A neonatal patient was placed on VV ECMO for acute hypoxic respiratory failure.  The patient was unstable and cannulated bedside on the PICU under echo guidance.  X-ray confirmed correct placement of the cannula.  The cannula was secured in the standard method for neck cannulation.  

After 3 days of therapy, it was noticed the recirculation increased significantly from 1-3% to 45%.  

During physiotherapy sessions, which included proning the patient, the cannula slipped out of the IVC and was free in the RA.  After discussions with an MDT, the balance of risk was discussed about recannulating.

There are case studies of repositioning the cannula with a “lasso” from the IVC but in this case it was decided to leave the cannula as the patient was improving and it was anticipated that they would be weaned the following day.  

The patient failed to wean from ECMO and was kept on ECMO.  1 day later the cannula pierced the RA causing a tamponade and required surgery and conversion to VA ECMO.  The patient was successfully weaned 3 days later.  

‍