(16) Apply tight diaper for 1 hour.

(17) For 24 hours after circumcision, check (or

instruct parents to check) for bleeding, excessive swelling, and difficulty voiding.

(18) Until circumcised area is completely healed,

do not immerse in water; give sponge bath.

b. Use of Plastibell

(1) Follow steps 3 to 5 of E11a.

(2) Select bell of correct size (see C).

(3) Cone should fit snugly without pressure on

glans.

(4) Grooved rim of bell should be just distal to apex

of dorsal slit.

Chapter 47 ■ Circumcision 349

Fig. 47.3. Circumcision. A: Marking the position

of the coronal sulcus. B: Dilating the preputial ring.

C: Separating the prepuce from the glans penis.

D: Grasping the prepuce with mosquito hemostats in

preparation for the dorsal slit procedure. E: Dorsal slit.

A

B

D

E

C

350 Section IX ■ Miscellaneous Procedures

(5) If necessary, cut small segment out of cone so

that it clears frenulum.

(6) Hold prepuce firmly in place over cone (Fig.

47.5A).

(7) Tie suture tightly around rim of bell so that prepuce is firmly compressed into groove.

(8) Trim prepuce distal to ligature with tissue scissors. Use outer rim of cone as guide.

(9) Break off cone handle. Tissue beneath ligature

will atrophy and separate from bell in 5 to 8 days

(maximum 10 to 12 days) (Fig. 47.5B).

c. Observe and care for circumcision as in steps 17 and

18 of Gomco clamp (E11a).

F. Management of Postoperative

Bleeding

Postoperative bleeding usually stems from inadequate

hemostasis (e.g., unrecognized neonatal hepatitis (14) or

hereditary clotting disorders). Rarely, anomalous vessels are

responsible.

Continuous Ooze

1. Apply manual pressure for 5 to 10 minutes.

Check that the string on the Plastibell is in place

and is sufficiently tight.

2. Assess bleeding site. If continued oozing

A B

C

Fig. 47.4. Circumcision with a Gomco clamp. A: Placing the stud over the glans. B: Placing the baseplate of the clamp over the stud until the stud engages with the baseplate (inset). C: Gomco clamp in

position for circumcision.

 

to 25 degrees from midline.

f. Pierce skin over one of dorsal nerves at penile root,

and advance carefully posteromedially (0.25 to

0.5 cm) (Fig. 47.2) into subcutaneous tissue to avoid

lodging in the erectile tissue. After entering skin,

needle should not meet resistance and tip should

Fig. 47.1. Plastibell with linen suture.

Fig. 47.2. Penis is stabilized at angle of 20 to 25 degrees from

midline. The formation of a lidocaine ring is shown (see text).

348 Section IX ■ Miscellaneous Procedures

remain freely movable. If the tip of the needle is not

freely mobile, it is probably embedded in the corpora cavernosum beneath the dorsal nerve and

should be withdrawn slightly.

g. Aspirate to rule out intravascular position.

h. Slowly infiltrate area with 0.2 to 0.4 mL of lidocaine

(never infiltrate as needle is advanced or withdrawn).

i. Repeat procedure at other dorsolateral position.

After infiltration, a small lidocaine ring forms

(Fig. 47.2). The swelling is minimal and does not

interfere with the circumcision procedure.

j. Wait 3 to 5 minutes for analgesia.

Analgesia is usually obtained after 3 minutes and

typically disappears within 20 to 30 minutes. However,

there is individual variation, and testing of the prepuce with a hemostat is suggested prior to dissection.

7. Locate coronal sulcus (Fig. 47.3A). Marking the position of the sulcus with ink on the skin of the penile

shaft, prior to the procedure, is helpful in demarcating

this vital landmark.

8. Use mosquito hemostat to dilate preputial ring (Fig.

47.3B).

9. Use blunt probe to separate inner epithelium of prepuce from glans penis (Fig. 47.3C).

Failure to do this completely may result in a concealed penis (see G3c and G14).

