Appendicitis Care Map

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Appendicitis Care Map

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Quick Overview: Appendicitis Epidemiology, Pathophysiology, and Treatment

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Appendicitis Care Map Dashboard

Suggested Inclusion Criteria for Appendicitis Care Map

• Age > than 3 months

• Presenting with the chief complaint or concern of acute abdominal pain

Patient Appendicitis Education Booklet

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Executive Summary

Prospective evaluation of a Clinical Pathway for Suspected Appendicitis

Executive Summary

Appendicitis Care Map

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Potential Reasons to Avoid Appendicitis Care Map

• Known Inflammatory Bowel Disease

• Sickle Cell DZ

• Chronic Steroids

• Immunosuppressed

Quick Overview: Appendicitis Epidemiology, Pathophysiology, and Treatment

Appendicitis Care Map Dashboard Go directly to Care Map Flowchart

This care map document does not supersede the clinical judgment of a provider regarding the care that is ultimately ordered for a given patient. Click to see full disclaimer.

Patient Appendicitis Education Booklet

P

Prospective evaluation of a Clinical Pathway for Suspected Appendicitis

The Pediatric Appendicitis Scoring Grid

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Original grid sourced from: Prospective Evaluation of a clinical Pathway: Pediatrics 10.1542/peds.2013-2208

Signs /Symptoms Points

Cough/percussion/heel tapping tenderness at RLQ 2

Anorexia 1

Low-grade fever ≥ 38.0 ( 100.4) 1

Nausea/Vomitting 1

RLQ tenderness on light palpation 2

Leucocytosis (>10,000/mm3) 1

Left shift (>75% neutrophils) 1

Migration of pain to RLQ 1

Diagnostic testing & therapies not

routinely recommended:

•CT Scan •KUB •ESR

*ESI = Emergency Severity Index

Emergency Department Care: Chief Complaint = acute abdominal pain

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Triage • Nurse performs initial assessment and assigns

ESI* level.

Provider Evaluation: H&P, Physical Exam, CBC, BMP, UA, HCG, +/- CXR/KUB , consider pelvic

ultrasound if female

TRANSFERS If a referral is called from an outside facility or from a PCP’s office and the patient has a CT scan that is positive

for appendicitis: 1. IF it is before 5 PM on M- Fri,

page surgery PA/resident for a potential direct admission or a direct transfer to their care in

ED. 2. IF after 5 PM or on weekends,

proceed through triage process Suspected APPI

Assign PAPY Score

Evaluate and treat

as indicated

YES NO

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Diagnostic testing & therapies not

routinely recommended:

•CT Scan •KUB •ESR

Emergency Department Care (continued)

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1 -3 Cont Susp.

Assign PAPY Score

4-7

8-10

Continued from previous page

Discharge with F/U within 24

hours

YES NO

NEG POS

Admit to Surgery /

Ask OR time

OR Available in 1-2 hrs

OR Available in >2 hrs

Admit is after 9:00 PM

Admit to OR Pre-Scrub in

ED**

Admit to floor Pre-Scrub on

floor**

Admit to floor Pre-Scrub on

floor**

Admit to CPG/GI

NEG POS Consider CONSULT SURGERY

CONS Surgery

•Antibiotics* •NPO •IVF

•Pain Control •Antiemetics

Consider CT**

USG

ANTIBIOTICS* Uncomplicated (Early):

•Cefoxitin (Pen Allergic) •Zosyn •Cipro/Flagvl (Severe Pen Allergic)

Complicated (Late): •Zosyn •Cefipime/Flagvl (Mild Pen Allergic) •Cipro/Flagvl (Severe Pen Allergic)

Reassign Score

Radiology Criteria for CT scan

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(IV Contrast ONLY**)

1. If diagnosis uncertain after scoring and ultrasound

2.If requested by surgery 3. Or to assess for intra-abdominal abscess.

