This handout is for intestinal malrotation with midgut volvulus. Your care team identified this based on: bilious vomiting (green / yellow-green) in an infant (especially < 1 month of life) — cardinal alarm signal; malrotation with midgut volvulus until proven otherwise (apsa + aap); emergent surgical consult + stat upper gi series (or directly to or if unstable).
Other reasons your team may use this plan: neonate (< 24 h of life) with bilious emesis — life-threatening; differential includes malrotation-volvulus + duodenal atresia + intestinal atresia; emergent ugi + stat surgery; older child with recurrent / intermittent crampy abdominal pain + chronic vomiting / failure to thrive — atypical malrotation; auto-detorsing intermittent volvulus; whirlpool sign on bedside us (clockwise rotation of smv around sma) — sensitivity 80-90 % in skilled hands; specificity > 95 %; first-line bedside screen.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| normal saline / lactated Ringer's | 20 mL/kg IV bolus over 30-60 min, repeat × 1-2 PRN; max ~ 60 mL/kg total before reassessing for fluid overload | IV | bolus PRN with reassessment | AAP pediatric resuscitation principles; SSC peds 2020 if Phoenix-2024 sepsis; resuscitation in parallel with imaging / OR mobilization — do NOT delay OR for fluid completion in the unstable bilious-emesis infant |
| D5 0.45% NaCl maintenance with electrolytes | Maintenance rate with deficit replacement after first void documented | IV | continuous | Pre-op + post-op maintenance fluid posture |
| cefazolin | 25-30 mg/kg IV single dose at induction | IV | pre-op single dose | Pre-op single-dose antimicrobial prophylaxis for clean elective laparoscopic Ladd; no prolonged course (Cantey SCOUT Lancet Infect Dis 2016 PMID 27452782 stewardship principles) |
| piperacillin-tazobactam | 80-100 mg/kg IV q6-8h (piperacillin component) × 5-7 d for source-controlled bowel ischemia / perforation; 7-14 d if uncontrolled source | IV | q6-8h | Broad Gram-positive + Gram-negative + anaerobe single-agent backbone for intra-abdominal contamination per Solomkin IDSA intra-abdominal 2010 peds-adapted PMID 20583865 |
| metronidazole | 10 mg/kg IV q8h (max 500 mg/dose); add to cefotaxime if < 28 d (avoid ceftriaxone; AAP Puopolo 2018) | IV | q8h | Anaerobic cover adjunct; combination alternative to single-agent pip-tazo (Solomkin IDSA 2010 peds-adapted) |
| cefotaxime | 50 mg/kg IV q8h (q12h if < 7 d of life and < 2 kg); preferred over ceftriaxone if < 28 d due to bilirubin-displacement risk (AAP Puopolo 2018) | IV | q8h | Third-gen cephalosporin for neonatal-band intra-abdominal source; avoid ceftriaxone in < 28 d due to bilirubin displacement (AAP Puopolo 2018 PMID 30455342) |
| meropenem | 20 mg/kg IV q8h × 7-14 d for severe / refractory / hospital-acquired or prior resistance | IV | q8h | Carbapenem-grade broad-spectrum for severe or hospital-acquired or refractory intra-abdominal sepsis (Solomkin IDSA 2010 peds-adapted) |
| vancomycin | 15 mg/kg IV q6-8h; AUC target 400-600 mg·h/L (NOT trough alone) per Rybak IDSA 2020 PMID 32191793 | IV | q6-8h | MRSA / Gram-positive line-source cover; AUC monitoring per Rybak IDSA 2020 |
| epinephrine | 0.05-0.3 mcg/kg/min IV (central access); titrate to age-appropriate MAP | IV | continuous | SSC peds 2020 — first-line for cold shock (pediatric phenotype) |
| norepinephrine | 0.05-0.5 mcg/kg/min IV (central access); titrate to age-appropriate MAP | IV | continuous | SSC peds 2020 — first-line for warm shock (pediatric phenotype) |
| acetaminophen | 10-15 mg/kg PO/PR/IV q4-6h PRN (max 60 mg/kg/day in infants; lower than older pediatric ceiling) | PO/PR/IV | q4-6h PRN | First-line post-op analgesic in infants; avoid opioids when possible |
| morphine | 0.025-0.05 mg/kg IV PRN (HALVED infant doses vs older pediatric); 0.05-0.1 mg/kg IV PRN in older children; monitor respiratory depression with capnography | IV | PRN with monitoring | For severe post-op pain; infant respiratory depression risk is elevated; HALVED doses + capnography monitoring |
| ondansetron | 0.1-0.15 mg/kg IV (max 4 mg single dose); cautious in infants | IV | PRN | Post-op anti-emetic; FDA pediatric label considerations; minimal QT risk at single doses |
Plan: Pediatric malrotation-volvulus pre-op resuscitation + perioperative antibiotics + RSI + analgesia + vasoactives (APSA + AAP + pediatric anesthesia society + Solomkin IDSA intra-abdominal 2010 peds-adapted + SSC peds 2020 + Cantey SCOUT 2016 stewardship)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Post-op pediatric surgical follow-up at 2-4 weeks for wound check + scar inspection + weight-gain review; pediatrician follow-up within 1-2 weeks for routine well-baby / well-child care including weight-gain trajectory + feeding tolerance; pediatric GI consult at 4-6 weeks for short bowel syndrome management if applicable (TPN tolerance, enteral advance, line-source surveillance, glucagon-like peptide-2 analog teduglutide consideration in select); intestinal transplant program referral for irreversible TPN dependence + life-threatening complications (APSA + pediatric GI / transplant consensus); recurrence surveillance for the ~ 2-5 % post-Ladd recurrence rate (return precautions taught + low threshold for repeat UGI on recurrent symptoms). Heterotaxy / CDH / omphalocele / gastroschisis patients — ongoing multidisciplinary follow-up for index syndrome.
Guideline: APSA (American Pediatric Surgical Association) pediatric surgical-emergency guidance for malrotation + midgut volvulus + AAP infant-vomiting guidance + ACR Appropriateness Criteria — Vomiting in Infants Up to 3 Months of Age + SPR / ACR consensus on UGI series technique (ligament of Treitz position + duodenal C-loop + corkscrew + beak deformity findings; sensitivity ~ 96 %, specificity ~ 98 %) + APSA heterotaxy / CDH / omphalocele / gastroschisis consensus (high malrotation prevalence; prophylactic Ladd controversial) + APSA short bowel syndrome consensus + pediatric GI / transplant programs (long-term TPN + intestinal rehabilitation; teduglutide for adaptive failure; intestinal transplant for irreversible TPN dependence) + Pediatric anesthesia society consensus (RSI for full stomach + aspiration risk; NG decompression pre-op; avoid nitrous oxide in suspected obstruction) + Solomkin IDSA Complicated Intra-Abdominal Infection 2010 PMID 20583865 (peds-adapted for confirmed bowel ischemia + perforation / peritonitis) + SSC peds 2020 (for shock physiology if bowel necrosis precipitates sepsis)