What is the sex?
IV antibiotics for a minimum of 72 hours
Reassessment
≥ Post-Op day #3
Meet discharge criteria?
Daily reassessment
Continue IV antibiotics daily reassessment until failure after post-op day #7
Abnormal serum WBC?
BMI > 85th percentile?
High risk for appendicitis pediatric patients still may benefit from imaging
Clinical assessment of the likelihood of appendicitis (PAS/AS or labs not required). Clinical prediction scores for appendicitis are equivalent to an experienced (surgical or ED) physician's clinical impression.
- CBCD, CMP
- Consider ultrasound or CT
- If NPO, consider TPN/PPN
Recent antibiotics?
Treat appropriately
Surgery consultation
Treat appropriately
Contact a surgical specialist. If excluded for pregnancy, consider MRI appy.
Severe pain?
What is the sex?
Severe penicillin or cephalosporin allergy?
Septic or immunocompromised?
Urinalysis, urine pregnancy and gonorrhea/chlamydia testing and pelvic exam in appropriate menstrual age females
For patients > 9 months
Continued clinical concern for appendicitis?
Meets discharge criteria?
Perforation, gangrene, abscess or supperative/purulent findings?
Discharge
Meets discharge criteria?
Discharge, follow up with PMD within 24 hours
- < 4 years old?
- CT abdomen/pelvis with IV contrast
- 4 years to 17 years old?
- MRI appendix (CT if MRI unavailable or patient unable to tolerate MRI)
Patients with perforated appendicitis or abscesses DO NOT need different antibiotics from uncomplicated appendicitis.
Pediatric Appendicitis Score (PAS) | Alvarado Score (AS) | ||||
Nausea/Vomiting | 1 | 1 | |||
Anorexia | 1 | 1 | |||
Fever | 1 | Temperature ≥ 37.3 C (99.1 F) | 1 | ||
RLQ tenderness | 2 | 2 | |||
Migration of pain to RLQ | 1 | 1 | |||
Cough, percussion or hopping tenderness | 2 | Rebound tenderness | 1 | ||
Leucocytosis (WBC > 10k) | 1 | 2 | |||
Neutrophilia (ANC > 7,500) | 1 | 1 |
Uncomplicated appendicitis
- Admit to PACU
- Clear diet (advance as tolerated)
- Start oral NSAIDs for pain control if no contraindications
Contraindications to ketorolac
- Allergy or hypersensitivity
- Active peptic ulcer disease, GI bleeding
- Renal insufficiency or failure
- Patients at increased risk of hemorrhage
- Admit
- Clear diet (advance as tolerated)
- Start oral NSAIDs/opioids for pain control
- No labs, no antibiotics unless there is an appropriate need
- Discharge
- Follow up with PMD within 24 hours
- 7 days total antibiotic course
- If penicillin allergic
- Ciprofoxicin 15 mg/kg PO Q12 hours (max 750 mg)
- Metronidazole 10 mg/kg PO Q8 hours (max 750 mg)
- if non-penicillin allergic
- Amoxicillin/clavulanic acid 20 mg/kg PO Q12 hours (max 875 mg)
White blood cell count (WBC)
- May be useful as an adjunct test in some patients. Poor specificity.
Absolute neutrophil count (ANC)
- May be useful as an adjunct test in some patients. Poor specificity.
C-reactive protein (CRP)
- May be useful as an adjunct test in some patients. Poor specificity.
Procalcitonin
- Performs worse than WBC/CRP and is not routine recommended.
Urinalysis
- Should be performed in most females; males with specific risk factors.
Complicated appendicitis
- Admit
- NPO
- Maintence fluids
- IV pain control
- Advance diet if patient non-distended, not nauseated and well appearing
Daily reassessment
Discharge, follow up with PMD within 24 hours
- Clinical concern for appendicitis
- Pregnancy
- Immunosuppresed, cancer
- Complicating functional or anatomical abdominal history
- History of abdominal surgery
- Signs of Systemic Inflammatory Response Syndrome (SIRS)
Discharge criteria
- Reassuring vital signs
- Tolerating PO
- Pain well controlled
- Ambulatory
- Well-appearing
- No social/family concerns
- Reliable follow up in 24 hours
- Parents comfortable and understand discharge plan
- Provider comfortable with outpatient therapy
Non-diagnostic US with no secondary signs of appendicitis
- If no secondary signs of appendicitis are seen on US, the risk of appy appear to be very low
- Surgery consultation
- 20 ml/kg NS IV bolus unless contraindicated
- D5 NS + appropriate electrolytes at maintenance rate
- CBC, CRP
Operating room
- IV antibiotics within 1 hours of incision
Discharge criteria
- No significant pre-operative concerns
- Reassuring vital signs
- Tolerating PO
- Pain well controlled
- Ambulatory
- Well-appearing
- No social/family concerns
- Reliable follow up in 24 hours
- Parents comfortable and understand discharge plan
- Provider comfortable with outpatient therapy
1 or more sign of poor hydration:
- No oral intake
- Minimal urine output
- Clinical signs of severe dehydration
IV morphine, intranasal fentanyl or intranasal ketamine
Operating room
- Interoperative transversus abdominis plane (TAP) block
- Interoperative ketorolac if no contraindications
