216 Section V ■ Vascular Access
12. Continue to use the electrocautery to cut through the
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
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
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
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.
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
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
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
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.
1. Dissect the vein free and isolate with two 2-0 silk ties.
Do not apply traction to the vein with the ties, to
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
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).
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).
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