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Criteria for Positive Ultrasound

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Ultrasound Diagnostic for Appendicitis Primary signs:

Max outer diameter >7 mm Max wall thickness > 1.7 mm

Secondary signs:

Presence of periappendiceal fat Presence of a fluid collection Presence of local dilatation and

hypoperistalsis

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Diagnostic testing & therapies not

routinely recommended:

•CT Scan •KUB •ESR

OR Findings

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Uncomplicated Appendicitis Post Operative Care: • Diet-advance as tolerated •IV Fluids •Pain Management •Monitoring •Labs-none •IV Antibiotics- None

Complicated Appendicitis Post Operative Care: •NPO •Advance Diet as tolerated •IV Fluids •Pain Management •Monitoring •IV Antibiotics*

Complicated Appendicitis: •Perforated •Gangrenous •Suppurative •Peritonitis •Abscess

Discharge Readiness Assessment: Beginning at POD#3. continuing daily until post op discharge criteria are met: - Afebrile - Check CBC with diff - Tolerating Diet - Pain well managed - No sign of wound infection

Complicated vs. Uncomplicated

Discharge Criteria:

•Afebrile( T< 38 C) x48 hrs •Tolerating Diet •No sign of wound infection •CBC with diff evaluation nl •Pain is controlled on oral meds

Discharge Criteria ( same day ):

•Afebrile( T< 101 F) •Tolerating oral intake •Pain is controlled on oral meds

IF CBC is normal: Transition to PO antibiotics and

Discharge

IF CBC is Abnormal- Continue IV antibiotics and reassess daily until patient meets

discharge criteria or POD #7

Transition to PO antibiotics : IV + PO = 7 days total •PO Augmentin •IF severe Pen/ beta lactam allergy- Bactrim

IF patient has not met discharge criteria by POD

# 7 then reassess

Post discharge Care: F/U within 10-14 days

Call for fever, abdominal pain, N/V , or bilious emesis

Post discharge Care: F/U prn or per provider

order. Wound care instructions ***

7 Day reassessment : •CT scan with IV contrast •CBC

Off Pathway

Pre Op Surgical Scrub

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•Bathe patient (shower or bath wipes) •Scrub entire abdomen (sternum to pelvis, right flank to left flank) using 2% Clorhexidine wipes, paying close attention to the umbilicus

- Follow instructions on the product packaging

•Place clean gown on patient - Instruct the patient and family to not touch the cleaned area

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Executive Summary

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Order Sets : Appendectomy Admission

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Order Sets: Post op Appendectomy

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References • Adefurin A, Sammons H, Jacqz-Aigrain E, Choonara I. Ciprofloxacin safety in paediatrics: A

systematic review. Arch Dis Chil[Appendectomy].2011;96(9):874-880

• Lee SL, Islam S, Cassidy LD, Abdullah F, Arca MJ, 2010 American Pediatric Surgical Association Outcomes and Clinical Trials,Committee. Antibiotics and appendicitis in the pediatric population: An american pediatric surgical association outcomes and clinical trials committee systematic review. J Pediatr Surg [Appendectomy]. 2010;45(11):2181-2185.

• Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: Guidelines by the surgical infection society and the infectious diseases society of america. Clin Infect Dis [Appendectomy]. 2010;50(2):133-164.

• Solomkin JS, Mazuski JE, Baron EJ, et al. Guidelines for the selection of anti-infective agents for complicated intra-abdominal infections. Clin Infect Dis [Appendectomy]. 2003;37(8):997-1005

• Seattle Children’s Hospital, Ledbetter D, Mazor S, Beardsley E, Hsieh V, Magin J, Moriarty E, Leu M, Popalisky J. 2014 July. Appendicitis Pathway. Available from: http://etch-etchnet/intranet/departments/Policies/nssup/1006633.pdf?CFID=46056&CFTOKEN=13327542

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Physician Disclaimers: Appendicitis Care Map Medical Disclaimer

Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required. The authors of this Care Map have checked with sources believed to be the most current and reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical sciences, neither the authors nor East Tennessee Children’s Hospital warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions, or for the results obtained from the use of such information. Readers should make every effort to confirm the information contained herein with other sources, and are encouraged to consult with other health care providers in the making of clinical care decisions. References to specific products, processes, websites, or services within this Care Map neither constitute nor imply corporate recommendation or endorsement by East Tennessee Children’s Hospital.

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Contact and Revisions Number

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• Last Update: 11/7/16

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