE MOMENT
Back up console always plugged in and ready to
go
Low battery-pump won’t turn back on…
Checklist to include battery standby
Handcrank

43. PUMP HEAD THROMBOSIS
Haemolysis, noisy pump
Rx; Change ciruit (URGENT)

44. TRANSPORT

45. AFTER ECMO
Decision making
Timing of removal/separation
Defining the response to failure clearly
What next- destination therapy? bridge to bridge

46. HOW CAN YOU RESPOND ADEQUATELY
AT ALL TIMES OF DAY AND NIGHT
Robust system
Centre volume
All staff caring for the patient trained in emergency
responses
Frequent rehearsal of key responses e.g. clamping circuit

47. HOW TO AVOID
Logistics:
ECMO safety/ set up
Clamps/spare circuit primed
Training for life threatening emergencies
Simulation training
Checklists
Maintenance of training -re-accreditation

48. BEATING MURPHY
cognitive challenges
share experiences, write up results, registry data, case
conferences, M and Ms, evidence based decision support
technical challenges
training (individual and team)
learning from errors as a team/ craft group/ specialty
on the spot trouble shooting

49. BEATING MURPHY
!
there are some things we don’t
have time not to do…..