Appendicitis — General Principles — Clinical Pathway: Inpatient

Appendicitis Clinical Pathway — Inpatient

General Principles

The following reflect recent changes in our management.

  1. In the absence of a visible hole in the appendix, a free fecalith, diffuse peritonitis or an abscess, a “suppurative” or “gangrenous” appendix or cloudy fluid is not sufficient for a definition of perforated appendicitis.
  2. The attending will decide if the patient should be treated as non-perforated or perforated (document this clearly in the operative note), and will monitor the patient’s daily progress and make decisions along the way as to whether the patient’s care should deviate from the guidelines.
  3. In no group is a PICC line recommended or required. The data support the use of PO Cipro/Flagyl for the treatment of patients with an intra-abdominal abscess.
  4. The smallest effective dose of metronidazole should be prescribed, which for most patients will be 7.5 mg/kg/dose PO QID. For patients who weigh ~ 50 kg, they should receive 375 mg PO QID (7.5x50). Patients who weigh more than 50 kg should get 7.5 mg/kg PO QID up to a maximum of 500 mg PO QID.
  5. For perforated appendicitis patients receiving IV ceftriaxone/metronidazole who are still febrile and symptomatic on POD 3, it is reasonable to consider switching to a different antibiotic regimen (Piperacillin/Tazobactam).
  6. Discharge is based on clinical criteria only. With rare exception, laboratory studies (WBC, CRP) and repeat imaging are not needed to make the right decision.
  7. We will be very careful about discharge so as not to rush them out or prolong their stay. Whenever possible, we want to send kids home in the morning to make room for other kids coming from the OR, but the decision to send them home must be based on their clinical picture and postoperative milestones, not the clock.
  8. NPs will call the family several days after discharge to help anticipate issues related to pain, constipation, wound care, etc.