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Apendisitis akut adalah peradangan akut dan infeksi usus buntu berbentuk vermiform

(ulat), yang paling sering disebut sebagai apendiks. Apendiks adalah sebuah struktur

yang berakhir buntu yang timbul dari sekum. Apendisitis akut adalah salah satu

penyebab paling umum sakit perut dan merupakan kondisi yang paling sering

menyebabkan pembedahan perut emergensi pada anak-anak. Apendiks mungkin terlibat

dalam proses infeksi, inflamasi, atau kronis lainnya yang dapat mengarah kepada

apendiktomi; Namun, artikel ini berfokus pada apendisitis akut. Apendiks dan

apendisitis akut digunakan secara bergantian. (Lihat Anatomi, serta Patofisiologi.)

Gambar apendisitis anak di bawah ini.

Pemeriksaan ultrasonografi kuadran kanan bawah menunjukkan struktur yang lebuh

besar dari pada struktur tubular noncompressible 6mm yang ditunjukkan pada cross

section. Rasa tidak nyaman dirasakan jika probe mernekan di atas struktur ini.

Sejumlah kecil cairan bebas juga didapatkan di sekitar apendiks. CT scan

menggambarkan struktur tubular menggelembung turun ke dalam panggul dan

mengandung kalsifikasi bulat (yaitu appendicolith).

Gejala umum apendisitis akut termasuk sakit perut, demam, dan muntah. Diagnosis

apendisitis bisa sulit pada anak-anak karena gejala klasik sering tidak ada. (Lihat Gejala

Klinis.)

Diagnosis apendisitis yang terlambat berkaitan dengan ruptur dan komplikasi, terutama

pada anak-anak. Peningkatan resiko rupture apendiks dapat diketahui menggunakan

pencitraan radiologis canggih. Apendisitis adalah diagnosis klinis dengan pencitraan

yang digunakan untuk mengkonfirmasi kasus yang masih samar. (Lihat hasil

pemeriksaan.)

Lihat Apendisitis: Menghindari Pitfall pada Diagnosis, gambar-gambar, untuk

membantu membuat diagnosis yang akurat.

Pengobatan definitif untuk apendisitis adalah apendiktomi. Pemberian antibiotik di

awal pada diagnosis penting untuk memperlambat proses infeksi dan membantu

mencegah perkembangan apendiks nonperforata. Kunci untuk setiap evaluasi dan

rencana perawatan adalah sebagai berikut: mengurangi rasa sakit pasien dan

ketidaknyamanan awal dan secara konsisten; berkomunikasi dengan pasien dan

keluarga tentang rencana; sering ulangi pemeriksaan; menyesuaikan diagnosis banding

yang tepat; dan menjaga pasien untuk observasi jika diagnosis pasti belum tegak. (Lihat

Pengobatan dan Manajemen).

Regimen antibiotic yang paling banyak digunakan adalah kombinasi ampisilin,

klindamisin (atau metronidazole), dan gentamisin. (Lihat Obat.)

Edukasi pasien

Untuk memberikan informasi kepada pasien, lihat Esofagus, Abdomen, dan Intestinum,

serta Apendisitis dan perut Nyeri pada Anak.

Anatomi

Apendiks vermiformis umumnya 5-10 cm. Apendiks muncul dari sekum, pada

kebanyakan anak berada di perut kuadran kanan bawah.

Meskipun basis apendiks fixed (tetap) terhadap sekum, ujung apendiks dapat ditemukan

di pelvis, retrocecum, atau ekstraperitoneum. Perhatikan bahwa posisi anatomi

apendiks menentukan gejala dan lokasi tenderness ketika apendiks inflamasi.

Apendiks dilapisi oleh epitel kolon yang khas. Submukosa mengandung folikel limfoid,

sangat sedikit ketika lahir. Jumlah ini secara bertahap meningkat dan mencapai puncak

sekitar 200 folikel pada usia 10-20 tahun dan kemudian menurun. Pada orang yang

berusia lebih dari 30 tahun, ada kurang dari setengah jumlah keseluruhan, dan

jumlahnya terus menurun sepanjang masa dewasa.

Patofisiologi

Setelah apendiks tersumbat, bakteri terperangkap di dalam lumen appendiks dan mulai

berkembang biak, kemudian apendiks menjadi menggelembung. Meningkatkan tekanan

intraluminal dan menghalangi drainase vena, kemudian apendiks menjadi kongesti dan

iskemik.

Kombinasi infeksi bakteri dan iskemia menghasilkan peradangan atau inflamasi, yang

berkembang menjadi nekrosis dan gangren. Ketika apendiks menjadi gangren, mungkin

bisa perforasi. Perkembangan dari obstruksi menjadi perforasi biasanya berlangsung

selama 72 jam.

Sebuah penelitian mencatat bahwa perforasi appendiks lebih sering terjadi pada anak-

anak, khususnya anak-anak muda, dibandingkan pada orang dewasa. Risiko besar

terjadi perforasi dalam waktu 24 jam dari onset tercatat (7,7%) dan ditemukan

meningkat dengan durasi gejala. Sementara itu, perforasi berhubungan langsung dengan

durasi gejala sebelum operasi, risiko dikaitkan lagi dengan penundaan pra-rumah sakit

dibandingkan dengan penundaan rawat inap di rumah sakit. [1]

Pada tahap awal apendisitis, pasien mungkin merasa sakit hanya periumbilikalis karena

persarafan apendiks di T10. Peradangan memburuk, eksudat terbentuk pada permukaan

serosa appendiks. Ketika eksudat menyentuh peritoneum parietal, berkembang menjadi

sakit yang lebih sering dan terlokalisir.

Perforasi menyebabkan pengeluaran cairan inflamasi dan bakteri ke dalam rongga

perut. Hal ini semakin menyebabkan permukaan peritoneal inflamasi, dan berkembang

menjadi peritonitis. Lokasi dan luasnya peritonitis (difus atau lokal) tergantung pada

sejauh mana omentum dan loop usus yang berdekatan dapat berisi tumpahan isi lumen

usus.

Jika isi usus membentuk dinding dan abses, rasa sakit dan nyeri dapat dilokalisir di

tempat abses. Jika isi usus membentuk dinding dan cairan dapat menyebar di seluruh

peritoneum, rasa sakit dan nyeri menjadi umum serta tidak terlokalisir.

