Download The Ladd`s Procedure for Correction of Intestinal

2.1
The Ladd’s Procedure for
Correction of Intestinal
Malrotation With Volvulus in Children
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Renee Ingoe, RN;
Patricia Lange, MD
I
ntestinal malrotation with volvulus
is an emergent and possibly lifethreatening condition that can occur
in infants and children and that requires
immediate surgical intervention. The
term malrotation is defined as an abnormality of the anatomic position of the
bowel that occurs in utero during embryonic development. The term volvulus
describes a situation in which a portion
of the bowel becomes twisted upon itself. This can cause bowel necrosis from
lack of a blood supply.
Symptoms of intestinal malrotation
with or without a volvulus can be varied, but when a volvulus is suspected or
diagnosed, emergency surgery is performed during which the intestines are
untwisted to allow restoration of blood
flow, and the mesentery (ie, tissue containing blood and lymphatic vessels) is
widened to prevent recurrence of the
ABSTRACT
•
MALROTATION that occurs when the embryonic, two-part, intestinal rotation does not proceed normally results in an abnormal anatomical position of
the intestines.
•
VOLVULUS OCCURS when the intestines are
not fixated to the intestinal wall but are suspended
on a narrow stalk of mesenteric tissue containing the
supplying blood vessels. This formation allows the
intestines to twist on themselves and cut off the
blood supply to the bowel.
•
WHEN MALROTATION WITH VOLVULUS is
diagnosed, emergency surgery must be performed to
untwist the intestines, restore blood flow, and widen
the mesentery. AORN J 85 (February 2007) 300-312.
© AORN, Inc, 2007.
300 • AORN JOURNAL • FEBRUARY 2007, VOL 85, NO 2
volvulus. The Ladd’s procedure is the
gold standard for treatment of intestinal malrotation.1
EPIDEMIOLOGY
Intestinal malrotation occurs in approximately one in 500 births and occurs
equally in males and females.2 Approximately 60% of intestinal malrotation
cases present in the first month of life,
about 20% present between one month
and one year of age, and the remainder
present after the first year.3 Malrotation
may occur as an isolated condition, but
it usually is found in combination with
other congenital anomalies. As many as
70% of children with intestinal malrotation also have other congenital malformations (eg, any combination of digestive system, cardiac, or spleen and liver
abnormalities).3 When intestinal malrotation is associated with volvulus,
however, the anomaly usually is the patient’s only disorder.4 Intestinal malrotation is considered a life-threatening situation when it occurs in conjunction
with a volvulus that is causing a bowel
obstruction.
All children diagnosed with or suspected of having intestinal malrotation
should be referred to a pediatric surgeon who should look immediately for
any signs of obstruction or sepsis related to the condition. It is not clear, however, whether intestinal malrotation
should be treated when the condition is
discovered inadvertently and no symptoms are present. Some surgeons advise that the abnormality be surgically
corrected only in patients younger than
two years of age. Others believe that
treatment should be more aggressive
and that it should be corrected whenever it is discovered to minimize the
chance of an emergent situation later.5
© AORN, Inc, 2007
Ingoe — Lange
ANATOMY
FEBRUARY 2007, VOL 85, NO 2
AND
PHYSIOLOGY
During embryonic development, the
colon and small bowel grow very rapidly.
The bowel starts out as a straight tube
from the end of the stomach to the rectum.6 As the intestines develop further,
they move into the umbilical cord for a
short time where they receive nutrients.
Between the seventh and 10th week of
gestation, the bowel begins to gravitate
back toward the abdominal cavity, during which time the intestines undergo a
two-part rotation before assuming their
normal position in the abdominal cavity.
In the first phase of rotation, the
duodenojejunal junction passes behind
the superior mesenteric artery and becomes attached to the upper left retroperitoneum. In the second phase, the
cecum passes from the left side of the abdomen, anterior to the superior mesenteric artery, and assumes its normal position right of the midline. At completion of
the rotation, the mesentery becomes attached to the retroperitoneum by a broad
band from the upper left at the duodenojejunal junction (ie, the ligament of Trietz)
to the lower right abdomen at the ileocecal junction, which prevents the intestines from twisting on themselves.4 This
process usually is complete by the 12th
week of gestation.
