Complicated Appendicitis: Post Operative Management

Clinical Practice Guideline REVISED 12/29/21

ORIGINAL 12/15/16

Appendectomy with a Complicated Appendix (Category 2b & 2c)

2B: Focal perforation – hole clearly in the appendix, focal collection of pus in the right gutter or pelvis, small perf created during extraction, et c.
2C: Gross contamination - purulence throughout abdomen/pelvis, fecal contamination, grossly perforated. Pus outside of RLQ. Diffuse peritonitis. Floating fecalith.

Initial Post-operative Management

Antibiotic Therapy Antibiotic Step up Nutrition/GI Pain Control* Activity/Consults
See table on pg. 2 Therapy (NG not recommended) • Acetaminophen: 10mg/kg/dose po (Routine Labs not recommended)
for dosing schedule • 72hrs post op if • Clears and advance as q4hr (max 500mg) for pain • OOB on surgical day X1
• Ceftriaxone febrile, vomiting, tolerated • Toradol: 0.5mg/kg/dose IV q 6hrs minimally & ambulate 3x qd
• Metronidazole (max 30 mg/dose) Max 20 doses • Consult Child Life
poor po intake • When tolerating regular diet
• Morphine: 0.1mg/kg/dose IV q 3hr • Consult PT as needed
D/C Ceftriaxone start Miralax PO (max 17 gm)
PRN pain if acetaminophen or • Consult Nutrition as needed
&Metronidazole prn no stool for 24 hours (see
IF PCN ALLERGY dosing pg.2) toradol is not effective (max 5mg/ • Avoid placing a foley; if used
USE • Start Zosyn unless dose) in surgery remove on POD 1
pt. has a PCN Allergy • Advance to oral pain
Ciprofloxacin & medications* once tolerating • Gabapentin 10 mg/kg/dose po TID
(See table on pg. 2 for
Metronidazole dosing schedule) reg. diet (max 300mg)

Evaluate Fever Curve (including daily T-max), Pain response, and GI response to diet
Every Day
1
Fever Curve improved,
Pain decreased
& Ileus resolved Continue IV antibiotic
Patient
Is patient therapy
NO 1 YES meets D/C No
Improved? No labs necessary
Criteria2
Reassess in 24hrs.

NO ≥ POD 7? Yes

Reassess in 24 hrs
YES
& Check WBC, CRP
Yes
NO Abscess Obtain Labs &
Present? Imaging US/CT No
per surgeon discretion
Transition to Oral
YES WBC & CRP
Yes Amoxicillin/Clavulanate
trending down?
Assess ( if no PCN allergy)
Abscess Management daily if patient
(Obtain cultures from abscess when draining) improved1

Continue NO Tolerating
Drain in IR No
Antibiotics Are any of Oral ABx?
NO YES or Operating
reassess in the abscesses
Room Repeat Imaging Yes
48-72 hrs ≥ 2cm? No
Yes

Keep on IV Discharge2 Home and

ABx and complete a total of 7 days
Tolerating
reassess oral Yes of antibiotics from the day
≥3 Abscess tolerance in
Oral ABx?
of source control. (IV & PO
Drain in IR NO YES Drain in OR
abscesses? Resolved? 24hr combined)

2
NO
Discharge Criteria
*ADVANCING ORAL PAIN REGIMEN: • Afebrile (< 38° C) > 24 hrs
Once pain controlled and tolerating PO, change these • Tolerating regular diet
• Return to OR/IR for
medications from IV to PO: o 50% of 3 consecutive meals
• Toradol to Ibuprofen 10mg/kg/dose po q 6hr prn (max
drainage • Adequate pain control with oral medications
400mg/dose) • Consider ID Consult o Pain score is 3 or less within 1 hr. after oral medication
• Morphine to : Hydrocodone with Acetaminophen 325 mg • Assess susceptibility of administered
0.2mg hydrocodone/kg/dose po q6hr PRN pain • Benign Abdominal Exam by attending surgeon/designee
organism to antibiotic • Ambulation without assistance (250 feet)
(max 5mg hydrocodone/dose)
• Patient is off Guideline • If discharging home with a drain, include drainage care
• If discharged on opioids also order Miralax qd X 5 days
• Consider Gabapentin as a discharge medication instructions
Developed through the efforts of Children's Healthcare of Atlanta and physicians on Children’s medical staff in the interest of advancing pediatric healthcare. This pathway is a general guideline and does not
represent a professional care standard governing providers' obligation to patients. Ultimately the patient’s physician must determine the most appropriate care. © 2016 Children’s Healthcare of Atlanta, Inc.
Complicated Appendicitis: Post Operative 2b & 2c REVISED 12/29/21
Clinical Practice Guideline ORIGINAL 12/15/16

Empiric IV Therapy for Appendicitis

MIRALAX DOSING
When tolerating regular diet start Miralax po (max 17 gm) prn no
stool for 24 hours AND If discharged on narcotics also order Miralax
qd X 5 days
• Age 1-5 years 4.25 grams (1/4 capful)
• Age 6-11 years 8.5 grams (1/2 capful)
• Age 12 and up 17 grams (1 whole capful)
Developed through the efforts of Children's Healthcare of Atlanta and physicians on Children’s medical staff in the interest of advancing pediatric healthcare. This pathway is a general guideline and does not
represent a professional care standard governing providers' obligation to patients. Ultimately the patient’s physician must determine the most appropriate care. © 2016 Children ’s Healthcare of Atlanta, Inc.