213

Khodayar Rais-Bahrami

Gary E. Hartman

Billie Lou Short

Extracorporeal Membrane

Oxygenation Cannulation and

Decannulation

33

Extracorporeal membrane oxygenation (ECMO) is

defined as the use of a modified heart–lung machine combined with an oxygenator to provide cardiopulmonary support for patients with reversible pulmonary and/or cardiac

insufficiency in whom maximal conventional therapies

have failed (1–3). After decades of laboratory and clinical

research, ECMO is well accepted as a standard treatment

for neonatal respiratory failure refractory to conventional

techniques of pulmonary support (4–7). Most causes of

neonatal respiratory failure are self-limited, and ECMO

allows time for the lung to recover from the underlying disease process and for reversal of pulmonary hypertension,

which frequently accompanies respiratory failure in the

newborn.

Venoarterial Extracorporeal Membrane

Oxygenation—Cannulation

A. Indications

Placement of carotid arterial and internal jugular venous

catheters for use in venoarterial (VA) ECMO. VA ECMO

should be used in patients with significant cardiovascular

instability.

B. Relative Contraindications for

ECMO in the Neonatal Period (5,7)

1. Gestational age <34 weeks

2. Birthweight <2,000 g

3. Uncontrolled coagulopathy or bleeding disorders

4. Congenital heart disease without lung disease.

Exception: Postoperative cardiac patients, a topic that

will not be covered in this chapter.

5. Irreversible lung pathology

6. Intracranial hemorrhage more than grade II

7. Major lethal congenital anomaly

8. Duration of maximum ventilatory support, >10 to

14 days

9. Responding to ventilator management and/or inhaled

nitric oxide

C. Precautions

1. Ensure that the patient is paralyzed before placing the

venous catheter to prevent air embolus.

2. Recognize that

a. Internal jugular lines placed for IV access prior to

ECMO may cause clot formation, resulting in the

need for thrombectomy before placement of the

venous ECMO catheter.

b. Excessive manipulation of the internal jugular vein

may cause spasm and inability to place a catheter of

appropriate gauge.

c. A lacerated vessel may result in the need for a sternotomy for vessel retrieval.

Appropriate instruments should be on the bedside tray or cart.

A backup unit of blood should be available in the

blood bank.

d. Blood loss sufficient to produce hypotension can

occur during a difficult cannulation.

Emergency blood should be available at the bedside (10 to 20 mL/kg).

e. The vagus nerve is located next to the neck vessels,

and may be injured or manipulated during isolation

of the vessels. Manipulation can cause bradycardia

or other arrhythmias.

f. Vital signs and pulse oximetry values must be monitored at all times because clinical observation of the

infant is prevented by the surgical drapes.

g. If the patient has been hand bag–ventilated for stabilization, do not place the Ambu bag on the bedside when surgical drapes are placed. The bag may

entrap oxygen, which can result in a fire when electrocautery is used.

D. Personnel, Equipment, and

Medications (8)

Personnel

1. Surgical team

a. A senior surgeon (pediatric, cardiovascular, or thoracic)

with assistant

b. A surgical scrub nurse and a circulating nurse

214 Section V ■ Vascular Access

2. Medical team