ABNORMAL BOWEL DEVELOPMENT
Intestinal malrotation occurs when the
two-part process does not proceed normally and the intestines do not make
complete turns on re-entry into the abdominal cavity from the umbilicus. This
abnormal rotation can have variable results. The cecum and the attached appendix may be positioned in the right upper
quadrant, midline, or to the left of midline. With malrotation, the intestines are
not secured to the abdominal cavity by
the mesentery; instead, the intestines are
suspended on a narrow stem of tissue (ie,
mesenteric stalk) containing the supplying blood vessels (Figure 1).
Lack of fixation and a narrow, mesenteric stalk allow the intestines to twist on
themselves, a condition known as volvulus. A volvulus cuts off the intestinal
blood supply (ie, from branches of the superior mesenteric artery) causing vascular compromise that ultimately leads to
catastrophic bowel infarction (ie, a massive loss of bowel as a result of the lack of
blood supply) that could result in death.
When a volvulus involves the entire
small bowel, it is referred
to as a mid-gut volvulus
(Figure 2). This can reThe intestines
sult in the loss of most of
the intestine and, in
gravitate from
some cases, may result
in death.4
Additionally, bands the umbilical cord
that normally fix the ceback to the
cum to the sidewall may
be abnormally situated
abdominal cavity
within the abdominal
cavity in such a position
and undergo a
that they compress underlying bowel, causing
two-part rotation
partial or complete obstruction. These abnorbefore assuming
mally positioned bands,
referred to as Ladd’s
their normal
bands, are named after
William Ladd, MD, a piposition in the
oneer in pediatric surgery. During a Ladd’s
abdomen.
procedure, the mesentery is widened, the bands
are ligated, and the appendix is removed to prevent future confusion because the cecum will be on the left
side of the abdomen after the procedure.
Obstructions caused by a volvulus or
Ladd’s bands are life threatening and indicate the need for an emergency surgical
procedure.6
SIGNS
AND
SYMPTOMS
The presentation of intestinal malrotation can be extremely varied, from lifethreatening sepsis as a result of bowel
AORN JOURNAL •
301
Ingoe — Lange
FEBRUARY 2007, VOL 85, NO 2
Figure 1 • Part of the small and large
intestine are unattached so they can twist
and cut off blood supply, which will kill
that part of the intestines.
failure to pass flatus or stool. The child
may become very dehydrated, which
may manifest as decreased urination;
dry mouth, lethargy; and possibly a
depressed fontanel. When the intestines are compromised because of lack
of blood flow, the infant’s vomit can
become bloody.5 Rectal bleeding is an
ominous sign of bowel compromise
and may indicate that the infant has a
gangrenous bowel.
A person can live with intestinal malrotation for life, however, and never experience any symptoms or present with
signs of malrotation. In fact, malrotation
in an adult usually is an incidental sign
on a computed tomography (CT) scan
diagnosed by the anatomic location of a
right-sided small bowel, left-sided
colon, and an abnormal relationship of
the superior mesenteric artery.7 This
malrotation would have occurred in
utero but not have been found until
much later in life. Intestinal malrotation
in an adult also may be discovered during abdominal surgery that is being performed for another reason (eg, cholecystectomy, trauma).
DIAGNOSIS
Figure 2 • In
a midgut
volvulus, the
colon is
tightly coiled
around the
base of the
mesentery of
the small
intestine.
necrosis to no symptoms at all. Bilious
vomiting is the most common sign of intestinal malrotation with volvulus and
should be considered a volvulus in infants until proven otherwise. Abdominal
pain and lethargy also are common.
Other symptoms may include sudden bouts of crying and drawing up of
the legs because of abdominal cramps;
rapid heart rate; rapid breathing; and
302 • AORN JOURNAL
AND
FINDINGS
The most common and accurate way
to diagnose intestinal malrotation with or
without volvulus is an upper gastrointestinal (UGI) series. A barium enema
(BE) also may be performed but yields
less information. Both diagnostic procedures are quick and relatively safe, and
they identify malrotation by demonstrating an abnormally positioned intestine.
A UGI series is valuable in demonstrating the position of the ligament of
Treitz, a band of tissue that anchors the
last part of the duodenum to the retroperitoneum. This portion of bowel
should be positioned to the left of midline and approximately at the level of the
gastroduodenal junction. Any abnormal
positioning of this portion of intestine
should be considered diagnostic or at
Ingoe — Lange
least suspicious for intestinal malrotation. A volvulus may be seen as a thin
line of contrast in a portion of intestine
that is abnormally positioned. Either
finding should generate an immediate
referral to a pediatric surgeon.