10. Perform dorsal slit if desired.

This step is not mandatory as long as there is adequate separation of the glans from the prepuce.

a. Grasp rim of prepuce on dorsal aspect with mosquito hemostats, approximately 2 to 4 mm apart

(Fig. 47.3D).

b. Visualize urethra.

c. Place lower blade of large, straight hemostat

between prepuce and glans to within 3 to 4 mm of

corona, making sure to avoid urethra.

d. Close hemostat for 5 to 10 seconds to crush foreskin

in dorsal midline.

e. Use tissue scissors to cut prepuce along crush line

(Fig. 47.3E).

 

cm for average newborn glans (size range 1 to 3.5 cm)

Be sure to use a size that is large enough to protect

the glans (10).

b. No. 11 scalpel blade and holder

c. A small safety pin

5. Additional Equipment for Use with Plastibell

All equipment is sterile.

a. Plastibell plastic cone (Hollister, Libertyville, Illinois);

available in presterilized packs; size range based on size

of glans penis: 1.1, 1.3, and 1.5 cm. A linen suture is

included in the pack (Fig. 47.1). When selecting size,

make sure that it is not so large that it allows proximal

migration of the bell and excessive loss of penile skin,

nor so small that it could impair penile circulation.

b. Scissors capable of cutting through plastic

Chapter 47 ■ Circumcision 347

D. Precautions

1. Obtain fully informed consent (see Chapter 2).

a. Explain expected course of circumcision to parents.

When Plastibell is used, parents should be told to

call their physician if ring has not fallen off within

10 days.

b. Be aware of laws pertaining to ritual circumcision

(e.g., Jewish brit milah) and the complications of

the practice of orally suctioning the blood after cutting the foreskin (oral metzitzah) (11).

2. Never circumcise at time of delivery. Circumcise long

enough before discharge to allow adequate wound

observation.

3. Do not use local anesthetic containing epinephrine.

4. Specifically locate coronal sulcus and urethral meatus.

5. Make sure that inner epithelium is completely separated from glans penis and that prepuce can be retracted

to visualize entire circumference of coronal sulcus.

6. Never use electrocautery.

7. Do not use circumferential dressing.

8. Recheck wound prior to discharging patient and 1 to 2

weeks after circumcision. Residual skin should retract

completely, and the entire coronal sulcus must be visible to avoid postcircumcision adhesions, the most common complication.

E. Technique

A complete description of formal surgical excision has been

excluded from this edition because of the requirement to

use sutures and the associated increased risk of bleeding

compared with methods that involve crushing of tissue.

Ritual circumcisions are most commonly performed

using a Mogen clamp. The method involves no dorsal incision or sutures (5); however, because the glans is not visible

at the time of excision of the prepuce, there is potential for

damage to the glans and urethra.

1. Immobilize infant in supine position.

2. Put on cap and mask.

3. Scrub as for major procedure.

4. Put on gown and gloves.

5. Prepare skin with antiseptic, and drape.

6. Perform penile dorsal nerve block if desired.

a. Be familiar with anatomy of dorsal nerves of penis

(Fig. 47.2) (9). Although only the two dorsal penile

nerves are targeted by the injection of lidocaine, the

ventral penile nerve is also blocked by infiltration

through the subcutaneous tissue. Some have advocated additional anesthesia ventrally, blocking the

perineal nerves (a branch of the pudendal nerve)

b. Identify dorsal nerve roots at 10- and 2-o’clock positions.

c. Identify by palpation the symphysis pubis and corpora cavernosa at the penile base.

d. Estimate depth of pubic bone from penile base to

indicate necessary depth of injection (should not

exceed 0.5 cm).

