ECMO-/ECLS

the jugular and carotid vessels. One possible method for cannulation is described
[ 5 ][see Figure 2]:
The infant is positioned with the neck extended with a shoulder roll, facing
the left side. A 2-3 cm transverse cervical incision is made one finger’s
breadth above the clavicle over the right sternocleidomastoid muscle
(SCM). Dissection between the heads of the SCM exposes the carotid
sheath which is opened as the internal jugular vein, common carotid
artery, and vagus nerves are identified. Gentle proximal and distal
dissection of the vein should be performed; manipulation of the vein
should be minimized to avoid induction of venospasm which may preclude
placement of a large venous cannula. The common carotid artery lies
medial and posterior and may be safely dissected since it has no
branches at this level.
Ligatures of 2-0 silk are placed proximally and distally around the internal
jugular vein and the carotid artery. Heparin (100 units/kg) is administered
intravenously. During a 3 minute period, to allow heparin recirculation,
papaverine may be instilled into the wound to enhance dilatation of the
vein. The tips of the arterial and venous cannulas will be optimally located
at the opening of the right brachiocephalic artery and the inferior aspect of
the right atrium, respectively. The cannulas are marked with a suture at
the intended extent of insertion (arterial = 2.5 cm and venous = 6 cm in the
neonate).
An obturator is placed into the venous cannula to prevent bleeding via the
cannula side holes during insertion. The common carotid artery is ligated
distally and an angled ductus clamp is placed proximally. A transverse
arteriotomy is made near to the distal ligature. 6-0 polypropylene stay
sutures are placed on the edge of the artery to prevent subintimal
dissection during cannula insertion. The cannula is anchored in place with
two circumferential 2-0 silk ligatures with a small piece of plastic vessel
loop inserted between the vein and ligature to prevent vessel injury during
incision of the anchoring sutures at the time of decannulation. The
marking ligature is tied to the most distal circumferential ligature for extra
security and the cannula is debubbled. The vein is then ligated distally
and occluded proximally by gently retracting the proximal suture. A
venotomy is performed and the cannula is placed into the vein, secured,
and debubbled.