Management of complicated appendicitis. A rational approach based on clinical course
M. S. Keller, W. J. McBride and D. W. Vane
Department of Pediatric Surgery, University of Vermont College of Medicine, Burlington, USA.
OBJECTIVE: To better define the appropriate management of children with
complicated appendicitis, using an outcome approach based on clinical
parameters. DESIGN: Retrospective study. SETTING: A 500-bed tertiary care
university-based hospital. PATIENTS: Fifty-six consecutively admitted
children (age <19 years) with a diagnosis of complicated appendicitis
(gangrenous or perforated) confirmed at laparotomy. INTERVENTION: All
children were managed postoperatively using an institutionally established
protocol requiring hospitalization and broad-spectrum intravenous
antibiotics until three criteria were met permitting discharge: (1)
resolution of fever for 24 hours; (2) normalization of white blood cell
count; and (3) normal results of clinical examination. MAIN OUTCOME
MEASURES: Length of stay, costs, and infectious complications. RESULTS:
Overall, infectious complications occurred in only two patients (3.5%). No
complications occurred in any patient who met the criteria for discharge.
The average length of stay for all patients was 5.1+/-3.0 days (range, 3 to
18 days). Using this approach instead of current standards reported in the
literature resulted in an estimated savings of over $4000 per patient and
$224000 for the entire cohort. CONCLUSIONS: Postoperative management of
complicated appendicitis can be safely based on a defined clinical
algorithm that should replace empirical therapy as the "gold standard."