Etiologi

Apendisitis akut disebabkan obstruksi apendiks yang berakhir buntu, sehingga loop

usus tertutup. Pada anak-anak, obstruksi biasanya terjadi akibat hiperplasia limfoid

pada folikel submukosa. Penyebab hiperplasia ini kontroversial, kemungkinan dehidrasi

dan infeksi virus. Penyebab umum lainnya obstruksi apendiks adalah fekalith

Penyebab yang jarang termasuk benda asing, infeksi parasit (misalnya, nematoda), dan

striktur inflamasi.

Epidemiologi

Apendisitis memiliki insiden 70.000 kasus anak per tahun di Amerika Serikat. Insiden

antara baru lahir dan usia 4 tahun adalah 1-2 kasus per 10.000 anak per tahun. Insiden

meningkat menjadi 25 kasus per 10.000 anak per tahun antara 10 dan 17 tahun. Secara

keseluruhan, 7% dari orang di Amerika Serikat telah melakukan apendiktomi selama

masa hidup mereka. Rasio laki-laki perempuan sekitar 2: 1.

Apendisitis jauh lebih umum terjadi di negara-negara maju. Walaupun alasan untuk

perbedaan ini tidak diketahui, faktor risiko potensial termasuk diet rendah serat dan

tinggi gula, riwayat keluarga, dan infeksi.

Apendisitis terjadi pada semua kelompok umur tapi jarang terjadi pada bayi.

Apendisitis paling sering terjadi pada dekade kedua kehidupan (usia 10-19 tahun),

terjadi pada tingkat 23,3 kasus per 10.000 per tahun. Setelah itu, kejadian tersebut terus

menurun, meskipun apendisitis terjadi pada usia dewasa dan sampai usia tua.

Prognosis

Umumnya, prognosis apendiksitis sangat baik. Pada saat diagnosis, tingkat perforasi

appendiks sebesar 20-35%. Tingkat perforasi adalah 80-100% untuk anak-anak muda

dari 3 tahun, dibandingkan dengan 10-20% pada anak-anak berusia 10-17 tahun. Anak-

anak dengan rupture apendiks beresiko pembentukan abses intra-abdominal dan

obstruksi usus kecil, dan mereka dapat tinggal di rumah sakit sampai lama (beberapa

minggu atau lebih). Tingkat kematian untuk anak-anak dengan apendisitis adalah 0,1-

1%. Kematian yang disebabkan apendisitis yang paling umum pada neonatus dan bayi

untuk 2 alasan berikut:

Apendisitis langka di kelompok usia ini; dengan demikian, kecuali indeks

kecurigaan dokter tinggi, diagnosis banding apendisitis rendah.

pasien yang sangat muda tidak dapat berkomunikasi lokasi dan sifat nyeri

mereka. Beberapa neonatus mungkin demam. Seringkali, gejala pasien hanya

menjadi iritabel atau rasa tidak nyaman.

Sejarah

Sejarah klasik anoreksia dan nyeri periumbilikalis jelas, diikuti oleh migrasi nyeri ke kuadran

kanan bawah (RLQ) dan timbulnya demam dan muntah, diamati dalam waktu kurang dari 60%

pasien. [2] Jika usus buntu perforasi, selang nyeri lega diikuti dengan perkembangan nyeri

perut umum dan peritonitis. Meskipun beberapa pasien kemajuan dalam mode klasik,

beberapa pasien menyimpang dari model klasik. Presentasi atipikal yang umum pada pasien

neurologis gangguan dan immunocompromised, serta anak-anak yang sudah pada antibiotik

untuk penyakit lain.

Pada pasien dengan usus buntu retrocecal, yang merupakan 15% dari kasus, tanda-tanda dan

gejala mungkin tidak melokalisasi ke RLQ tetapi sebaliknya ke otot psoas, panggul atau

kuadran kanan atas. Pada pasien lain, ujung usus buntu yang jauh di dalam panggul, dan

tanda-tanda dan gejala melokalisasi ke rektum atau kandung kemih yang mengakibatkan rasa

sakit dengan buang air besar atau buang air.

Fitur tertentu dari presentasi anak mungkin menyarankan lampiran berlubang. Seorang anak

muda dari 6 tahun dengan gejala selama lebih dari 48 jam jauh lebih mungkin untuk memiliki

usus buntu yang berlubang. Anak mungkin telah umum sakit perut dan mungkin memiliki

detak jantung yang tinggi dan suhu yang lebih tinggi dari 38 ° C.

Sebuah risiko besar perforasi dalam waktu 24 jam dari onset tercatat (7,7%) dalam satu studi

dan ditemukan meningkat dengan durasi gejala. Sementara perforasi berhubungan langsung

dengan durasi gejala sebelum operasi, risiko dikaitkan lagi dengan penundaan pra-rumah sakit

dibandingkan dengan di rumah sakit delay. [1]The classic history of anorexia and vague

periumbilical pain, followed by migration of pain to the right lower quadrant (RLQ)

and onset of fever and vomiting, is observed in fewer than 60% of patients.[2] If the

appendix perforates, an interval of pain relief is followed by development of

generalized abdominal pain and peritonitis. Although some patients progress in the

classical fashion, some patients deviate from the classic model. Atypical presentations

are common in neurologically impaired and immunocompromised patients, as well as

in children who are already on antibiotics for another illness.

In patients with a retrocecal appendix, who constitute 15% of cases, signs and

symptoms may not localize to the RLQ but instead to the psoas muscle, the flank or

right upper quadrant. In other patients, the tip of the appendix is deep in the pelvis, and

the signs and symptoms localize to the rectum or bladder resulting in pain with

defecation or voiding.

Certain features of a child's presentation may suggest a perforated appendix. A child

younger than 6 years with symptoms for more than 48 hours is much more likely to

have a perforated appendix. The child may have generalized abdominal pain and may

have a high heart rate and a temperature higher than 38°C.

A substantial risk of perforation within 24 hours of onset was noted (7.7%) in one study

and was found to increase with duration of symptoms. While perforation was directly

related to the duration of symptoms before surgery, the risk was associated more with

prehospital delay than with in-hospital delay.[1]

Pain

All patients with appendicitis have abdominal pain, and many have anorexia; absence

of both of these findings should place the diagnosis of appendicitis in question. A child

who states that the ride to the hospital is painful when the vehicle hits bumps in the

road suggests peritoneal irritation.