Although the ideal area for infiltration corresponds to the 2- and 10-o’clock positions, 1 cm distal

to the penile base, if the base is buried in pubic fat,

the injection must be done at the junction of pubic

and pelvic skin.

e. Stabilize organ, with gentle traction, at angle of 20

 

344

Nickie Niforatos

Khodayar Rais-Bahrami

Removal of Extra Digits

and Skin Tags

46

A. Indications

Removal of Nonfunctional Extra Digit

1. Prevention of accidental avulsion or torsion around

narrow base

2. Cosmetic correction at parental request

3. Consider surgical excision as an alternative to prevent

the development of amputation neuromas (1,2)

B. Contraindications

1. Concomitant illness in infant

This is an elective procedure that is painful when

the clamp is applied. To prevent accidental avulsion of

appendage if extra digit on a narrow base were to

become entangled, apply a soft dressing or adhesive

bandage until infant is stable enough for removal.

2. Bleeding diathesis

3. Additional anomalies where further surgical correction

may be necessary (3)

4. Base of extra digit >2 mm wide

5. Bone crossing the isthmus between extra digit and hand

C. Equipment

All Sterile

1. Antiseptic solution and swabs appropriate for major

procedure

2. Straight mosquito hemostat

3. Surgical silk suture, 3-0 or 4-0

4. Fine or delicate scissors

5. Adhesive bandage

6. Local anesthetic cream

D. Precautions

1. Perform procedure only on stable, healthy infant

2. Consider surgical evaluation for any questionable digit.

a. When base is >2 mm wide

b. When extra digit is on radial side of hand or is a

duplicated thumb

c. When clamping will not crush base to a thin, translucent, layer indicative of hemostasis after excision

d. When there appears to be a joint at the base

e. When bony structures are present in the digit as

confirmed by radiography (4)

3. Consider surgical evaluation for any questionable skin tag.

a. When tag may be used for ear or nasal deformity

reconstruction (5)

b. When tag is large or in critical areas

4. Apply hemostat to base of extra digit prior to placing

ligature.

a. Allows closer amputation without residual bump

b. Allows faster autoamputation or removal of most of

digit within a few hours

E. Technique

Removal of Nonfunctional Digit (Fig. 46.1)

1. Apply local anesthetic cream to appendage and base.

2. Cleanse digit and the surrounding skin with antiseptic.

Allow to dry.

 

3. Clamp hemostat as close to the base of extra digit as

possible but without drawing up extra skin (Fig. 46.2A).

4. Tightly tie suture around digit between hemostat and

hand.

5. Keep clamp in place until digit has turned white (at

least 5 minutes).

6. Using as a cutting guide the edge of the hemostat farther from the hand, excise the digit (Fig. 46.2B).

7. Remove hemostat and observe for hemostasis, leaving

ligature in place. If there is any bleeding, reapply hemostat and ligature.

8. Cover with an adhesive bandage until residual stump

autoamputates.

Removal of Skin Tags (Fig. 46.3)

The removal of small skin tags follows essentially the same

technique as for extra digits: Clamp close to base of lesion

to achieve hemostasis, and apply ligature between hemostat and normal area. If the lesions are large or in critical

areas, removal is best delayed beyond the neonatal period.

Consider other diagnoses associated with skin tags (6).

Chapter 46 ■ Removal of Extra Digits and Skin Tags 345

F. Complications

1. Hemorrhage

a. Failure to achieve complete hemostasis prior to

excision

b. Loosening of ligature before blood supply is

retracted

2. Infection

3. Inappropriate removal of digit or tag in presence of

related anomalies

4. Incomplete ligation leading to traumatic neuroma (1,2)

References

1. Leber GE. Surgical excision of pedunculated supernumerary digits prevents traumatic amputation neuromas. Pediatr Dermatol.

2003;20:108.

2. Mullick S, Borschel GH. A selective approach to treatment of

ulnar polydactyly: preventing painful neuroma and incomplete

excision. Pediatr Dermatol. 2010;27(1):39.

3. Horii E, Hattori T, Koh S et al. Reconstruction for Wassel type III

radial polydactyly with two digits equal in size. J Hand Surg Am.

