Extracorporeal Membrane Oxygenation Cannulation and Decannulation
Extracorporeal Membrane Oxygenation Cannulation and Decannulation
M. Kabir Abubakar
Manuel B. Torres
Extracorporeal membrane oxygenation (ECMO) has now become the standard of care for patients with reversible pulmonary or cardiac insufficiency in whom optimized conventional treatments have failed. It is defined as the use of a modified heart-lung machine combined with an oxygenator to provide temporary cardiopulmonary support allowing time for recovery or as a bridge to organ transplant (1, 2, 3, 4, 5, 6, 7). As most causes of neonatal respiratory failure are self-limited, ECMO allows time for the lung to recover from the underlying disease process and for reversal of pulmonary hypertension, which frequently accompanies respiratory failure in the newborn.
Placement of carotid arterial and internal jugular venous catheters for use in venoarterial (VA) ECMO. VA ECMO should be used in patients with significant cardiovascular instability as it provides both respiratory and cardiac support.
B. Relative Contraindications for ECMO in the Neonatal Period (5, 7)
1. Gestational age <34 weeks
2. Birthweight <2,000 g
3. Uncontrolled coagulopathy or bleeding disorders
4. Congenital heart disease without lung disease. Exception: Postoperative cardiac patients, a topic that will not be covered in this chapter
5. Irreversible lung pathology
6. Intracranial hemorrhage grade 3 or more
7. Major lethal congenital anomaly
8. Duration of maximum ventilatory support >10 to 14 days
9. Patients responding to ventilator management and/or inhaled nitric oxide
C. Precautions
1. Ensure that the patient is paralyzed before placing the venous catheter to prevent air embolus.
2. Recognize that
a. Internal jugular lines placed for IV access prior to ECMO may cause clot formation, resulting in the need for thrombectomy before placement of the venous ECMO catheter.
b. Excessive manipulation of the internal jugular vein may cause spasm and inability to place a catheter of appropriate gauge.
c. A lacerated vessel may result in the need for a sternotomy for vessel retrieval.
Appropriate instruments should be on the bedside tray or cart.
A backup unit of blood should be available in the blood bank for immediate release.
d. Blood loss sufficient to produce hypotension can occur during a difficult cannulation.
Emergency blood should be available at the bedside (10 to 20 mL/kg).
e. The vagus nerve is located next to the neck vessels, and may be injured or manipulated during isolation of the vessels. Manipulation can cause bradycardia or other arrhythmias.
f. Vital signs and pulse oximetry values must be monitored at all times because clinical observation of the infant is prevented by the surgical drapes.
g. If the patient has been manually ventilated for stabilization with a self-inflating bag, do not place the bag on the bedside when surgical drapes are placed. The bag may entrap oxygen, which can result in a fire when electrocautery is used.
a. Experienced surgeon (pediatric, cardiovascular, or thoracic)
b. Assistant surgeon (Fellow, resident, physician assistant, registered nurse first assistant)
c. Surgical scrub nurse/tech
d. Circulating nurse
2. Medical team
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
(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 directly proportional 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) (Medtronic, 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 (Medtronic, Minneapolis, Minnesota).
2. Surgical instruments required are listed in Tables 35.1 and 35.2
3. Gowns and gloves
4. Saline for injection
5. Syringes (1 to 20 mL) and needles (19 to 26 gauge)
