Appendicitis Clinical Pathway – Inpatient

Inpatient Clinical Pathway for Evaluation/Treatment
of Children with Appendicitis

Goals and Metrics
Patient Education
Diagnosis of appendicitis based on physical exam, imaging
 
 
Initiate Antibiotics
 
 
 
 
Appendectomy
Medical Management of Perforated Appendicitis/Abscess/Phlegmon
Consider for prolonged symptoms (5–7 days)
 
 
 
 
 
 
Acute Appendicitis
Non-Perforated
Perforated Appendicitis

IV Antibiotics

Abd CT with IV contrast or MR

Consult IR for drainage procedure
  • Discharge from PACU
  • No postoperative antibiotics
  • Acetaminophen/ibuprofen
  • Regular diet
 
 
 
 
 
 
Postoperative IV antibiotics

Adequate IR Drainage

Continue IV antibiotics

No IR drainage or incomplete drainage with residual abscess

Continue IV antibiotics
 
 
 
 
 
 
 
 
 
 
 
 
Clinical improvement
No clinical improvement after 3–5 days
Clinical improvement
No clinical improvement after 3–5 days
Clinical improvement
  • Discharge when clinical criteria met
  • No antibiotics after discharge
  • Discharge when clinical criteria met
  • Complete 5 days total (IV+PO) antibiotics after IR drainage
  • Follow-up General Surgery in 2 wks
  • Interval appendectomy scheduled for 6–8 wks from discharge
  • Discharge when clinical criteria met
  • Complete 10–14 days total (IV+PO) antibiotics
  • Follow-up General Surgery in 2 wks
  • Interval appendectomy scheduled for 6–8 wks from discharge
Care of Children with Appendectomy
  • General antibiotic recommendations
  • IV fluids, advance diet as tolerated
  • Pain management
    • IV acetaminophen, nalbuphine
    • Ketorolac if no bleeding concerns
    • Opioids are not typically required
  • Non-Perforated vs. Perforated
    • In the absence of visible hole in appendix, free fecalith, diffuse peritonitis or abscess, a “suppurative” or “gangrenous” appendix or cloudy fluid is not sufficient for a definition of perforated appendicitis
  • Clinical Criteria for Discharge
    • Normal vital signs, afebrile
    • Abdominal exam reassuring
    • Tolerating PO
    • Ambulating
    • Comfortable on PO pain medications