Chapter 33 ■ Extracorporeal Membrane Oxygenation Cannulation and Decannulation 221

2. Aortic dissection associated with arterial cannulation

(15).

3. Blood loss, particularly during the venous cannulation,

when side holes in the catheter are outside the vein

4. Venous spasm, resulting in inability to place a large

enough venous catheter to meet the required ECMO

flow to support the patient adequately

The rate of blood flow is impeded by the small

gauge of the catheter, requiring that a second venous

catheter be placed in the femoral vein. The two catheters must be Y-connected together into the ECMO

circuit.

5. Arrhythmias and/or bradycardia can occur, owing to

stimulation of the vagus nerve

6. Hypotension, due to an increase in the intravascular

space when the patient is connected to the ECMO

circuit

7. Conversion to VA from VV ECMO. This will occur if

a. The patient remains hypoxic despite adequate

ECMO flow.

b. The patient remains hypotensive despite vasopressor

support.

c. Cerebral venous saturations remain persistently

<60% after adequate flows and ventilator management have been undertaken.

Converting from VV to VA ECMO requires cannulation of carotid artery with a Bio-Medicus arterial catheter, and the double-lumen VV catheter

must be “Y’d” in together to make a double-lumen

venous drainage catheter (Fig. 33.9).

Extracorporeal Membrane

Oxygenation—Decannulation

A. Indications

1. Removal from ECMO after lung recovery

2. Removal from ECMO because of a complication such

as uncontrolled bleeding or failure of lung recovery

B. Contraindications

All intensive support is being withdrawn, and permission for

autopsy is obtained. It is usually optimal to remove the catheters during the autopsy.

C. Precautions

1. The patient must be paralyzed during the removal of

the venous catheter to avoid an air embolus.

2. The vessels are fragile and may tear. A backup unit of

blood should be available at the bedside.

3. Delay removing catheter for 12 to 24 hours after taking

the patient off bypass in cases in which there is a high

risk of reoccurrence of pulmonary hypertension and

thus need for second ECMO run (e.g., severe congenital diaphragmatic hernia). This procedure places a risk

of development of right atrial clots from the venous

catheter and, in some patients, has resulted in superior

venocaval syndrome. Therefore, the time the catheters

are left in place should be limited to no more than

24 hours.

D. Personnel, Equipment,

and Medications

Personnel

Same as for cannulation, with the exception that the primer

is not required

Equipment

Sterile

1. Surgical tray with towels and suture as for cannulation

2. Semipermeable transparent dressing

3. Povidone–iodine ointment

4. Syringes (1 to 20 mL) and needles (18 to 26 gauge)

5. Unit of blood

6. Absorbable gelatin sponge

Nonsterile

Same as for cannulation

Medications

1. Fentanyl (10 to 20 μg/kg)

2. Vecuronium bromide (0.2 mg/kg)

3. A short-acting paralyzing agent is preferred because of

the relatively short duration of the procedure. This

allows the infant to breathe spontaneously as soon as

possible after decannulation, which facilitates rapid

weaning from ventilator support.

4. Lidocaine, 0.25%, with epinephrine

5. Topical thrombin

6. Protamine sulfate (1 mg only)