Acute onset of severe pain is not typical of acute appendicitis but is seen with acute

ischemic conditions such as volvulus, testicular torsion, ovarian torsion, or

intussusception. If the pain is initially located in the right lower quadrant, severe

constipation should be considered. A high index of suspicion should be maintained

when attributing pain to constipation, especially in a child who does not have a prior

history of constipation. Many children do not report the early symptoms of appendicitis

and only appreciate the pain when it localizes to the RLQ. In addition, children with a

retrocecal appendicitis may have a delay in the appreciable pain, leading to a delay in

presentation.

As appendicitis progresses, the pain migrates to the RLQ due to inflammation of the

parietal peritoneum. This pain is more intense, continuous, and localized than the initial

pain. This shift of pain rarely occurs in other abdominal conditions.

Atypical pain is common and occurs in 40-45% of patients. This includes children who

initially have localized pain and those with no visceral symptoms. Pain on urination can

be seen with pelvic appendicitis.

Nausea and vomiting

A unique feature of appendicitis is gradual onset of pain followed by vomiting.

Vomiting first is more typical of gastroenteritis.

Generally, vomiting that occurs prior to pain is unusual. However, in patients with

retrocecal appendices, particularly those that extend cephalad along the posterior

surface of the right colon, inflammation of the appendix irritates the nearby duodenum,

resulting in nausea and vomiting prior to the onset of RLQ pain.

Diarrhea

Significant diarrhea is atypical in appendicitis, and the physician should consider other

diagnoses, while not ruling out appendicitis. In patients with an appendix in a pelvic

location, inflammation of the appendix occasionally results in an irritative stimulation

of the rectum. These patients often report diarrhea. However, upon closer questioning,

such patients usually describe frequent, small-volume, soft stools rather than true

diarrhea.

Fever

Most children with appendicitis are afebrile or have a low-grade fever and

characteristic flushing of their cheeks. Severe fever is not a common presenting feature

unless perforation has occurred, and even then it may still be rare. According to one

study, vomiting and fever are more frequent findings in children with appendicitis than

in children with other causes of abdominal pain.

Physical Examination

The physical examination findings in children may vary depending on age. Irritability

may be the only sign of appendicitis in a neonate. Older children often seem

uncomfortable or withdrawn. They may prefer to lie still because of peritoneal

irritation. Teenaged patients often present in a classic or near-classic fashion.

Examination of the child requires skill, patience, and warm hands. Initial and continued

observation of the child is of critical importance. An ill-appearing quiet child who is

lying very still in bed, perhaps with the legs flexed, is much more a cause for concern

than a child who is laughing, playing, and walking around the room.

The examination should be thorough and start with areas other than the abdomen.

Because lower lobe pneumonias can cause abdominal findings, a history of such should

be elicited and a thorough chest examination performed. It is also important to exclude

urinary tract infection (UTI) as a cause of abdominal pain.

Children vary in their ability to cooperate with the physical examination. It is important

to tailor the physical examination to the child's age and developmental stage.

General examination

Patients’ general state should be observed before interacting with them. The patient’s

state of activity or withdrawal may lend information into their condition. The child's

gait may be observed if they are well enough to ambulate. A patient in obvious distress

with abdominal pain gives the impression of an infectious process; however, other

causes must be ruled out.

Cardiac and pulmonary examination

The findings on evaluation of the heart and lungs typically reflect the patient’s overall

state more than they may suggest appendicitis. Patients are often dehydrated or in pain

and may be tachycardic or tachypneic. Pediatric patients have great physiological

reserves and may not show any general symptoms until they are very ill.

Abdominal examination

Full exposure of the abdomen is key. Before examining the abdomen, ask the child to

point with one finger to the site of maximal pain. Begin palpation of the abdomen at a

site distant to this, with the most tender area examined last. If the child is particularly

anxious, palpation may be performed with a stethoscope.

Distracting questions concerning school and family members may be helpful to relieve

anxiety during the examination. Observing the child's facial expressions during this

questioning and palpating is critical.

Palpation of the abdomen should be performed with a gentle and light touch, searching

for involuntary guarding of the rectus or oblique muscles. In early appendicitis,

children may not have significant guarding or peritoneal signs. Younger children are

much more likely to present with diffuse abdominal pain and peritonitis, perhaps

because their omentum is not well developed and cannot contain the perforation.

Typically, maximal tenderness can be found at the McBurney point in the RLQ. A mass

may be palpable in the RLQ if the appendix is perforated.

However, the appendix may lie in many positions. Patients with a medially positioned

appendix may present with suprapubic tenderness. Patients with a laterally positioned

appendix often have flank tenderness. Patients with a retrocecal appendix may not have

any tenderness until appendicitis is advanced or the appendix perforates.

Presence of the Rovsing sign (pain in the RLQ in response to left-sided palpation or

percussion) strongly suggests peritoneal irritation.

To assess for the psoas sign, place the child on the left side and hyperextend the right

leg at the hip. A positive response suggests an inflammatory mass overlying the psoas

muscle (retrocecal appendicitis).

Check for the obturator sign by internally rotating the flexed right thigh. A positive

response suggests an inflammatory mass overlying the obturator space (pelvic

appendicitis).

During the abdominal examination, try to avoid eliciting rebound tenderness. This is a

painful practice and certainly destroys any trust that has been garnered during the

examination. Peritonitis can be confirmed with gentle percussion over the right lower

quadrant. Involuntary contraction of the abdominal wall musculature (involuntary

guarding) and tenderness can be elicited with minimal stress or discomfort to the child.

Other methods can be used to establish that the patient has peritoneal irritation. Asking

the patient to sit up in bed, cough, jump up and down, or bounce his or her pelvis off

the bed while in the supine position may elicit pain in the presence of peritoneal

irritation. Alternatively, other acceptable maneuvers are tapping the patient's soles and

shaking the stretcher. A child with advanced appendicitis typically prefers to lie still

due to peritoneal irritation.

Rectal examination

The digital rectal examination is often deferred but can be helpful in establishing the

correct diagnosis, especially in sexually active adolescent girls. The patient should be

told that the examination is uncomfortable but should not cause sharp pain. The caliber

of the patient's anus should be taken into consideration, and smaller digits should be

used for examining younger patients.

The rectal examination is particularly important in the child with a pelvic appendix, in

whom the findings on the abdominal examination for appendicitis may be equivocal

and indicative of peritoneal irritation.

Objective information to ascertain includes impacted stool or an inflammatory mass.