2009;34(10):1802.

4. Gomella TL, Cunningham MD, Eyal FG, et al. Newborn physical

exam. In: Gomella TL, ed. Neonatology: Management, Procedures,

On-Call Problems, Diseases, and Drugs. 4th ed. Stanford, CT:

Appleton & Lange; 2004:35.

5. Jones KL. Preauricular tags or pits: frequent in. In: Jones KL, eds.

Smith’s Recognizable Patterns of Human Malformations. 6th ed.

Philadelphia: Elsevier Saunders; 2006;899.

6. Eley KA, Pleat JM, Wall SA. Reconstruction of a congenital nasal

deformity using skin tags as a chondrocutaneous composite graft.

 

Chapter 45 ■ Brain and Whole Body Cooling 343

23. Chakkarapani E, Thoresen M. Use of hypothermia in the asphyxiated infant. Perinatology. 2010;1:20.

24. Hallberg B, Olson L, Bartocci M, et al. Passive induction of hypothermia during transport of asphyxiated infants: A risk of excessive

cooling. Acta Paediatr. 2009;98:942.

25. Kendall GS, Kapetanakis A, Ratnavel N, et al. Passive cooling for

initiation of therapeutic hypothermia in neonatal encephalopathy. Arch Dis Child. 2010;95:F408.

26. Thoresen M, Whitelaw A. Cardiovascular changes during mild

therapeutic hypothermia and re-warming in infants with hypoxicischemic encephalopathy. Pediatrics. 2000;106:92.

27. Horn A, Thompson C, Woods D, et al. Induced hypothermia for

infants with hypoxic- ischemic encephalopathy using a servocontrolled fan: An exploratory pilot study. Pediatrics. 2009;

123:e1090.

28. Thoresen M. Supportive care during neuroprotective hypothermia in the term newborn: Adverse effects and their prevention.

Clin Perinatol. 2008;35:749.

29. Hoque N, Chakkarapani E, Liu X, et al. A comparison of cooling

methods used in therapeutic hypothermia for perinatal asphyxia.

Pediatrics. 2010;126:e124.

30. Liu X, Chakkarapani E, Hoque N, et al. Environmental cooling of

the newborn pig brain during whole-body cooling. Acta Paediatr.

2010;100:29.

31. Battin M, Bennet L, Gunn AJ. Rebound seizures during rewarming. Pediatrics.2004;114:1369.

32. Van der Linden J, Ekroth R, Lincoln C, et al. Is cerebral blood

flow/metabolic mismatch during rewarming a risk factor after

profound hypothermic procedures in small children? Eur

J Cardiothorac Surg. 1989;3:209.

33. Roka A, Melinda KT, Vasarhelyi B, et al. Elevated morphine concentrations in neonates treated with morphine and prolonged

hypothermia for hypoxic ischemic encephalopathy. Pediatrics.

2008;121:e844.

34. Jacobs S, Hunt R, Tarnow-Mordi W, et al. Cooling for newborns

with hypoxic ischaemic encephalopathy. Cochrane Database Syst

Rev. 2007:CD003311.

35. Strohm B, Hobson A, Brocklehurst P, et al. Subcutaneous fat

necrosis after moderate therapeutic hypothermia in neonates.

Pediatrics. 2011;128:e450.

36. Gunn AJ, Wyatt JS, Whitelaw A, et al. Therapeutic hypothermia

changes the prognostic value of clinical evaluation of neonatal

encephalopathy. J Pediatr. 2008;152:55.

37. Rutherford M, Ramenghi LA, Edwards AD, et al. Assessment of

brain tissue injury after moderate hypothermia in neonates with

hypoxic-ischemic encephalopathy: a nested substudy of a randomised controlled trial. Lancet Neurol. 2010;9:39.

38. Thoresen M. Patient selection and prognostication with

hypothermia treatment. Semin Fetal Neonatal Med. 2010;15:247.

