Appendicitis (2 - 17 years)



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Appendicitis (2 - 17 years)

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

Complete Blood Count, Serum
Complete Metabolic Panel, Serum

Recent antibiotics?

Treat appropriately

Surgery consultation

Complete Blood Count, Serum
C-Reactive Protein (CRP), Serum

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

GC/CT NAAT
Urine Pregnancy, Urine
Urinalysis with micro, Urine

Metronidazole injection
Ciprofoxicin infusion

Ceftriaxone injection
Metronidazole injection

For patients > 9 months

Piperacillin-Tazobactam injection

Complete Metabolic Panel, Serum
NS Bolus
NS infusion

Continued clinical concern for appendicitis?

Meets discharge criteria?

Perforation, gangrene, abscess or supperative/purulent findings?

Discharge

Ultrasound Appendix

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)

CT Abdomen/Pelvis W Contrast
MRI Appendix

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

Admit to Floor
  • 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

Diet NPO

Daily reassessment

Discharge, follow up with PMD within 24 hours

Inclusion Criteria
  • Clinical concern for appendicitis
Exclusion Criteria
  • Pregnancy
  • Immunosuppresed, cancer
  • Complicating functional or anatomical abdominal history
  • History of abdominal surgery
  • Signs of Systemic Inflammatory Response Syndrome (SIRS)

Ultrasound Pelvis

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

Complete Blood Count, Serum
C-Reactive Protein (CRP), Serum
NS Bolus
NS infusion

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

Morphine injection
Fentanyl Intranasal
Ketamine Intranasal

Operating room

  • Interoperative transversus abdominis plane (TAP) block
  • Interoperative ketorolac if no contraindications

Ketorolac injection



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