Right-sided tenderness of the rectum is the classic finding in patients with pelvic

appendicitis or in those with pus that pools in the pelvis from an inflamed appendix

elsewhere in the abdomen.

Patients who are able to communicate should be asked if they have tenderness in

different areas of the rectum. The rectal examination in a young child may have to be

completely objective because they may not be able to communicate variations in

tenderness or may have general discomfort from the examination.

Genitourinary examination

An external genitourinary (GU) examination is helpful to rule out testicular or scrotal

tenderness in males and hematocolpos in pubertal girls.

Pelvic examination

A pelvic examination should be considered in sexually active adolescent girls to

evaluate for tenderness (adnexal and/or cervical motion tenderness), masses, bleeding,

or discharge.

Atypical findings

Becker et al found that 44% of patients diagnosed with appendicitis presented with 6 or

more of the following atypical features[3] :

No fever

Absence of Rovsing sign

Normal or increased bowel sounds

No rebound pain

No migration of pain

No guarding

Abrupt onset of pain

No anorexia

Absence of maximal pain in the RLQ

Absence of percussive tenderness

Diagnostic Considerations

The signs and symptoms of appendicitis are nonspecific and are common with other

diagnoses. Do not diagnose gastroenteritis rather than appendicitis unless the patient

has nausea, vomiting, and diarrhea. Even with the presence of vomiting and diarrhea,

consider the unusual presentations of retrocecal or pelvic appendicitis. Additionally,

appendicitis can develop as a sequela of gastroenteritis associated with lymphoid

hyperplasia.

Diagnose abdominal pain of unknown etiology in patients with nonspecific abdominal

symptoms if a diagnosis cannot be established. These patients may be discharged with

close follow up. Instruct patients to be reevaluated in 8-12 hours by their primary care

physician or to return to the emergency department. Patients with equivocal

examination findings but suspected to have early appendicitis should be admitted for

observation for serial abdominal examinations or to undergo imaging with

ultrasonography or abdominal CT scanning.

If constipation is diagnosed and treated with enemas and/or stool softeners with

resolution of the signs and symptoms, inform the patient and family that recurrence of

the abdominal pain in the future could be recurrent constipation or acute appendicitis

and to seek medical advice.

Appendicitis should be considered in special patient populations, such as the

immunocompromised and developmentally delayed. Appendicitis is rare in infants. If

an infant has appendicitis, the diagnosis of Hirschsprung disease should also be

considered.

Other problems to consider include the following:

Ovarian cyst

Ovarian torsion

Pelvic inflammatory disease (PID)

Pregnancy

Ectopic pregnancy

Renal calculi

Mesenteric lymphadenitis

Mittelschmerz

Pneumonia (right lower lobe)

Neutropenic typhilitis

Lymphoma

Epiploic appendagitis

Paratubal cysts

Volvulus

Typhlitis

Omental torsion

The major differential diagnoses for acute appendiceal abscess or mass include Crohn

disease and malignancy.

Differential Diagnoses

Constipation

Ectopic Pregnancy

Hemolytic-Uremic Syndrome

Henoch-Schoenlein Purpura

Meckel Diverticulum

Ovarian Cysts

Ovarian Torsion

Pancreatitis

Pediatrics, Gastroenteritis

Pediatrics, Intussusception

Pediatrics, Urinary Tract Infections and Pyelonephritis

Pelvic Inflammatory Disease

Pregnancy Diagnosis

Pregnancy, Ectopic

Pyelonephritis

Renal Calculi

Testicular Torsion

Urinary Tract Infection

Approach Considerations

Making a timely diagnosis of appendicitis is a difficult challenge in children with

abdominal pain. Laboratory findings may increase suspicion of appendicitis but are not

diagnostic. The minimum laboratory workup for a patient with possible appendicitis

includes a white blood cell (WBC) count with differential and urinalysis. Liver function

tests and amylase and lipase assessments are helpful when the etiology is unclear.

Baseline blood urea nitrogen and creatinine are needed prior to intravenous contrast CT

scanning.

Other studies, such as interleukin 6 and C-reactive protein (CRP) assays, have been

advocated by some in the diagnosis of appendicitis. However, in multiple clinical

series, these studies have not been shown to be of clear benefit and, for the most part,

only add to the cost of the evaluation.

CBC Count

The WBC count becomes elevated in approximately 70-90% of patients with acute

appendicitis. However, the WBC count is elevated in many other abdominal conditions,

as well. Furthermore, the WBC count is often within the reference range within the first

24 hours of symptoms. Elevation tends to occur only as the disease process progresses,

and it is usually mild. Therefore, its predictive value is limited. Elevation of the

neutrophil or band count can be seen without elevation of the total WBC count and may

support the diagnosis of appendicitis.

If the WBCs exceed 15,000 cells/μL, the patient is more likely to have a perforation.

However, one study found no difference in the WBC counts of children with simple

appendicitis and those with perforated appendicitis. In the immunocompromised

patient, a neutrophil count of less than 800 may suggest typhlitis.

Urinalysis

Urinalysis is useful for detecting urinary tract disease, including infection and renal

stones. However, irritation of the bladder or ureter by an inflamed appendix may result

in a few urinary WBCs. The presence of 20 or more WBCs per high-power field (hpf)

suggests a urinary tract infection.

Hematuria may be caused by renal stones, urinary tract infection, Henoch-Schönlein

purpura, or hemolytic-uremic syndrome. However, small numbers of red blood cells

(RBCs) can be found in as many as 20% of patients with appendicitis when an

overlying phlegmon or abscess lies adjacent to the ureter. Typically, urinary RBCs are

fewer than 20/hpf.

Ketonuria is suggestive of dehydration and is more common with perforated

appendicitis.

Normal urinalysis results have no diagnostic value for appendicitis. However, a grossly

abnormal result may suggest an alternative cause of abdominal pain

Abdominal Radiography

Abdominal radiography findings are normal in many individuals with appendicitis.

However, plain films may be helpful in the setting of severe constipation. A calcified

appendiceal fecalith is present in less than 10% of persons with inflammation, but its

presence suggests the diagnosis.

Radiographic signs suggestive of appendicitis include convex lumbar scoliosis,

obliteration of the right psoas margin, right lower quadrant (RLQ) air-fluid levels, air in

the appendix, and localized ileus. In rare incidents, a perforated appendix may produce

pneumoperitoneum.

If no other imaging studies are to be performed, an abdominal series may be helpful.