Plain x-rays, ultrasounds, and CT
scans are not as reliable as a UGI series
because the UGI uses contrast media
that lights up on the scan. The contrast
either stops flowing or only moves
through a thin opening. A contrast BE
may be performed for evaluation of
cecal position if the cause of the obstruction still cannot be determined
after a UGI series is performed.4 A BE is
more reliable than x-rays, ultrasounds,
and CT scans but is not as reliable as a
UGI series because the barium only
flows up a certain distance, whereas the
contrast in a UGI follows the intestines
all the way down. The area above the
obstruction would not be visualized
during a BE.
PREOPERATIVE PREPARATION
When the OR is being prepared for a
pediatric procedure, the circulating nurse
turns up the room temperature to between 75° F and 85º F (23.9º C and 46º C)
depending on the surgeon’s preference.
The circulating nurse places a pediatric,
underbody, forced-air, temperatureregulating blanket on the bed8 and obtains an IV-solution warmer and irrigation fluid warmer. The circulating nurse
ensures that the pediatric emergency
anesthesia cart is in the room.
PREOPERATIVE CARE OF THE PATIENT. After the
infant has been admitted to the preoperative holding unit, the circulating nurse
greets the patient and his or her parents
and confirms the patient’s identity using
at least two identifiers (eg, the identification band, medical record, parent’s confirmation). After reviewing the patient’s
medical record, the nurse ensures that
the patient’s laboratory, radiology, and
gastrointestinal test results are on the
FEBRUARY 2007, VOL 85, NO 2
chart and verifies that the surgical consent is accurate according to the patient’s
records, OR schedule, and parents. The
nurse verifies the patient’s allergies and
NPO status with the parents and medical record. The nurse then performs an
assessment that includes the patient’s
vital signs, nutritional status, skin turgor,
and skin pallor. The nurse then develops
a care plan specific for this patient undergoing the Ladd’s procedure (Table 1).
CARING FOR THE PARENTS BEThe circulating
FORE SURGERY. This surgery
usually is performed on an
nurse can take
emergency basis, so the infant’s parents may be emonumerous actions
tionally distraught. The
circulating nurse can take
to help alleviate
numerous actions to help
alleviate some of the parthe parents’ fear,
ents’ fear. If possible, the
circulating nurse should
such as speaking
sit down with the parents
and introduce himself or
in a reassuring
herself. The nurse should
explain exactly what the
voice and
role of the circulating
nurse is in taking care of
explaining the
their child and explain the
role of each perioperative
role of the
team member, including
ancillary personnel.
circulating nurse
The nurse should speak
in a soft, calm, and reassurin taking care of
ing tone and should not
speak rapidly. He or she
their child.
should give the parents
time to ask questions and
to contemplate what he or
she is telling them. To instill trust, the
nurse should make eye contact with
each parent and use touch when appropriate. The nurse should ensure that all
of the parents’ questions have been answered and that they understand the procedure completely. The nurse should reassure the parents that he or she will call
the waiting room periodically to give
AORN JOURNAL •
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Ingoe — Lange
FEBRUARY 2007, VOL 85, NO 2
TABLE 1
Nursing Care Plan for Pediatric Patients Undergoing the Ladd’s Procedure
Diagnosis
Risk for
compromised
family coping
related to the
stress of
surgery
•
•
•
•
•
•
Risk of
hypothermia
related to
perioperative
environment,
patient age,
and exposed
body surfaces
•
•
•
Risk for
infection
related to
immature
immune
system
and poor
nutritional
status
Interim outcome criteria
Outcome
statement
Identifies communication barriers and
knowledge level.
Assesses readiness to learn.
Elicits family members’ perception of
anesthesia and surgery.
Uses appropriate communication skills to
ease fears and improve comprehension of
patient and family members, such as
• sitting with family member when performing patient education,
• making eye contact with each parent,
• speaking slowly and clearly and observing for indications of confusion versus
comprehension, and
• allowing time for questions and answers.
Ensures parental presence during anesthesia
induction, if desired and permitted by facility policy.
Evaluates family members’ response to
instruction.
Patient’s family
members
• verbalize understanding of
the procedure,
sequence of
events, and expected outcomes and
• demonstrate
the ability to
cope throughout the perioperative period.
