a. A physician trained in management of ECMO

patients and cannulation techniques, who will

administer anesthetic agents and manage the infant

medically during the procedure

b. A bedside intensive care (neonatal or pediatric

intensive care unit) nurse, who will monitor vital

signs, record events, and draw up medications as

needed by the ECMO physician

c. A respiratory therapist, who will change ventilator

settings as necessary

3. Circuit specialists

a. A cardiovascular perfusionist, nurse, or respiratory

therapist specially trained in this procedure, who

will prime the pump

b. A bedside ECMO specialist (nurse, respiratory therapist, or cardiovascular perfusionist with special

training in ECMO management), who will manage

the ECMO system after the patient is on ECMO

Equipment (Fig. 33.1)

Sterile

1. Arterial and venous catheters (9)

a. Arterial

(1) The size of the arterial catheter determines the

resistance of the ECMO circuit because it is the

part of the ECMO circuit with the smallest internal diameter and thus the highest resistance.

(2) This catheter should be as short as possible, with

a thin wall and a large internal diameter (resistance is related directly to the length of the

catheter and inversely proportional to the diameter). An example of a suitable catheter is

the Bio-Medicus Extracorporeal Circulation

Cannula, 8 to 10 French (Fr) (Bio-Medicus,

Minneapolis, Minnesota).

b. Venous

(1) Venous catheter with

(a) As large an internal diameter as possible, to

allow maximal blood flow (the patient’s oxygenation is related directly to the rate of

blood flow).

(b) A thin wall/large internal diameter. An example of a suitable catheter is the Bio-Medicus

Extracorporeal Circulation Cannula, 8 to 14

Fr. (Bio-Medicus, Minneapolis, Minnesota).

2. Surgical instruments required are listed in Tables 33.1

and 33.2.

3. Gowns and gloves

4. Saline for injection

5. Syringes (1 to 20 mL) and needles (19 to 26 gauge)

6. Povidone–iodine solution

7. Povidone–iodine ointment

8. Semipermeable transparent membrane-type dressing

9. Absorbable gelatin sponge, for example, Gelfoam

(Upjohn, Kalamazoo, Michigan)

10. Surgical lubricant, bacteriostatic

Nonsterile

1. Surgical head covers and mask

2. Pulse oximeter

3. Surgical head light

4. Electrocautery

5. Wall suction

6. Shoulder roll, for example, a small blanket, to place

under infant’s shoulders

7. Tubing clamps

Medications

1. A long-acting paralyzing agent, for example, pancuronium bromide (0.1 mg/kg)

2. Fentanyl citrate (10 to 20 μg/kg)

3. Sodium heparin (75 to 150 U/kg)

4. Topical thrombin/Gelfoam

5. Lidocaine, 0.25%, with epinephrine

6. Lidocaine, 1%, plain (without epinephrine)

7. Cryoprecipitate, thawed, or commercially available

fibrin sealant (optional)

E. Technique—Preparation for

Cannulation

1. Place infant with head to “foot” of overhead warmer

bed.

2. Anesthetize the patient with fentanyl (10 to 20 μg/

kg).

Fig. 33.1. Schematic diagram of VA ECMO circuit, showing

the drainage from the right atrium into the bladder of the circuit,

with flow through the membrane lung, heat exchanger, and return

flow to the arch of the aorta via the carotid artery catheter. (From

Polin RA, Fox WC, eds. Fetal and Neonatal Physiology, Vol. 1.

Philadelphia: WB Saunders; 1992:933, with permission.)

Chapter 33 ■ Extracorporeal Membrane Oxygenation Cannulation and Decannulation 215

3. Paralyze the patient with pancuronium (0.1 mg/kg).

4. Hyperextend the patient’s neck with a shoulder roll,

and turn the head to the left (Fig. 33.2). Make sure that

the Bovie ground pad is placed at this time.

Observe closely for hypotension.

5. Monitor vital signs and give additional fentanyl and/or

pancuronium as needed (see Chapter 6).

6. Clean a wide area of the right neck, chest, and ear with

Betadine solution.

7. Drape the infant and entire bed with sterile towels.

8. Use Steri-Drapes (3M Health Care, St. Paul,

Minnesota) to secure the towels to the skin.

Table 33.1 Surgical Instruments for

ECMO Cannulation

Number Item

Place in a 12- × 18-inch mayo tray with a Huck towel on the bottom of the

tray.

2 Custard cup (place on inside of other cup with a 3- × 4-inch

sponge)

1 Medicine cup (place inside of custard cup with a 3- × 4-inch

sponge)

2 Straight bulldog clamps

1 Sauer eye retractor

1 Alm retractor

1 Mastoid Jansen retractor

2 Vein retractors

2 Octagonal forceps

2 7-inch Gerald forceps

2 6-inch DeBakey forceps

1 Adson forceps, plain

2 Adson forceps with teeth

2 No. 3 knife handles