39. Elstad M, Whitelaw A, Thoresen M. Cerebral Resistance Index is

less predictive in hypothermia encephalopathic newborns. Acta

Paediatr. 2011;100:1344.

 

6. Edwards AD, Brocklehurst P, Gunn AJ, et al. Neurological outcomes at 18 months of age after moderate hypothermia for perinatal hypoxic ischaemic encephalopathy: synthesis and metaanalysis of trial data. BMJ. 2010;340:c363.

7. Chakkarapani E, Harding D, Stoddart P, et al Therapeutic hypothermia: surgical infant with neonatal encephalopathy. Acta Paediatr.

2009;98:1844.

8. Thoresen M. Hypothermia after perinatal asphyxia: selection for

treatment and cooling protocol. J Pediatr. 2011;158:e45.

9. Liu X, Chakkarapani E, Hoque N, et al. Environmental cooling

of the newborn pig brain during whole-body cooling. Acta

Paediatr. 2011;100:29.

10. O’Reilly KM, Tooley J, Winterbottom S. Therapeutic hypothermia during neonatal transport. Acta Paediatr. 2011;100:1084.

11. Pappas A, Shankaran S, Laptook AR, et al. Hypocarbia and

adverse outcome in neonatal hypoxic-ischemic encephalopathy.

J Pediatr. 2011;158:752.

12. Chakkarapani E, Thoresen M, Liu X, et al. Xenon offers stable

haemodynamics independent of induced hypothermia after

hypoxia-ischaemia in newborn pigs. Intensive Care Med. 2011;

38:316.

13. Thoresen M, Hellstrom-Westas L, Liu X, et al. Effect of hypothermia on amplitude-integrated electroencephalogram in infants

with asphyxia. Pediatrics. 2010;126:e131.

14. Glass HC, Glidden D, Jeremy RJ, et al. Clinical neonatal seizures

are independently associated with outcome in infants at risk for

hypoxic-ischemic brain injury. J Pediatr. 2009;155:318.

15. Nadeem M, Murray DM, Boylan GB, et al. Early blood glucose

profile and neurodevelopmental outcome at two years in neonatal hypoxic-ischaemic encephalopathy. BMC Pediatr. 2011;

11:10.

16. Bhat MA, Charoo BA, Bhat JI, et al. Magnesium sulfate in severe

perinatal asphyxia: A randomized, placebo-controlled trial.

Pediatrics. 2009;123:e764.

17. Thoresen M, Satas S, Loberg EM, et al. Twenty-four hours of

mild hypothermia in unsedated newborn pigs starting after a

severe global hypoxic-ischemic insult is not neuroprotective.

Pediatr Res. 2001;50:405.

18. Thoresen M, Simmonds M, Satas S, et al. Effective selective head

cooling during posthypoxic hypothermia in newborn piglets.

Pediatr Res. 2001;49:594.

19. Van Leeuwen GM, Hand JW, Lagendijk JJ, et al. Numerical

modeling of temperature distributions within the neonatal head.

Pediatr Res. 2000;48:351.

20. Gunn AJ, Gluckman P, Wyatt JS, et al. Selective head cooling after

neonatal encephalopathy - author’s reply. Lancet. 2005;365:1619.

21. Wyatt JS, Gluckman PD, Liu PY, et al. Determinants of outcomes

after head cooling for neonatal encephalopathy. Pediatrics. 2007;

119:912.

22. Burnard ED, Cross KW. Rectal temperature in the newborn after

birth asphyxia. BM J. 1958;2:1197.

 

(5) After 1 minute, press Temp Set (Fig. 45.18D).

(6) Press the ∆/∇ (Fig. 45.18) button to set the

temperature to 33.5°C.

The status display (Fig. 45.19C) will read 33.5°C.

(7) Press Gradient Variable (Fig. 45.19H).

(8) Press ∆/∇ (Fig. 45.16) to 20°C.

(9) Press the Gradient Variable (Fig. 45.19H) again.