For more information, see the Medscape Reference article Appendicitis Imaging.

Ultrasonography

Given the potential risks of radiation from CT scans, graded compression

ultrasonography may be the preferred initial imaging modality in the evaluation of

pediatric acute appendicitis. This technique involves locating the appendix and then

attempting to compress its lumen.

For ultrasonography to be diagnostic of appendicitis, the operator must visualize the

appendix. Even if the appendix is not visualized, however, appendicitis can be excluded

more confidently if ultrasonography shows no secondary signs of appendicitis (eg,

hyperechoic mesenteric fat, fluid collection, localized dilated small bowel loop).[4, 5]

A positive finding is a noncompressible tubular structure 6 mm or wider in the RLQ

(see the images below). This structure is tender during palpation with the

ultrasonographic probe. Additional supportive findings include an appendicolith, fluid

in the appendiceal lumen, focal tenderness over the inflamed appendix (sonographic

McBurney point), and a transverse diameter of 6 mm or larger. In patients with a

perforated appendix, ultrasonography may reveal a periappendiceal phlegmon or

abscess formation.

Ultrasonographic examination of the right lower

quadrant reveals a greater than 6-mm noncompressible tubular structure shown in cross

section. Discomfort was noted as the probe was depressed over this structure. A small

amount of free fluid is also noted surrounding the appendix.

Ultrasonographic examination of the right lower

quadrant reveals a greater than 6-mm noncompressible tubular structure shown in cross

section. Discomfort was noted as the probe was depressed over this structure. A small

amount of free fluid is also noted surrounding the appendix.

Abdominal ultrasonography has proved to be valuable for diagnosing appendicitis in

children, with most published reports indicating a sensitivity, specificity, and accuracy

of at least 90-95%. Furthermore, some authors have found that ultrasonography is more

sensitive and specific than clinical impression and increases diagnostic accuracy when

used either alone or in conjunction with laboratory results.[6]

The advantages of ultrasonography include its noninvasiveness, lack of radiation, no

contrast medium, and minimal pain. The downside of ultrasonography is that the

examination is operator dependent and may not be available at some institutions.

Factors that add difficulty to the examination include obesity and gaseous distention of

the intestines overlying the appendix. However, results of one study determined that

ultrasonography should continue to be the first diagnostic imaging study in suspected

appendicitis, regardless of the child's body mass index (BMI).[7]

Ultrasonography is also useful in diagnosing alternative pathologies (eg, tubo-ovarian

abscess, ovarian torsion, ovarian cyst, mesenteric adenitis).

A prospective study by Lowe et al comparing noncontrast CT scanning and

ultrasonography revealed a sensitivity, specificity, and accuracy of 97%, 100%, and

98%, respectively, for unenhanced CT scanning, compared to 100%, 88%, and 91%,

respectively, for ultrasonography.[8] Still others have shown that the perforation rate and

negative appendectomy rate can be decreased by using both tests in tandem.


Computed Tomography

CT scanning is a useful modality for diagnosing appendicitis in children. Although

radiation exposure is a concern, CT scans have been shown to have an accuracy of 97%

in diagnosing appendicitis. Advantages of CT scan include the availability at most

institutions, the ability to evaluate the entire abdomen and locate abscesses and

phlegmon, the lack of dependence on operator skill, and physician familiarity with

reading CT scans.

CT findings that are indicative of appendicitis include a thickened appendix, fat

streaking around the appendix, or thickening of the cecal wall (see the images below).

CT scan depicting a distended tubular structure

descending into the pelvis and containing a round calcification (ie, an appendicolith).

CT scan revealing an enhancing tubular structure

descending into the pelvis. Periappendiceal inflammation and streaking, so-called dirty

fat, is noted surrounding the appendix.

CT findings that suggest perforated appendicitis include periappendiceal or pericecal

air, abscess, phlegmon, and extensive free fluid. Because the disease is due to

obstruction of the appendix and the inflammation occurs distal to the obstruction,

extravasation of contrast or extensive free air is rarely seen. If a patient is found to have

free air throughout the abdomen or under the diaphragm, other diagnoses should be

entertained.

CT scanning may be helpful in obese patients or those in whom a localized appendiceal

abscess is clinically suspected. In patients with abscesses, CT scanning may also be

helpful in the CT-guided drainage of the abscess.

CT scanning has been found to have sensitivity, specificity, and accuracy similar to

those of ultrasonography.[8, 9] Disadvantages include the aforementioned radiation

exposure, the need for oral and intravenous contrast and its related disadvantages, and

the need for the patient to be still, which is often difficult for small children.

Because of the advantages of CT scans, 62% of surveyed North American pediatric

surgeons preferred it for evaluation of appendicitis. Of note, less than 1% of pediatric

surgeons favored CT scanning for every case of suspected appendicitis. Most preferred

CT scanning on a selected basis, with 51-58% of patients with suspected appendicitis

undergoing CT scanning.

However, despite now-widespread use of CT scanning for evaluation of appendicitis

with its superior sensitivity and specificity, the negative appendectomy rate in children

has not shown a statistically significant reduction.

Peck et al and Mullins et al have reported sensitivities of 92-97% and sensitivities of

99.6-99%, respectively, using noncontrast helical CT scanning.[9, 10] Callahan et al

reported equivalent results using helical CT scanning and rectally administered contrast

material.[11] They reported that this technique results in decreased total number of

inpatient observation days, decreased number of negative laparotomies, and decreased

per-patient cost.

Additional radiographic testing is clearly indicated in patients who present with

equivocal signs and symptoms of appendicitis. Whether noncontrast CT scanning,

rectally administered contrast-enhanced CT scanning, CT scanning with oral and

intravenous contrast, or ultrasonography is used may be a function of the institution or

time of day. The data clearly show that each has sensitivities and specificities over 90%

and that each can be helpful in clinical decision-making.

For more information, see Appendicitis Imaging.

Chest Radiography

If the history, physical examination, laboratory tests, and imaging studies have failed to

produce a satisfactory differential diagnosis, anteroposterior (AP) and lateral chest

radiography should be performed to look for right lower lobe pneumonia.

Typically, histologic findings range from acute inflammatory infiltrate most apparent in

the submucosal level in early appendicitis to transmural infarction in perforated

appendicitis.