Patient’s
family
members
demonstrate
knowledge
of the
physiological
and
psychological
responses
to the
procedure.
Monitors body temperature throughout the
perioperative period.
Implements thermoregulation measures,
including
• heating the OR to between 75° F and
85º F (23.9º C and 46º C);
• placing a pediatric, underbody, forcedair, temperature-regulating blanket
on the OR bed under the patient;
• placing a stocking cap on the infant’s
head;
• using IV and irrigation solution warmers according to manufacturer instructions; and
• wrapping the infant’s extremities with
cotton cast padding to help minimize
skin exposure as much as possible.
Evaluates response to thermoregulation measures.
Patient’s core
body temperature
remains in expected range throughout the perioperative experience.
Patient is at
or returning
to normothermia at the
conclusion of
the immediate postoperative period.
Assesses skin integrity, sensory impairments, and gastrointestinal status.
Observes sterile field and perioperative
team members to ensure that asepsis is
maintained.
Validates that preoperative antibiotic was
administered according to facility policy.
Allows sufficient time for surgical prep
solution to dry before the patient is
draped.
Patient’s wound
is dry, nonreddened, and
non-tender.
Patient is
free of
signs and
symptoms of
infection
through the
30 days
after the
perioperative
procedure.
Nursing interventions
•
•
•
•
304 • AORN JOURNAL
Parents and
patient demonstrate appropriate
bonding.
Patient does not
demonstrate
symptoms of infection (eg, wound
induration, foul
odor, purulent
drainage, fever)
Ingoe — Lange
them updates on how the procedure is
progressing.
INTRAOPERATIVE NURSING CARE
The circulating nurse and anesthesia
care provider transport the patient to the
OR. The circulating nurse ensures that all
surgical team members are present and
then initiates the surgical time out.
INTRAOPERATIVE PATIENT WARMING. Infants
and children—particularly those who
are younger than one month old as is
the case for many patients with intestinal malrotation—can lose body heat
very rapidly and will lose even more
body heat when the abdomen is
opened. Infants
• have a large body surface area in comparison to their size,
• have only a thin layer of subcutaneous
fat, and
• are unable to shiver.
All of these factors contribute to the
possibility of rapid hypothermia for infants during surgery.
Before transporting the patient from
the preoperative area, the circulating
nurse ensures that the patient is wearing
a hospital stocking cap to prevent heat
loss from the head. As soon as the patient
is placed on the OR bed, the circulating
nurse and anesthesia care provider institute active warming techniques. The
anesthesia care provider implements
temperature monitoring that he or she
will maintain throughout the surgical
procedure; a nasopharyngeal temperature probe is a reliable method to approximate the infant’s core temperature. The
circulating nurse ensures that the pediatric, underbody, forced-air, temperatureregulating blanket is turned on.8
The circulating nurse remains with
the patient throughout induction of
anesthesia and offers assistance to the
anesthesia care provider as necessary.
The anesthesia care provider inserts peripheral IV lines and uses a solution
warmer according to the manufactur-
FEBRUARY 2007, VOL 85, NO 2
er’s instructions to warm the IV solutions. When the peripheral IV lines have
been inserted, the circulating nurse
wraps the patient’s extremities with cotton cast padding, making sure it is not
too tight. The scrub person uses irrigation fluids warmed by an irrigation
warmer to approximately 98.6º F (37º C).
The irrigation warmer keeps the fluids
warm throughout the procedure and
prevents the fluids from getting too
hot, which can occur if irrigation fluids are taken
directly out of a fluidInfants are
warming unit.
ESSENTIALS OF POSITIONING.
vulnerable to
The circulating nurse,
anesthesia care provider,
hypothermia
and surgeon place the patient in the supine posiduring surgery
tion. The circulating nurse
places rolled-up sheets
lengthwise alongside the because they have
patient according to sura large body
geon preference to keep
the patient from shifting to
surface area in
the side. The surgeon may
place a rolled towel under
comparison to
the patient’s buttocks to
gently lift the pelvis into
their size, have
a modified Trendelenburg
position to displace abonly a thin layer
dominal contents upward.
The circulating nurse or
of subcutaneous
surgeon may place plastic
adhesive drapes around
fat, and are
the abdomen before the
surgical skin prep is perunable to shiver.
formed to keep the patient
warm and dry and to prevent pooling of fluids during the prep and the procedure.
THE SURGICAL SKIN PREP. Patients of this
age have immature immune responses.
