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Management of complicated appendicitis. A rational approach based on clinical course
M S Keller1, W J McBride, D W Vane
1Department 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."