Leading Perfusionist Discusses Air Embolism From Extracorporeal Membrane Oxygenation System Failure

Case Overview

This case involves a juvenile female patient in Idaho who underwent a number of surgeries to repair a congenital heart defect that was diagnosed shortly after birth. After the child was born, she underwent a number of surgeries to repair the defect. During one of these surgeries, the ECMO machine that was being used to oxygenate the patient’s blood malfunctioned, causing the perfusionist to manually crank the machine to re-initiate the flow of blood. As this occurred the machine allowed air into the system that subsequently enter the patient. As a result, the child suffered an air embolism and died shortly after the surgery was completed.

Questions to the Pediatrics expert and their responses

Do you have experience in using the ECMO machine? If so, how often do you use it?

Yes, I have experience in using the ECMO machine. I use it frequently in critical care settings.

What are the common complications that can arise from using this machine?

Common complications include bleeding, infection, and thrombosis.

How does one mitigate the risk of air embolism?

To mitigate the risk of air embolism, ensure all connections are secure, monitor for air in the system, and use proper priming techniques.

About the expert

This expert has been board certified by the American Board of Cardiovascular Perfusion for 33 years. He has held numerous Chief Perfusionist positions at major hospitals and is currently the Chief Pediatric Perfusionist at a major medical university hospital while also managing the Non-Cardiac Autotransfusion program at the same institution. He is a fellow of the American Academy of Cardiovascular Perfusion and has authored 25 perfusion protocols. This expert has dedicated much of his professional career to teaching the mechanics of perfusion technology to perfusion students, residents, interns and attending cardiothoracic surgeons.