Furthermore, they may have poor nutritional status as a result of their condition, so they are less capable of
fighting infection. It is of great importance, therefore, to ensure that all team
AORN JOURNAL •
305
Ingoe — Lange
FEBRUARY 2007, VOL 85, NO 2
Figure 3 • The surgeon excises Ladd’s bands so
that the mesentery can be released, allowing the
intestines to relax unrestrained.
members strictly adhere to aseptic
technique.
The circulating nurse performs a
surgical skin prep of the patient’s entire
abdomen from nipple line to pubis
with a solution of the surgeon’s preference. The nurse ensures that the prep
solution has enough time to dry sufficiently and that no solution pools
under the patient.
THE PROCEDURE
After the surgeon makes a midline laparotomy incision to ensure adequate visualization of the intestines and related
structures, he or she takes the intestines
out of the abdominal cavity and untwists
them if a twist is present. The surgeon
then removes any Ladd’s bands overlying the cecum or duodenum (Figure 3)
with a goal of spreading out the mesentery, separating the small and large intestines as much as possible. Eventually, the
surgeon positions the small bowel primarily to the right of the patient’s midline and positions the large intestine on
the left. Although these bowel positions
are the opposite of where they normally
would lie if the complete turn had oc-
306 • AORN JOURNAL
curred during fetal development, the
bowel will remain in this backwards position for the rest of the patient’s life. The
cecum and appendix, therefore, are positioned on the left, and appendicitis could
very easily be misdiagnosed later in life.
To prevent this kind of misdiagnosis
from occurring, the surgeon also will
perform an appendectomy.4
When a volvulus is present, the surgeon’s first step is to immediately untwist the intestine by rotating the bowel
counterclockwise. After the surgeon has
reduced the volvulus, the intestines
usually are edematous and congested,
and some areas may even appear necrotic.4 The surgeon observes the bowel
closely for several minutes to verify viability of the bowel. If the bowel does not
regain some normality before the end of
the procedure (ie, color change to indicate improved blood flow), the surgeon
will resect the necrotic portions. If the
surgeon has doubts as to the viability of
some areas, the patient will be brought
back to surgery within 24 to 36 hours for
reevaluation.
When the surgery is underway, the
circulating nurse calls the waiting
room to tell the parents that the procedure has started. The circulating nurse
then calls periodically during the procedure to update the parents on the
progress of surgery.
POSTOPERATIVE NURSING CARE
Where the patient is cared for and recovers after surgery depends on the
surgical findings. Patients with uncomplicated malrotation with or without
volvulus are managed on the pediatric
surgical unit. Patients with severe volvulus or those needing extensive bowel resection often are acutely ill with shock or
sepsis after the procedure, and require
monitoring in the pediatric intensive care
unit (PICU). The circulating nurse communicates closely with the anesthesia
care provider and surgeon to plan for the
Ingoe — Lange
postoperative needs of the patient. The
circulating nurse calls the pediatric
surgical unit nurse or PICU nurse during wound closure to communicate
these needs. This gives the receiving
nurse time to prepare the room for the
patient. The circulating nurse’s report
includes
• the type and length of procedure that
was performed,
• the amount and type of narcotics administered during the procedure,
• the antibiotics received before and
during the procedure,
• the total amount of IV fluids administered intraoperatively,
• the blood or blood products administered during surgery,
• whether the patient will be extubated, and
• the patient’s temperature during
the procedure and a current end-ofprocedure temperature.
More information may be provided depending on specific unit policies and patient circumstances. The nurse also ensures that extra support staff members
are available to assist with transporting
the patient.
ENSURING POSTOPERATIVE NORMOTHERMIA. A
child’s body temperature can drop
very quickly, particularly during extubation or transport to the postoperative unit. The nurse ensures that the
patient is kept warm during this time.
If the child will be transported in a
crib, the circulating nurse lines the bed
of the crib with warm blankets immediately before placing the patient in the
crib and keeps the patient securely
wrapped in a warm blanket, papoosestyle, as much as possible. The circulating nurse also places a rolled blanket behind the patient’s back to keep
the patient on his or her side to prevent
aspiration if vomiting occurs.
