E. Technique

Postdecannulation vessel reconstruction is beyond the

scope of this chapter.

1. Place the neck in an extended position, using the

shoulder roll.

2. Give fentanyl for analgesia, prior to giving vecuronium.

Because of the risk of air embolism during the

removal of the venous catheter, the infant must not be

allowed to breathe during decannulation. If two doses

of vecuronium do not produce paralysis, give pancuronium.

3. Increase ventilator setting to a rate of 40 to 50 breaths/

min, a peak inspiratory pressure of 20 to 25 cm H2O

222 Section V ■ Vascular Access

(depending on chest movement), and FiO2 of 0.30 to

0.40 after paralytic agent is given.

4. Clean the neck, and drape as for cannulation.

5. Anesthetize with 0.25% lidocaine with epinephrine.

6. Cut and remove the Vicryl suture.

7. Remove absorbable gelatin sponge packing, exposing

the catheters and vessels.

If a jugular bulb catheter is in place, it is usually

removed first to allow better visualization for removal

of the VV ECMO catheter.

8. The jugular bulb catheter should be clamped off before

removal, after the patient is taken off bypass. Be aware

that removing the catheter while on bypass without a

clamp in place will result in the introduction of air into

the circuit.

In case of VA ECMO, the venous catheter is usually

removed first because it is most readily accessible.

9. Separate the catheter from surrounding tissue by blunt

dissection.

10. Encircle the vein with a 2-0 silk tie, which is used for

traction and hemostatic control.

11. Place a Satinsky clamp around the vein to stabilize the

catheter (Fig. 33.10).

12. Place a 2-0 silk tie proximal to the clamp.

13. Cut the silk ties securing the catheter in the vein with a

no. 11 scalpel blade. The two proximal ties should be

cut where they cross the vessel loop (“bootie”).

14. Ask the ECMO specialist to remove the patient from

the ECMO circuit.

15. Monitor vital signs and oxygen saturation as an indication that ventilator settings are appropriate. Settings

may have to be increased when the patient is removed

from the circuit.

16. Provide an inspiratory “hold” on the ventilator while

the surgeon removes the venous catheter. Failure to do

this can result in air embolus.

17. Replace any significant blood loss.

18. Cut the 2-0 silk traction suture and tie the suture

proximal to the Satinsky clamp. Remove the Satinsky

clamp.

19. Isolate the arterial catheter, dissect free, and remove.