(10) Listen for the activation of the pump.

(11) Check that the water flow indicator (Fig.

45.18F) is rotating.

(12) Place the dry sheet or disposable cover over the

infant, to decrease convection losses and fluctuations in water temperature in blanket (Fig.

45.20).

(13) Monitor temperature displays. The Patient display (Fig. 45.19E) will show the infant’s actual

temperature.

The Water display (Fig. 45.19A) will show

the actual temperature of the circulating

water.

The Status display (Fig. 45.19C) will show

the mode of operation and set temperature.

Monitor core temperature every 15 minutes

to determine when the target temperature is

reached.

Maintain HT (Gradient Variable Mode)

1. Press Temp Set (Fig. 45.19D).

2. Press the ∆/∇ (Fig. 45.19) button to maintain core

temperature at 33.5°C.

3. Press Gradient Variable (Fig. 45.19H).

4. Press the ∆/∇ (Fig. 45.19) button to 5°C to minimize

the temperature fluctuations between the patient and

the water in the cooling blanket.

5. Press the Gradient Variable (Fig. 45.19H) again.

6. Listen for the activation of the pump.

7. Check that the water flow indicator (Fig. 45.18F) is

rotating.

Initiate Manual Rewarming after 72 hours of HT

1. Press Temp Set (Fig. 45.19D).

2. Press ∆ button to 0.5°C.

3. Increase 0.5°C every hour until the core temperature is

36.5°C.

4. Press Gradient Variable (Fig. 45.19H).

5. Press ∆ to 5°C to minimize the temperature fluctuations

between the patient and the water in the cooling blanket.

6. Press Gradient Variable (Fig. 45.19H).

Fig. 45.20. Blanketrol III setup for cooling.

 

Chapter 45 ■ Brain and Whole Body Cooling 341

7. Listen for the activation of the pump.

8. Check that the water flow indicator (Fig. 45.18F) is

rotating.

Initiate Post-Rewarming Care

When the rectal temperature has been 36.5°C for 60 minutes, the Blanketrol can be set to Monitor Only and the

infant can be kept normothermic (36.5 ± 0.2 °C) with a

servocontrolled overhead radiant warmer and overhead

reflective shield (Fig. 45.21).

1. Press Monitor Only (Fig. 45.19J).

2. Keep core temperature probe in place for 24 hours after

completion of cooling.

3. For radiant warmer, use servo control.

Place the skin probe over the liver, right upper quadrant, below ribs.

Set servo to achieve axillary temperature of 36.5 ±

0.2°C.

4. Cover the face and head with a reflective shield to prevent elevation of the superficial brain temperature (Fig.

45.21)

 Alternatively, the infant can be warmed in a

Babytherm infant warmer (Dräger Medical Inc.,

Telford, Pennsylvania) or any “hot cot,” which has the

option of increasing the temperature of the mattress,

by setting the temperature of the cot at the same temperature that the water in the Blanketrol was set at to

maintain the infant normothermic.

a. Place a six-layered bubble wrap “pillow” between

the infant’s head and the hot cot, to prevent elevation of the superficial brain temperature (Fig.

45.14B, D).

b. Discontinue hourly core temperature monitoring

after 24 hours, and resume routine 4 hourly temperature monitoring.

Precautions

1. Do not use deionized water. The majority of deionizers

do not maintain a neutral pH of 7.

This results in acidification of water, which can deteriorate the battery and the copper refrigeration line, ultimately leading to a leak in the refrigeration system.

 

340 Section IX ■ Miscellaneous Procedures

on the cooling unit (Fig. 45.18G) and the male

coupling to the female return coupling (Fig.

45.18H) by pushing back the collar of the

female coupling while connecting to the male

coupling, followed by releasing the collar.

(8) Gently pull the connecting hose to ensure a

positive connection, that there are no twists in

the connecting hose, and that the blanket is

flat.

