ECMO
Position to the top of the bed, towards the middle of the bed, maybe slightly to the right. (Head slightly down makes the vein bigger.) Shoulder roll to extend until chin is away. Head pointing to the left with ETT on the left. (If rotated too much to the left, then the lateral and medial heads of the SCM is more difficult to separate.) Diathermy pad on, ECG wires out of the way. Prep including behind the ear. Drape with enough space to see the chest. If there is a right central line that is inserted away from the proposed incision, take out the line, place a skin stitch, and proceed.
Knife. 2-3cm transverse incision in the second neck crease that is 1.5-2cm above the medial third of the clavicle; traversing the medial border of the sternocleidomastoid (SCM) which will be later retracted laterally. Diathermy to split the fat and platysma. Sharp and blunt (Ragnells/small Langenbeck) dissection medial to the SCM in a longitudinal fashion to get to the carotid sheath behind. Anteriorly and superiorly on the sheath is the ansa cervicalis and behind/between the vessels is the vagus nerve.
Decide on the vessel sizes and open the cannulae. Straight DB to split the two vessels. Right-angle to create space above and below. Silk ligatures above and below on both vessels and leave them on artery clips. (If VV-ECMO, then take a large purse-string on the vein (5-0 prolene, can cut the needles; access the vein 1cm above the incision using a small sheath to place the guidewire and a larger sheath. Can use the dilators without cutting the skin by using torque. Ensure the guide-wire is in the IVC at all passes.)
Give heparin (50-100mg/kg). Take the circuit on the field and secure. Divide. Examine the cannulae and plan the length to which the cannulae are inserted. Wet the cannulae.
Pull down the RCCA gently to get some length and tie off distal RCCA with a silastic piece under the silk, place the end on some traction with an artery clip. Pull up the artery and place a right-angled clamp that is sufficiently distal to comfortably control. Make a small incision with fine scissors, or with knife – can enlarge with mosquito. Place the cannula into the incision holding the vessel with one forceps. Remove the clamp and push the cannula into the required depth. Arterial from incision to the required depth. Once the cannula is in, place a silastic piece on top and tie the silk over it to secure its position. Tie the same silk around the cannula. Remove the obturator enough to clamp the cannula. Tie the distal silk around the cannula as well. Deair and connect.
Pull down the RIJV gently to get some length and tie off the distal RIJV with a silastic piece under the silk, placing the tied ends on traction with an artery clip. Place a right-angled clamp that is sufficiently distal to comfortably control. Make a small incision with fine scissors, or with knife. Use the assistant to expose the cut ends to enlarge the venotomy as needed. Holding the end of the venotomy, place the cannula into the venotomy, and release the clamp to advance the cannula to the required depth, twisting the cannula as necessary to get under the clavicle and navigate the angles. Tie the proximal silk onto the cannula with a silastic piece, and then once again over just the cannula. Remove the obturator enough to clamp the cannula. Tie the distal silk around the cannula as well. Deair and connect.
Check ACT and confirm with perfusion the correct limbs before going on. Secure the cannula to the skin in at least two places using silk. Place gauze pieces as required to any pressure areas near the ear. Close the incision with interrupted vertical mattress sutures and use fibrillar/kaltestat if necessary. Remove the roll and check the position of the cannula on the echocardiogram.
Decannulation and repair
Once the weaning gases are back and echo is completed, set up the patient as above. Have a strategy if patient deteriorates very quickly – e.g. chest prepped for central cannulation, or recannulation with new cannula/circuit. Ensure blood is available.
Open the wound and washout with saline to clean the area. Identify the proximal and distal vessels. Once the lines are clamped, get a cross clamp ready ensuring it can go around the proximal vessel. Remove the silk ties by cutting onto the silastic pieces. Get the assistant to clamp while you remove the cannula. If suitable for reconstruction, adjust the clamp and reconstruct with 7-0 or 8-0 prolene starting at each corner. Do the same for the vein.
If the vessel is disconnected, then place a stay suture on the proximal part before taking out the cannula.
Close the wound in layers approximating the fascial and muscle layers, platysma/subcut fat and skin with interrupted or subcuticular as required.