Page 36 - JSOM Spring 2024

TABLE 2 Initial Procedural Performance Checklist for Bifemoral Veno-Venous Extracorporeal Membrane Oxygenation (ECMO)
1. Utilize two sterile personnel for this procedure.
2. Assess the patient for any contraindications prior to procedure.
3. Prime and prepare ECMO circuit. Flush cannulas with sterile saline and tighten all stopcocks and caps on the cannulas.
4. Assess femoral vein anatomy bilaterally and evaluate using ultrasound prior to starting procedure.
5. Clean hands. Put on sterile gloves. Use sterile probe cover for ultrasound.
6. Clean insertion sites with chlorhexidine.
7. Drape blue towels. Make every effort to maintain a sterile field and equipment throughout procedure.
8. Using ultrasound, identify the needle insertion site that will allow cannulation of the femoral vein cephalad to the insertion of the saphe-
nous vein but below the inguinal ligament bilaterally.
9. Anesthetize the area over the insertion sites (as clinically indicated).
10. The right femoral vein site is the preferred location for the return cannula while the left femoral vein location is the preferred location for
the drainage cannula. Cannulation is ideally performed with two people for access and wire control. Ideally, the right femoral vein would
be used for the return cannula and the left femoral vein for the drainage cannula.
11. Insert introducer needle with syringe under ultrasound guidance to the 12 o’clock position of the right femoral vein. Micropuncture use
can be considered.
12. Visualize insertion of the needle into the right femoral vein and confirm with return of blood into the syringe.
13. Remove syringe. Place 160cm 0.035 J-tip wire through introducer needle or micropuncture wire and sheath.
14. Confirm placement of wire within the right femoral vein using ultrasound guidance. Remove needle, leaving wire in place OR if micro-
puncture was used, remove sheath, leaving wire in place. If the patient is attached to continuous telemetry monitoring, ectopy may also be
observed, indicating wire in the right ventricle. Retract the wire until ectopy is no longer observed.
15. Use ultrasound to confirm wire placement for the return cannula at the level of the inferior vena cava/right atrial junction.
16. Sequentially dilate the return cannula site over wire. 1/3 to 1/2 of dilator should be placed with each dilation. Ensure wire can easily move
back and forth after each dilation. Dilate to one size smaller than planned cannula size.
17. Advance return cannula with introducer until position in right atrium is confirmed with ultrasound guidance.
18. Remove wire and introducer from return cannula and clamp the end.
19. Flush return cannula with sterile saline and clamp the end.
20. Insert introducer needle with syringe under ultrasound guidance to the 12 o’clock position of the left femoral vein. Micropuncture use can
be considered.
21. Visualize insertion of the needle into the left femoral vein and confirm with return of blood into the syringe.
22. Remove syringe. Place 160cm 0.035 J-tip wire through introducer needle or micropuncture wire and sheath.
23. Confirm placement of wire within the left femoral vein using ultrasound guidance. Remove needle, leaving wire in place OR, if micropunc-
ture was used, remove sheath, leaving wire in place.
24. Sequentially dilate the drainage cannula site over wire. 1/3 to 1/2 of dilator should be placed with each dilation. Ensure wire can easily
move back and forth after each dilation. Dilate to one size smaller than planned cannula size.
25. Advance drainage cannula with introducer until the last hole is through skin and not visible. Retract introducer to designated line and
advance the drainage cannula.
26. Remove wire and introducer from drainage cannula and clamp the end.
27. Flush drainage cannula with sterile saline and clamp the end.
28. Once both cannulas are in place in each femoral vein, administer an IV bolus of heparin. Heparin bolus may be withheld if anticoagulation is
contraindicated as determined by the proceduralists (high risk of bleeding complications, active and ongoing correction of coagulopathy, etc).
29. Place circuit tubing on the field identifying drainage and return tubing and placing next to drainage and return cannulas.
30. Connect drainage cannula to circuit with air-free technique.
31. Connect return cannula to circuit with air-free technique.
32. Ensure no air entrainment in the circuit.
33. Initiate circuit flow, remove clamps closest to cannulas, and then remove clamps closest to circuit.
34. Note cannula positions.
35. Secure cannulas with purse string non-absorbable suture where cannula enters the skin and at least 3 additional securing sutures on the
legs per cannula.
36. Cover cannula sites with sterile dressings.

cannula under ultrasound guidance was removed (item 15) as (1). Hand sanitizer may or may not be available in the oper-
this was felt to be redundant with subsequent return cannula ational environment, so this was removed (item 5). In addi-
placement guidance. The remaining items had mean scores of tion, cleaning supplies may differ based on group and team,
>3 and <7 in the first two rounds of review and the investiga- so chlorhexidine was removed (item 6). The final checklist
tors considered them to be essential to the checklist. was updated to include having the guidewire directed toward
the right atrium for the return cannula, given the possibility
No additional checklist items were suggested by the expert of migration into a hepatic vein and malposition resulting in
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participants; however, edits to the existing items were sug- lower flows (14). Making a skin incision at the wire entry site
gested. All edits were incorporated into rounds 1 and 2 and prior to dilation was added, as this is an important component
were included in the final round of scoring. First, given po- of percutaneous access that was not initially included (items
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tential resource limitations, the word “consider” was added 16 and 24). Cannula flushing was updated to include using
34 | JSOM Volume 23, Edition 1 / Spring 2024