Suspected Appendicitis

Care Guideline

Inclusion Criteria: children 2 - 16 yrs old with acute

Postoperative abdominal pain
Management – p. Exclusion Criteria: history of trauma, pregnant, Recommendations/
2 previous abdominal surgery Considerations
Non-operative
Management – p.
Assessment Appendicitis is the
3
History: inquire specifically about onset & intensity of most common
symptoms, anorexia, nausea/vomiting, diarrhea, atraumatic surgical
migration of pain condition in children
Clinical examination: guarding/rigidity, localized who present with
tenderness, presence of rebound, observe walking, note abdominal pain
fever Most common
Interventions signs/symptoms in
CBC with differential, CRP, UA, HCG if > 10yrs and young children are
female periumbilical pain
NPO with migration to
IV fluids/bolus for evidence of hypovolemia RLQ, anorexia,
Morphine 0.1 mg/kg IV q3h PRN pain or 3 mg IV nausea/emesis,
q3h PRN if > 30 kg guarding, cough/
percussion
tenderness
Laboratory findings
History, exam, labs commonly include
Non-surgical Surgery
No consistent with Yes leukocytosis and
diagnosis consult
appendicitis bandemia.
Evidence supports
the use of narcotic
analgesics in
If morbidly obese, children with
proceed to CT scan Equivocal
abdominal pain
with oral/IV contrast
For true allergy to
Appendix penicillin, use
ultrasound, IV gentamicin/
Negative Positive
NS 20 mL/kg clindamycin
bolus

Equivocal

Prep for OR
Phone consult with
NPO
surgeon to decide IV 20 cc/kg NS bolus then D5½ NS w/
re: CT scan 20 mEq/L KCL (rate dependent on age)
Cefoxitin 40 mg/kg IV (max dose
2000mg) OR
For strong suspicion of perforation, give
CT scan ceftriaxone 50 mg/kg IV or 2000 mg IV
Negative with oral/IV Positive q24 h> 40 kg AND metronidazole 30
contrast mg/kg IV or 1500 mg IV q24h > 50 kg
Consent for laparoscopic
appendectomy, possible open
Equivocal
appendectomy, possible central line
insertion

Serial exams,
temperature Transport to Pre-Op or
curve, Med/Surg Unit Page 1
repeat CBC, CRP dependent on OR time

Approved Care Guidelines Committee 12-16-09

Revised 3-28-13, 7-19-13 antibiotic dose change Reassess the appropriateness of Care Guidelines as condition changes and 24 hrs after admission. This guideline is a tool to aid clinical
decision making. It is not a standard of care. The physician should deviate from the guideline when clinical judgment so indicates.
© 2013 Children’s Hospital of Orange County
 Appendectomy (Post-operative)
Care Guideline

Inclusion Criteria: Postoperative laparoscopic or open

appendectomy patients, Interval/delayed appendectomy
for perforated appendicitis Recommendations/
Exclusion criteria: Incidental appendectomy Considerations

Postoperative – All Patients For abscess

Vital signs q 1 hr x 2, then q 4 hrs, strict I/O formation, culture and
OOB/ambulate QID; begin today consider use of Zosyn
IV D5½ NS + KCL 20 mEq/L (high dosing)
Incentive spirometry q 1 hr x 24 hrs, then q 6 hrs while awake Central line care
Morphine 0.1 mg/kg/dose IV q 4 hrs PRN severe pain (<50 should be performed
kg) AND +/- Ketorolac 0.5 mg/kg/dose IV q 6 hrs x 48 hrs then per CHOC procedure
PRN pain (<30kg) for 72 hrs (Mosby – CVAD)
Odansetron 0.1 mg/kg/dose IV q 8 hrs PRN nausea/vomiting Pain Assessment and
(<40 kg) Management per
CHOC procedure
(Mosby – Pain
Management)
Complicated Appendicitis (perforated or
Uncomplicated Appendicitis (acute For true allergy to
gangrenous)
inflammatory or suppurative) or penicillin, use
Normal Appendix gentamicin/
NPO until awake clindamycin
NGT to low intermittent suction (if
Clear liquid diet when placed) -note amount & color of
drainage
awake, then regular diet
JP drain (if placed) – note amount
by 2nd meal if clears
& color of drainage
tolerated Central line care (if placed) Patient/Family
Saline lock IV when Ceftriaxone 50 mg/kg IV q24h or Education
taking adequate fluids 2000 mg IV q24 h> 40 kg AND Postop care;
Metronidazole 30 mg/kg IV q24h discharge
or 1500 mg IV q24h > 50 kg instructions, signs/
symptoms for
complications, diet,
POD 1 bathing & wound
Discharge if NPO Patients NGT Patients care, activity
criteria met restrictions, pain
management,
Clear liquids and advance DC NGT, start clear liquids
diet as tolerated, once ileus
medications, return
and advance diet as
resolved to school, follow up
tolerated, once ileus
resolved
appointment
Discharge Criteria
POD 2
VS stable, afebrile x 24 hrs Transition to oral
Tolerating diet pain meds POD 4
Abdomen soft, non-distended, Transition to
without significant tenderness oral pain meds
Discharge Criteria
Ambulating
Improving CRP
Comfortable on PO pain meds POD 4 VS stable, afebrile x 24 hrs
Repeat labs if CRP on POD 5 Tolerating diet
POD 3 was <70 but > CBC, CRP Abdomen soft, non-
50 mg/L Discharge if distended, without
Discharge if criteria criteria met significant tenderness
met Ambulating
Comfortable on PO pain
meds
POD 5
CBC, CRP
Discharge if
criteria met