The finding of an apparently normal appendix at surgery requires careful follow-up of

the histologic findings. Occasionally, early appendicitis is histologically identified and

clinically correlates with the resolution of preoperative symptoms. Additionally,

unsuspected findings of luminal nematodes should indicate further anthelmintic therapy

(eg, mebendazole [Vermox]). Chronic inflammation or fibrosis of the tip of the

appendix are occasionally seen and coincide with resolution of the symptoms.

Many surgeons now encounter patients with “early appendicitis” based on history,

physical examination findings, and/or CT scans who had minimal changes found in the

appendix in the operating room or only intraluminal inflammatory cells on histology.

Most of these patients have complete resolution of their signs and symptoms after

appendectomy. Whether this is because the appendectomy is performed at an earlier

stage of appendicitis or is due to the placebo effect of the appendectomy is unknown.


Electrolyte levels

Electrolyte assessments and renal function tests are more helpful for management than

diagnosis. Indications for these tests include a significant history of vomiting or clinical

suspicion of significant dehydration.

Pregnancy Testing

A beta–human chorionic gonadotropin (beta-HCG) test should be performed to rule out

pregnancy or ectopic pregnancy in adolescent girls.

Scoring Systems

Evaluation rules and algorithms have been proposed to help the clinician make the

correct diagnosis and treatment plan. Although these decision rules may help predict

which children are at low risk for appendicitis, they are not used consistently

Kharbanda et al scoring system

The system proposed by Kharbanda et al assigns scores based on the following 6

findings[12] :

Nausea (2 points)

History of focal RLQ pain (2 points)

Migration of pain (1 point)

Difficulty walking (1 point)

Rebound tenderness/pain with percussion (2 points)

Absolute neutrophil count of greater than 6.75 X 103/µL (6 points)

A score of 5 or less had a sensitivity of 96.3%, a negative predictive value of 95.6%,

and a negative likelihood ratio of 0.102 in the validation set.

The Samuel score (pediatric appendicitis score)

This scoring system is based on 8 variables, as follows[13] :

RLQ tenderness elicited by cough, hopping, or percussion

Anorexia

Elevated temperature

Nausea/vomiting

Tenderness over the right iliac fossa

Leukocytosis

Increased polymorphonuclear neutrophil percentage (ie, left shift on white

blood cell differential)

Migration of pain

Samuel recommended that patients with a score of 5 or lower should be observed, while

those with a score of 6 or higher should undergo surgical consultation.

The Alvarado score (MANTRELS score)

The MANTRELS score is based on the following 8 variables:

Migration of pain to RLQ

Anorexia

Nausea/vomiting

Tenderness in RLQ

Rebound pain

Elevated temperature (>37.3° C)

Leukocytosis (>10,000/µL)

Left shift

Schneider et al found that an Alvarado score of 7 or higher yielded a sensitivity of 73%

and a specificity of 80%.[14] Use of this scoring system is limited to risk stratification of

suspected appendicitis in children.

Staging

The clinical staging of appendicitis has important implications in the postoperative

treatment of the child. Although somewhat subjective at the time of surgery,

appendicitis may be divided into 3 broad categories: acute (nongangrenous),

suppurative or gangrenous (nonperforated), and perforated. Perforated appendicitis can

be divided further into cases with diffuse or with localized peritonitis.

Acute (nongangrenous) appendicitis

This stage of appendicitis is referred to as early appendicitis. No mural gangrene or

infarction is present. This type requires no further antibiotic therapy in most settings.

The child may be discharged home as soon as diet and oral pain medications can be

tolerated.

Suppurative or gangrenous (nonperforated) appendicitis

Patients with exudative appendicitis, particularly those with mural gangrene, have an

increased rate of postoperative intra-abdominal and wound infections, even in the

absence of demonstrable perforations. Often, microperforations are present and may be

identified if cultures of the fluid are obtained. However, if the the child is clinically

improved and Gram stain and culture findings, if available, are negative, the

intravenous antibiotics can be stopped in approximately 24 hours, and the child may be

discharged home as soon as diet and oral pain medications can be tolerated. A decision

can be made by the surgeon to continue oral antibiotics at home.

Perforated appendicitis

Perforated appendicitis (diagnosed either by intraoperative findings or by positive

intraoperative cultures) is associated with a postoperative infection rate of as high as

30%. Children with perforated appendicitis require antibiotic therapy for a minimum of

7-10 days. Often, intra-abdominal abscesses that require drainage may develop. A high

index of suspicion for a postoperative abscess is required in the patient with perforated

appendicitis who has fevers or ileus that last more than 5 days. A child who develops a

postoperative abscess or a small bowel obstruction may need additional surgery and

may have a prolonged hospital stay.

Approach Considerations

Given that patients with possible appendicitis may have an equivocal history and

physical examination findings and inconclusive supporting test results, the following

measures are key to any evaluation and treatment plan:

Relieve the patient's pain and discomfort early and consistently

Communicate with the patient and family about the plans

Repeat the examination often

Adjust the differential diagnosis as appropriate

Keep the patient for observation if a firm diagnosis is not made or for follow-up

Algorithms, scoring systems, imaging studies, and consultation reports are part of the

clinician's armamentarium. Documentation of medical decision making is important, as

is knowledge of the current literature. Consultations with a pediatrician or general

surgeon may be appropriate.

Because of the short time from obstruction of the appendix to perforation, 20-35% of

patients who present with acute appendicitis have already perforated. In fact, estimates

suggest that most patients perforate within 72 hours of symptom onset. A substantial

risk of perforation within 24 hours of onset was noted (7.7%) in one study and was

found to increase with duration of symptoms. While perforation was directly related to

the duration of symptoms before surgery, the risk was associated more with prehospital

delay than with in-hospital delay.[1]

If a patient presents beyond 72 hours from symptom onset, perforation is highly likely.

However, if a patient presents with symptoms of appendicitis beyond 72 hours and has

not perforated, diagnoses other than appendicitis must be entertained.

Avoid treating vague abdominal pain by administering parenteral opiates and then

discharging the patient. Narcotics and potent nonsteroidal anti-inflammatory drugs may

be needed for pain control. Large doses or ongoing use should be avoided until after

surgical consultation.

Patients with a classic history require prompt surgical consultation. Maintain nothing-

by-mouth status in patients with suspected appendicitis, and start intravenous fluids to

restore intravascular volume. Antibiotics should be started upon diagnosis of

appendicitis.

Emergency medical service (EMS) personnel are well trained and cognizant of how to

assess and begin treatment of the febrile, vomiting child with abdominal pain.

