216 Section V ■ Vascular Access

12. Continue to use the electrocautery to cut through the

subcutaneous tissue.

13. Coagulate all visible bleeding sites.

14. Spread the fibers of the sternocleidomastoid muscle

apart with a hemostat and retract using hemostats

clamped onto the muscle (Fig. 33.4).

15. Open the carotid sheath, taking care to avoid the vagus

nerve.

16. Irrigate both the common carotid artery and internal jugular vein with 1% plain lidocaine to vasodilate the vessels.

17. Encircle the artery with silicone loop, and proximal

and distal 2-0 silk ties held with clamps but not tied.

Avoid “sawing” the ties on the artery.

18. Avoid excessive handling of the internal jugular vein.

Some isolate the vein after cannulation of the carotid

artery to avoid spasm.

19. Estimate the length of the cannula to be inserted.

a. Identify the sternal notch and the xiphoid process.

b. The arterial catheter is inserted approximately one

third of the distance between the sternal notch and

the xiphoid process. This is typically between 3 and

4 cm.

c. The venous catheter is inserted approximately one-half

the distance between the sternal notch and the xiphoid

process. This is typically between 7 and 7.5 cm.

d. Mark these distances on the catheters with a 2-0 tie,

or note the distance if the cannula is marked.

20. Heparinize the patient with a bolus of 75 to 150 U/kg of

heparin, depending on the estimated risk of bleeding,

and wait 60 to 90 seconds before proceeding with cannulation.

Arterial Cannulation

1. Tie the distal ligature on the carotid artery, and place a

bulldog clamp on the proximal portion of the artery.

Allow blood to dilate the artery before placing the

bulldog clamp.

2. Make an arteriotomy using a no. 11 scalpel blade, and

place two traction sutures of 6-0 Prolene (Ethicon,

Somerville, New Jersey) on the proximal side of the

arteriotomy (Fig. 33.5).

Always use traction sutures, to prevent intimal tears.

3. If desired, lubricate Garrett dilators with sterile surgical

lubricant and dilate the artery to the approximate size

of the catheter.

4. Place a sterile tubing clamp on the catheter. Lubricate

the catheter and insert the catheter into the vessel as

Fig. 33.4. Split sternocleidomastoid and open carotid sheath. the bulldog clamp is removed.

Fig. 33.3. Landmarks over the sternocleidomastoid

muscle for making the incision with electrocautery.

Chapter 33 ■ Extracorporeal Membrane Oxygenation Cannulation and Decannulation 217

5. Secure the catheter with a 2-0 silk ligature tied over a

0.5- to 1-cm vessel loop (“bootie”) (Fig. 33.6).

6. Place a second 2-0 silk ligature. Tie the distal tie around

the catheter, and then tie the distal and proximal ties

together. Some surgeons place two ties proximally and

one distally for added security.

7. Allow blood to back up into the catheter to remove air.

Venous Cannulation

1. Dissect the vein free and isolate with two 2-0 silk ties.

Do not apply traction to the vein with the ties, to

avoid spasm.

2. Place a bulldog clamp on the proximal end of the vein,

allowing blood to distend it. Then tie the distal end of

the vein with the 2-0 silk ligature.

3. Make a venotomy with a no. 11 scalpel blade, and place

two stay sutures of 6-0 Prolene as traction sutures, as for

arterial cannulation.

4. Lubricate the venous catheter, place a sterile tubing

clamp on the catheter, and dilate the venotomy.

5. Insert the catheter as surgical assistant places traction

on the proximal tie, and apply pressure over the liver to

increase the backflow of blood out of the catheter (to

decrease the risk of an air embolus).

A B

Fig. 33.5. A: Carotid artery isolated with vessel clamp in place and with arteriotomy site showing

the placement of the 6-0 Prolene traction sutures. B (inset): Magnified view of (A).

A B

Fig. 33.6. A: Securing the catheter with proximal and distal ties onto a “bootie.” B (inset): Magnified

view of (A).