MAT # 17261433
Eight-year-old child (DOB 06/24/2016) with a history documented as possible asthma/atopy was hospitalized in early February 2025 with severe Influenza A infection complicated by bacterial pneumonia and sepsis. After outpatient influenza diagnosis on 02/06/2025, the patient deteriorated and presented to the ED on 02/08/2025 with worsening respiratory distress. Workup documented Influenza A on PCR, chest X-ray with right middle/lower lobe pneumonia and a small right pleural effusion, and subsequent blood and sputum cultures that grew Streptococcus pneumoniae. Despite escalation from high-flow oxygen to BiPAP, the patient required PICU admission and was intubated on 02/08/2025 for worsening respiratory failure. By 02/09/2025, the course included severe inflammatory markers (CRP 45.8; procalcitonin >100), thrombocytopenia, and progression to multifocal pneumonia with a moderate parapneumonic effusion.
On 02/10/2025, the patient experienced further respiratory decompensation despite a trial of inhaled nitric oxide. Imaging documented near-complete opacification/diffuse airspace disease. A TTE prior to cannulation documented normal cardiac anatomy and biventricular size with EF 50–55%, and bilateral pleural effusions. Pediatric surgery/ECMO consultation was obtained for emergent VV-ECMO based on documented severe gas exchange failure (pH 7.1, pCO₂ 77, pO₂ 45) with hypoxemia (SpO₂ 66–80%) on FiO₂ 100%. A nursing note in the source indicates transfer for ECMO initiation, with reported oxygen saturations falling into the 60s around the time cannulation commenced.
During cannulation, echocardiography at 10:57 documented the VV-ECMO cannula entering from the SVC into the right atrium and then being withdrawn to the mid-right atrium. The same echocardiogram documented a large pericardial effusion with evidence of tamponade physiology. The ECMO flowsheet referenced the patient as “on ECMO” at 11:23. The subsequent period was marked by hemodynamic collapse and recurrent arrest: asystole beginning 11:56 with transient ROSC/bradycardia, recurrent asystole, ventricular fibrillation at 12:54, and asystole again at 13:02. CPR was performed while on VV-ECMO with documentation of excessive bleeding and initiation of massive transfusion. Pericardiocentesis with drain placement was performed; aspirated blood was returned via CellSaver per the source. ECMO flow difficulties were documented with repositioning attempts.
The source further documents escalation from VV-ECMO to VA-ECMO (noted at 12:05) including right carotid cannulation during the arrest, continued bleeding around the cannula site, and abdominal distension with concern for abdominal compartment syndrome (abdomen opened) with ongoing poor flow described. Objective data in the record excerpt includes lactate 7.3 at 12:03 rising to 13.66 at 12:42 and an ABG at 12:03 showing severe acidosis/metabolic derangement (pH 6.78, pCO₂ 58.1, pO₂ 49.1, HCO₃ 8.6, base deficit 25). Medications documented during resuscitation included multiple rounds of epinephrine, calcium chloride, bicarbonate, amiodarone, and initiation of an epinephrine infusion. Death was pronounced at 13:02 on 02/10/2025.
***Please see attached OP notes/TEE for reference****
We seek an opinion concerning the surgical technique and treatments rendered during the ECMO process. We welcome questions and appreciate your time in advance.
Files:
Q: Any images of the echocardiogram and/or CXR available showing the cannula?
A: we do not have them, would not have access until later in litigation
Q: Was there an autopsy? What cannula was used?
A: No autopsy, 26Fr cannula per the documentation we have
Do you believe there might have been medical error?
This is an unfortunate case. The physicians appropriately escalated care to VV ECMO due to respiratory failure in the context of pneumonia and resulting sepsis. However, the ECMO cannula very likely perforated the heart and/or the IVC during placement/repositioning. The notes appear that the procedure was done using standard technique and do not note challenges with placement. Nonetheless, this perforation is ultimately the cause of the patients demise. The pediatric surgeon was not capable of dealing with this complication, requiring a pediatric cardiac surgeon. It is unclear how much of a delay this caused. I would want to know what cannula was used and if an autopsy was performed. This could help delineate the exact location of the perforation.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
See above. Cardiac perforation during ECMO cannulation led to cardiac tamponade and cardiac arrest. This is an unfortunate case. The physicians appropriately escalated care to VV ECMO due to respiratory failure in the context of pneumonia and resulting sepsis. However, the ECMO cannula very likely perforated the heart and/or the IVC during placement/repositioning. The notes appear that the procedure was done using standard technique and do not note challenges with placement. Nonetheless, this perforation is ultimately the cause of the patients demise. The pediatric surgeon was not capable of dealing with this complication, requiring a pediatric cardiac surgeon. It is unclear how much of a delay this caused. I would want to know what cannula was used and if an autopsy was performed. This could help delineate the exact location of the perforation.
What makes you a good expert for this case?
I am a pediatric cardiologist with expertise in heart failure, cardiomyopathy.
How often do you encounter cases similar to this one in your practice?
Yes. I have experience with similar cases and have experience with VV and VA ECMO.
Do you believe there might have been medical error?
Cardiac perforation is a well known complication during VV ECMO cannulation. It is not specifically named in the case, but I suspect they used an Avalon cannula where the tip should be positioned in the IVC. Incorrect guidewire placement during introduction can lead to cannula tip malposition leading RA or RV perforation. You mentioned a transesophageal echocardiogram (TEE) but the report indicated a transthoracic echocardiogram being performed. Typically, a TEE would be performed. It would be helpful to review the echo images or flouroscopy if available. The patient could not be resuscitated. Was an autopsy preformed? It would be helpful to know the site of the perforation. Some institutions have stopped using the Avalon cannula in neonates and switched the Crescent RA jugular dual lumen catheter.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The cardiac perforation immediately preceded the death of this child. I reviewed the answers you provided. I would need to review echo images to provide any more detail. Without autopsy will not know site of perforation, but likely right atrium or right ventricle.
What makes you a good expert for this case?
Pediatric cardiologist with more than 25 years experience in academic and private setting. Senior member of noninvasive cardiac imaging lab in an academic children's hospital.
How often do you encounter cases similar to this one in your practice?
Pediatric and neonatal ECMO is performed commonly in our facility.
Do you believe there might have been medical error?
The order of events suggest potential heart perforation with the venous cannula. Echocardiography not always demonstrates the tip of the cannula, so likely upon advancing there was perforation with resulting mortality.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The patient was extremely sick with unclear outcome even if VV ECMO was successful. The potential injury caused the final outcome in a very sudden manner.
What makes you a good expert for this case?
I am primary operator for percutaneous ECMO cannulations in a high volume pediatric center. Support ECMO cannulation for surgical teams when percutaneous is not appropriate
How often do you encounter cases similar to this one in your practice?
I have seen two more in my career like this. Usually not having live fluoroscopic guidance is a limitation with increased likelihood for this to happen. But still very rare.
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Comments are accepted only from Pediatrics - Cardiology experts.