Approved Care Guidelines Committee 12-16-09,

revised 3-28-13
Previous version 11-05
© 2013 Children’s Hospital of Orange County

Reassess the appropriateness of Care Guidelines as condition changes and 24 hrs after admission. This guideline is a tool to aid clinical
Page 2
decision making. It is not a standard of care. The physician should deviate from the guideline when clinical judgment so indicates.
 Non-Operative Management of Perforated Appendicitis
Care Guideline

Inclusion Criteria: children 2 - 16 yrs old with: Recommendations/

Symptoms > 5 days Considerations
CT confirmed appendicitis
There are no randomized
trials comparing different
antibiotic regimens for
Interventions the nonoperative
If drainable abscess on CT scan - percutaneous treatment of perforated
drainage by Interventional Radiology appendicitis in children.
Culture drainage The Surgical Infection
If no drainable abscess -> PICC line placement by Society recommends
PICC RN or Interventional Radiology either multi-drug therapy
IV D5½ NS + KCL 20 mEq/L or monotherapy as long
Diet for age as tolerated as adequate Gram-
Clear liquids if unable to tolerate solids; advance as negative and anaerobic
tolerated coverage is provided.
Morphine 0.1 mg/kg/dose IV q 4 hrs PRN severe If abscess not drainable,
pain (<50 kg) AND +/- Ketorolac 0.5 mg/kg/dose IV use of Zosyn is
q 6 hrs x 48 hrs then PRN pain (<30 kg) for 72 hrs recommended.
VAD care For true allergy to
Arrange Home Care for IV Antibiotics (RN visits, penicillin, use
meds, supplies, labs) gentamicin/clindamycin
Central line care should
Antibiotics be performed per CHOC
Ceftriaxone 50 mg/kg IV q24h or 2000 mg IV q24 h> procedure (Mosby –
40 kg AND CVAD)
Metronidazole 30 mg/kg IV q24h or 1500 mg IV Pain Assessment and
q24h > 50 kg Management per CHOC
procedure (Mosby – Pain
Management)

Continued Considerations
CBC and CRP when afebrile and tolerating regular
diet
Parent/Patient
Adjust antibiotics based on culture results and Education
evaluate for transition to oral route when clinically CVAD care
appropriate Wound care
If uncontrolled sepsis or bowel obstruction develops,
consider proceeding to appendectomy
Discharge Criteria
If a drain was placed, assess for removal
Afebrile x 24 hours
Change antibiotics to single agent home regimen
Tolerating regular diet
before discharge; give a minimum of one dose (if
CRP trending down
requires IV route)
Ambulating
Discharge on oral antibiotics, if culture results
Comfortable on PO pain meds
available, for 14 day total course

Page 3

Approved Care Guidelines Committee 12-16-09

Revised 3-28-13 Reassess the appropriateness of Care Guidelines as condition changes and 24 hrs after admission. This guideline is a tool to aid clinical
decision making. It is not a standard of care. The physician should deviate from the guideline when clinical judgment so indicates.
© 2013 Children’s Hospital of Orange County