AVOIDING POSTOPERATIVE HYPOXIA. The circulating nurse ensures that a full oxygen
tank is on the transport vehicle (ie, crib,
FEBRUARY 2007, VOL 85, NO 2
bed) and easily accessible. After moving
the patient from the OR bed to the transport vehicle, the circulating nurse attaches one end of the oxygen tubing to
the tank and holds or tapes the other
end close to the patient’s mouth and
nose so that the oxygen is blowing by
the patient. This is much like using a
nasal cannula for an older patient. This
method of administering supplemental oxygen is continued
until the patient’s oxygen saturation level conSupplemental
sistently remains within
normal limits.
oxygen is
If the anesthesia care
provider does not extuadministered
bate the patient, the circulating nurse ensures
until the
the availability of a selfinflating, bag-valve-mask
patient’s oxygen
resuscitator for transport.
The circulating nurse obsaturation level
tains a portable cardiac
monitor to monitor the
consistently
patient’s condition during transport to the postremains within
operative recovery unit.
PROVIDING POSTOPERATIVE
normal limits.
NUTRITION. Infants who undergo extensive intestinal
resections often are not
able to tolerate enteral nutrition for
quite some time. If that is the situation,
total parenteral nutrition (TPN) will be
started and continued long term. Children on long-term TPN will be monitored for chronic liver damage, a risk of
long-term TPN.2
PROGNOSIS
If intestinal malrotation with volvulus is recognized and treated quickly,
the patient should recover well and
not have any long-lasting effects, providing there is enough bowel left
to sustain life. Children who have undergone this procedure most often
progress through life with little or no
AORN JOURNAL •
307
Ingoe — Lange
FEBRUARY 2007, VOL 85, NO 2
additional consequences. Very rarely,
volvulus can recur after surgical correction. Small bowel transplantation
sometimes is indicated in children
who have lost a significant amount of
intestine.
Individuals with intestinal malrotation but without associated volvulus
may remain asymptomatic, and the
condition may go undetected throughout life. Although some surgeons believe it should not be treated when discovered after infancy if the patient is
asymptomatic, other surgeons believe
it always should be treated surgically
even if asymptomatic because of the
lifetime risk of volvulus.5 Some surgeons now are performing the Ladd’s
procedure laparoscopically if there is
no evidence of volvulus. This approach
is especially useful if a diagnosis of intestinal malrotation is in question.
Identifying structures appropriately
and obtaining adequate separation of
the mesentery, however, can be technically difficult during a laparoscopic approach. In this case, the surgeon may
need to abandon the laparoscopic approach midprocedure and convert to
an open procedure. This is especially
true for younger, smaller patients. ❖
Renee Ingoe, RN, CNOR, is a perioperative staff nurse at Wake Med Health
and Hospitals, Raleigh, NC.
Patricia Lange, MD, is an assistant professor of pediatric surgery at the University of North Carolina at Chapel Hill,
Chapel Hill, NC.
REFERENCES
1. Parish A, Hatley R. Intestinal malrotation.
Available at: http://www.emedicine.com/ped
/topic1200.htm. Accessed December 7, 2006.
2. Kamal, IM. Defusing the intra-abdominal
ticking bomb: intestinal malrotation in children. CMAJ [online serial]. 2000;162. Available at: http://www.cmaj.ca/cgi/content
/full/162/9/1315. Accessed December
7, 2006.
3. Cincinnati Children’s Hospital Medical
Center. Intestinal malrotation. February
2004. Available at: http://www.cincinnati
childrens.org/health/info/abdomen/diag
nose/intestinal-malrotation.htm. Accessed
December 19, 2006.
4. Ford EG, Senac MO Jr, Srikanth MS, Weitzman, JJ. Malrotation of the intestine in children. Annuals of Surgery. 1992;215:172-178.
5. The American Pediatric Surgical Association. Malrotation and volvulus. Available
at: http://www.eapsa.org/parents/rota
tional.htm. Accessed December 7, 2006.
6. KidsHealth. Intestinal malrotation. Available at: http://kidshealth.org/parent/med
ical/digestive/malrotation.html. Accessed
December 7, 2006.
7. MedPix. Incidental malrotation and acute
appendicitis. Available at: http://rad.usuhs
.mil/medpix/medpix.html?mode=+search2.
Accessed December 7, 2006.
8. Bair Hugger® temperature management:
model 555—pediatric underbody blanket.
Arizant Healthcare. Available at: http://
www.bairhugger.com/arizanthealthcare
/faw_b_pediatric_555.shtml. Accessed January 3, 2006.
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