Intravenous fluid administration, pain management, and antiemetic medication should

be administered based on local EMS protocols.

The insertion of nasogastric tubes (when necessary), intravenous lines, and urethral

catheters (when necessary) and the administration of antibiotics, antiemetic drugs,

antipyretic drugs, and analgesia should ideally be part of the emergency department

protocol for preoperative management.

Fluid Resuscitation

Ensure adequate hydration for patients who present with suspected appendicitis. Even

in early acute appendicitis, children frequently have not had sufficient oral intake and

present with some degree of intravascular dehydration. Intravenous hydration often

improves abdominal symptoms in children who do not have appendicitis.

Patients with appendicitis usually require fluid boluses prior to operation in order to

counteract dehydration. However, these patients need continued fluid resuscitation

appropriate to their fluid status and severity of appendicitis.

If fluid status is unclear, urine output is the most common measure. Urine output should

be no lower than 0.5 mL/kg/h. If dehydration is suspected, Foley catheter placement,

monitoring of urine output, and correct fluid replacement are indicated.

Postoperatively, the spectrum of fluid management ranges from patients with early

appendicitis who are started on clear fluids postoperatively and can have intravenous

(IV) fluids discontinued when advanced to a regular diet, to patients with perforated

appendicitis who require postoperative fluid boluses.

Antibiotic Therapy

Antibiotic therapy is an important aspect of the treatment of ruptured appendicitis.

Intravenous antibiotics should be started once the diagnosis of acute appendicitis is

confirmed. Antibiotic therapy should be directed against gram-negative and anaerobic

organisms such as Escherichia coli and Bacteroides species.

If the appendix is not gangrenous or perforated, no postoperative antibiotics are

indicated. A gangrenous appendix warrants antibiotics for 24-72 hours, depending on

clinical improvement and/or Gram stain, if one was obtained during surgery.

Antibiotic therapy for ruptured appendicitis is continued for a minimum of 7-10 days,

but a longer course may be needed. Intravenous antibiotics are used during the

hospitalization. Oral antibiotics may be used to complete therapy if a child is well

enough for discharge.

While appendectomy remains the definitive treatment for appendicitis, many patients

with perforated appendicitis are now treated with intravenous antibiotics alone with

drainage of the abscess if needed. Additionally, some advocate nonoperative treatment

with antibiotics only for early appendicitis, especially when the diagnosis is vague.

Appendectomy

The definitive treatment for appendicitis is appendectomy. Historically, appendectomy

had a 10-20% false-positive rate, but the widespread use of imaging studies has reduced

this rate.

Patients with perforated appendicitis can be divided into 2 cohorts; those whose

perforation is discovered in the operating room during appendectomy and those with

preoperative evidence of perforation, most commonly seen on CT scans or ultrasounds.

Increasingly, the approach in the latter group is conservative (nonoperative)

management, with percutaneous drainage if possible and surgery after 8-12 weeks (ie,

interval appendectomy).

Patients discovered to have perforated appendicitis during appendectomy should be

treated in the same fashion as those with nonperforated appendicitis. The surgeon

should complete the appendectomy in a normal fashion.

If a laparoscopic appendectomy is being performed, perforation alone is not a reason

for conversion to open appendectomy. However, if an abscess is encountered and

drained, placement of a drain in the abscess cavity should be considered. In addition,

when an open appendectomy is being performed on a patient with a perforated

appendix, the high incidence of wound infection should be considered in terms of skin

closure.

In rare instances, the inflammation can be so severe that the appendix cannot be safely

identified and removed. To avoid unnecessary morbidity, drainage procedures with

subsequent interval appendectomy (see conservative [nonoperative] management) is

acceptable.

To see complete information on Pediatric Appendectomy, please go to the main article.

Conservative (Nonoperative) Management

Historically, a patient with appendicitis, especially perforated appendicitis, was rushed

to the operating room for appendectomy; however, this is no longer the case.

Conservative management with interval appendectomy may be appropriate for

perforated appendicitis. Whyte et al have suggested that interval appendectomy may be

safely performed as an outpatient procedure.[15]

Conservative management begins with a trial of medical therapy. A patient found to

have perforated appendicitis based on imaging study findings should be admitted to the

hospital, should be placed on a nothing-by-mouth (NPO) diet, and should be given

intravenous (IV) fluid resuscitation.

If the patient is hemodynamically unstable or if urine output cannot be measured, a

Foley catheter should be placed. IV antibiotics should be started. Generally, antibiotics

for this condition are targeted at enteric flora (eg, second-generation cephalosporin,

gentamicin, metronidazole; see Medication). If the patient has an abscess that is

accessible, percutaneous drainage is performed. Discharge from the hospital is based on

lack of fever, tolerance of pain on oral medications, and adequate oral intake.

A patient who does not improve after admission and intravenous antibiotic therapy

should undergo surgery for drainage of the infection and appendectomy, if technically

feasible. Factors that suggest failure of conservative management include bandemia on

admission CBC count, fever of more than 38.3° C after 24 hours of medical therapy,

and multisector involvement on CT scan. Medical therapy is deemed to have failed at a

median of 3 days. Medical therapy fails in as many as 38% of children with perforated

appendicitis.

In children who recover with medical therapy, an alternative to interval appendectomy

is to postpone surgery indefinitely. Most patients do well with this approach.

Appendicitis recurrence rates range from 0-20%, with a pooled rate of 8.9% found by

one large meta-analysis.[16]

A much higher recurrence rate (72%) is seen in pediatric patients with an appendicolith

present during the initial acute episode. Consequently, many experts suggest that

interval appendectomy may be needed only in patients with appendicolith.

Most patients who experience recurrence do so within the first 6 months after their

initial episode of appendicitis; the longest follow-up to date is 13 years. However, it is

not known whether pediatric patients who receive conservative treatment for

appendicitis are at risk for recurrence during adulthood. Because of this uncertainty,

many pediatric surgeons prefer to perform interval appendectomy.

Delaying definitive surgery is associated with significant resource use, including

increased imaging, drainage procedures, and additional admissions. In addition,

conservative management with laparoscopic appendectomy performed at a later date

poses the risk of misdiagnosis. The major differential diagnoses for acute appendiceal

abscess or mass include Crohn disease and malignancy.