(9) Initiate precooling: Precooling may not be necessary if the infant’s temperature has already

been lowered (e.g., by passive hypothermia during transport).

(a) Switch on the cooling machine (Fig. 45.18B).

(b) Press Temp Set (Fig. 45.19D).

(c) Use the up (∆) or down (∇) arrows by the

side of Set Temp (Fig. 45.19) and set the

temperature to 33.5°C.

(d) Press Manual Control (Fig. 45.19B).

(e) Listen for the compressor to activate.

(f) Check the water flow indicator (Fig. 45.18,

F) to confirm that water is circulating.

(g) Place the infant on the blanket (Fig. 45.20).

(h) Place patient temperature monitoring probes.

Rectal Temperature Sensor

(1) Mark a 400 series probe at 6 cm from the tip

with tape/indelible pen (Fig. 45.2).

(2) Insert rectal probe 6 cm into the rectum, and

secure to leg using DuoDERM/Tegaderm and

tape, as described in E (Fig. 45.2).

Esophageal Temperature

(1) Measure a 400 series probe from nose/midline

of the mouth to ear and then to an imaginary

line between the nipples.

(2) Mark this position on the probe with tape/

indelible pen.

(3) Insert the probe via mouth or nose up to the mark.

(4) Secure the probe to the upper lip.

(a) Connect the rectal or esophageal probe to

black cable jack.

(b) Connect black cable to probe outlet in

Blanketrol (Fig, 45.18I).

(c) Initiate induction of HT (Gradient Variable

mode)

 

Chapter 45 ■ Brain and Whole Body Cooling 339

Fig. 45.18. Blanketrol III. A, control panel; B, power switch

(I–on; O–off); C, storage drawer; D, grill; E, protective bumper;

F, water flow indicator; G, male outlet coupling; H, female return

coupling; I, patient probe jack; J, water fill tank.

Fig. 45.19. Blanketrol III membrane

control panel (115-volt unit). A, water temperature; B, manual control of circulating

water temperature; C, LCD status display;

D, temperature set button; E, patient temperature; F, auto control mode; G, gradient 10c mode; H, gradient variable mode;

I, smart function; J, monitor patient temperature; K, test indicator (confirm all the

indicators are working) and silence alarm;

L, power failure (LED on the side flashes

with audible alarm when power has been

interrupted); M, low water symbol; N,

Celsius or Fahrenheit.

e. Gradient Variable (Fig. 45.19H): Same as Gradient

10C mode, except that the gradient can be determined by user. Smart mode can be added to

Gradient.

f. Variable: The gradient increases by 5°C beyond the

specified gradient until the set temperature is

reached. When the infant’s temperature deviates

from set point after having reached the target

temperature, the gradient returns to the specified

gradient.

g. Monitor Only (Fig. 45.19J): Displays the patient

temperature without heating or cooling or circulating the water.

The cooling system is activated by pressing Temp

Set and setting the target temperature, followed by

pressing the mode selector. To change to Monitor

Only, press the appropriately labeled button

(Fig. 45.19J).

WBC with Gradient Variable Mode is

Described Below

Technique

(1) Place the Blanketrol III unit in the patient area,

accessible to the correct power source.

(2) Check the level of the distilled water in the reservoir. Lift the cover of the water fill opening

and check that the water is visibly touching the

strainer (Fig. 45.18J).

(3) Check that the power switch is in the off position (Fig. 45.18B).

(4) Insert the plug into a properly grounded receptacle.

(5) Lay the hyper-hypothermia blanket flat (Fig.

45.20) with the hose routed, without kinks,

toward the unit.

(6) Cover the blanket with a dry sheet or disposable

cover (Fig. 45.20), if single patient use blanket

such as MAXI-THERM (Cincinnati Sub-Zero

Products, Inc., Cincinnati, Ohio) is used.

(7) Connect the blanket to the Blanketrol III unit:

Attach the quick-disconnect female coupling of

the connecting hose to the male outlet coupling