Appendicitis (2 - 17 years)



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Appendicitis (2 - 17 years)

Antibiotics are empirically directed at the more common bacteria associated with intraabdominal infections including Bacteroides fragilis, E. coli, other enterics and Enterococcus. Antibiotics should be modified based on clinical response and intraoperative cultures. If a patient is septic on presentation, please contact ID for more specific coverage. For true penicillin allergy, a combination of ciprofloxacin and metrondiazole can be used initially but ID should be called to help tailor antibiotics and to review the PCN allergy.

POD #2 and on

POD #0

POD #1

Complicated?*

Inclusion Criteria
  • Patients 0-2 days post-appendectomy
Exclusion Criteria
  • If patient meets Sepsis, SIRS criteria, has a history of abnormal bleeding or requires NGT, Hospitalist and Surgeon should discuss plan off pathway.

Uncomplicated: Inflamed but grossly intact, nongangrenous, nonsuppurative appendix with no associated abscess or peritonitis

Complicated: An appendix that is gangrenous, suppurative, grossly perforated or associated with an abscess or peritonitis

Pain Control:

  • IV ketorolac 0.5 mg/kg every 6 hours (max dose: 30 mg) PLUS Morphine 0.05-0.1 mg/kg every 3 hours as needed (PRN)

Antibiotics:

  • Ampicillin-sulbactam for 1 dose up to 1 hr before procedure, dose: 200 mg ampicillin/kg/day divided every 6 hours (max dose: 1000 mg ampicillin/dose)

Diet:

  • Start with Clears and advance as tolerated

Fluids:

  • D5NS + 20KCl Strict Is and Os

Activity:

  • Encourage OOB and Incentive Spirometery

Pain Control:

  • IV ketorolac 0.5 mg/kg every 6 hours (max dose: 30 mg) with IV famotidine 0.5 mg/kg/dose every 12 hours (max dose: 20 mg) PLUS PRN acetaminophen IV 15 mg/kg/dose q6h (max daily dose: 60 mg/kg/day) and morphine 0.05-0.1 mg/kg every 3 hours PRN if needed for pain scale 7-10

Antibiotics:

  • Ampicillin-sulbactam, dose: 200 mg ampicillin/kg/day divided every 6 hours (max dose: 1000 mg ampicillin/dose)

Diet:

  • NPO

Fluids:

  • D5NS + 20KCl Strict Is and Os

Activity:

  • Encourage Out of Bed (OOB) and Incentive Spirometery

Pain Control:

  • IV ketorolac 0.5 mg/kg every 6 hours (max dose: 30 mg) with IV famotidine 0.5 mg/kg/dose every 12 hours (max dose: 20 mg) PLUS morphine 0.05-0.1 mg/kg every 3 hours as needed for pain scale 7-10

Antibiotics:

  • Ampicillin-sulbactam, 200 mg ampicillin/kg/day divided every 6 hours (max dose: 1000 mg ampicillin/dose)

Diet:

  • Start with Clears and advance as tolerated

Fluids:

  • D5NS + 20KCl Strict Is and Os

Activity:

  • Encourage Out of Bed (OOB) and Incentive Spirometery

Pain Control:

  • When taking po well: ibuprofen 10 mg/kg (max: 600mg) every 6 hours and if pain not controlled within 3 hours then followed by PRN oral acetaminophen 15 mg/kg/dose q6h (max daily dose: 60 mg/kg/day)

Antibiotics:

  • N/a

Diet:

  • Advance as tolerated

Fluids:

  • D5NS + 20KCl Strict Is and Os

Activity:

  • Encourage OOB and Incentive Spirometery

Discharge:

  • If: 1. Walking; 2. Drinking; 3. Pain Controlled

Hospitalist and Surgeon should discuss plan off pathway

If you have questions about any of the clinical pathways or about the process of creating a clinical pathway please contact the Clinical Pathway Oversight Committee at CPOC@montefiore.org.

Disclaimer: Clinical pathways are intended as a resource to guide diagnosis, treatment and management in order to improve quality of care and promote better patient outcomes. They are based on available medical evidence at the time of development; the date on the pathway indicates the most recent update. Pathways are not intended to provide medical advice or consultation regarding the care of any individual patient, and should not replace or supersede a practitioner’s professional opinion or clinical judgment. Because medical knowledge is constantly evolving, and accepting the possibility of error, The Children’s Hospital at Montefiore does not warrant or represent that pathways are complete or accurate. Neither the Hospital nor the individuals involved in the development or publication of the pathways is responsible for results or outcomes related to their use.

Pain Control:

  • While NPO: IV ketorolac 0.5 mg/kg every 6 hours (max dose: 30 mg) with IV famotidine 0.5 mg/kg/dose every 12 hours (max dose: 20 mg) PLUS morphine 0.05-0.1 mg/kg every 3 hours as needed for pain scale 7-10 until taking po
  • When taking substanial po: ibuprofen 10 mg/kg (max: 600mg) every 6 hours and if pain not controlled within 3 hours then followed by PRN oral acetaminophen 15 mg/kg/dose q6h (max daily dose: 60 mg/kg/day)

Antibiotics:

  • Ampicillin-sulbactam, 200 mg ampicillin/kg/day divided every 6 hours (max dose: 1000 mg ampicillin/dose)

Diet:

  • Advance as tolerated

Fluids:

  • D5NS + 20KCl Strict Is and Os

Activity:

  • Encourage OOB and Incentive Spirometery

Discharge:

  • IF all conditions are met: 1. Afebrile 2. Drinking/Eating 3. Walking 4. Pain Controlled 5. Stable Follow-up 6. Prescriptions Filled
  • THEN, consider CBC and discharge (Consider Augmentin for 14 days)




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