The increased use of CT scanning or ultrasonography in the emergent setting has

decreased this risk of misdiagnosis. These studies help to confirm the diagnosis of

appendiceal mass and also guide drainage interventions. The increased use of

technology, combined with improvements in antibiotics, makes conservative

management a more attractive and less risky choice in terms of misdiagnosis or

treatment failure.

Nonoperative management with antibiotics for early appendicitis is a new concept in

the pediatric population and further studies are required prior to routine

recommendation of this practice.

Percutaneous Drainage

Often, patients with gangrenous or perforated appendicitis develop intra-abdominal

abscesses.[17] These may be present at the time of presentation or may develop after

surgery or during hospitalization if an interval appendectomy is planned. Commonly, a

patient who has a prolonged ileus or fever for more than 5 days postoperatively has an

intra-abdominal abscess.

The usual approach is to perform a CT scan of the abdomen and pelvis with oral and

intravenous contrast to define the presence of an abscess. If this study confirms the

presence and accessibility of an abscess, percutaneous drainage should be performed.

A drain is commonly left in the abscess cavity, and continued drainage is monitored.

Once drainage decreases, the drain can be removed. Repeat imaging is not always

needed.

Postoperative Pain Management

Patients who have undergone an appendectomy should be prescribed pain medication

upon discharge. Liquid acetaminophen usually suffices in smaller children, with liquid

acetaminophen plus codeine or hydrocodone administered for breakthrough pain. The

same medication combination in a tablet form can be used in older patients, assuming

they are able to swallow the tablets.

Patients who received inpatient narcotics or who are discharged on outpatient narcotics

should be cautioned about the possibility of becoming constipated. These patients may

need prescribed stool softeners.

Diet and Bowel Function

Patients with nonperforated appendicitis may be started on clear fluids postoperatively.

Diet is advanced as tolerated.

Patients who can tolerate regular diet may be discharged home. These patients have

minimal delay in the return of bowel function and do not need to have a bowel

movement prior to discharge.

Patients with perforated appendicitis who have immediate appendectomy should remain

NPO until their bowel function returns. They should then be started on clear fluids, and

the diet advanced as tolerated. Total parental nutrition may be needed in children with

prolonged hospitalization from a ruptured appendicitis.

Complications

Complications may include the following:

Perforation

Sepsis[18]

Shock

Postoperative adhesions

Infertility

Wound dehiscence

Wound infection

Bowel obstruction

Medication Summary

Administer 1 dose of preoperative antibiotics to children with suspected appendicitis.

Antibiotics can be discontinued after surgery if no perforation is noted.

Antibiotics are selected to provide coverage for aerobic and anaerobic organisms. The

most widely used regimen is the combination of ampicillin, clindamycin (or

metronidazole), and gentamicin. Alternative regimens include the following:

Ampicillin/sulbactam

Cefoxitin

Cefotetan

Piperacillin/tazobactam

Ticarcillin/clavulanate

Imipenem/cilastatin

Resistant organisms develop in 15% of patients with a ruptured appendix. Antibiotic

substitutions are made for patient allergies, poor clinical improvement or deterioration

on current regimen, or culture-proven antibiotic resistance.

Patients with appendicitis also require medication for pain control. Antiemetic and

antipyretic agents may also be indicated.

Antibiotic regimens should cover the most commonly encountered organisms,

including Escherichia coli and Bacteroides, Klebsiella, Enterococcus, and Pseudomonas

species.

Penicillins

Class Summary

The penicillins are bactericidal antibiotics that work against sensitive organisms at

adequate concentrations and inhibit the biosynthesis of cell wall mucopeptide.

Examples of extended-spectrum penicillins include ticarcillin and clavulanate

(Timentin) and ampicillin and sulbactam (Unasyn).

View full drug information

Ampicillin (Marcillin, Omnipen, Polycillin, Principen)

Ampicillin is a beta-lactam antibiotic with activity against some gram-positive and

gram-negative organisms. It inhibits bacterial cell wall synthesis during active

multiplication.


Ampicillin/sulbactam (Unasyn)

A combination of ampicillin with a beta-lactamase inhibitor, this agent has activity

against some gram-positive organisms, gram-negative organisms (nonpseudomonal

species), and anaerobic bacteria.


Piperacillin/tazobactam (Zosyn)

A combination of a beta-lactamase inhibitor with piperacillin, this agent has activity

against some gram-positive organisms, gram-negative organisms, and anaerobic

bacteria. It inhibits biosynthesis of bacterial cell wall mucopeptide and is effective

during the stage of active multiplication.


Ticarcillin and clavulanate potassium (Timentin)

This combination of an antipseudomonal penicillin plus a beta-lactamase inhibitor

provides coverage against most gram-positive and gram-negative organisms and most

anaerobes. It inhibits biosynthesis of cell wall mucopeptide and is effective during the

stage of active growth.


Imipenem and cilastatin (Primaxin)

This combination agent is indicated for treatment of multiple organism infections in

which other agents do not have wide-spectrum coverage or are contraindicated because

of potential for toxicity.

Aminoglycosides

Class Summary

Aminoglycosides are bactericidal antibiotics used to primarily treat gram-negative

infections. They interfere with bacterial protein synthesis by binding to 30S and 50S

ribosomal subunits.


Gentamicin (Garamycin, Gentacidin)

Gentamicin is an aminoglycoside antibiotic with activity against gram-negative

bacteria, including Pseudomonas species. It is synergistic with beta-lactams against

enterococci. Gentamicin interferes with bacterial protein synthesis by binding to 30S

and 50S ribosomal subunits. Dosing regimens are numerous; adjust the dose based on

creatinine clearance and changes in volume of distribution. Gentamicin may be

administered intravenously or intramuscularly.

Anti-Infectives

Class Summary

Anti-infectives such as metronidazole and clindamycin are effective against some types

of bacteria that have become resistant to other antibiotics.


Clindamycin (Cleocin)

Clindamycin is a lincosamide effective against gram-positive aerobic and anaerobic

bacteria (except enterococci). It inhibits bacterial growth, possibly by blocking

dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein

synthesis to arrest.


Metronidazole (Flagyl)

Metronidazole is often used in combination with an aminoglycoside, such as

gentamycin. It provides broad gram-negative and anaerobic coverage. It appears to be

absorbed into cells, and the intermediate-metabolized compounds that are formed bind

DNA and inhibit protein synthesis, causing cell death. Metronidazole is a synthetic,

nitroimadazole-derivative antibacterial and antiprotozoal agent. Metronidazole may be

administered intravenously or orally.

Cephalosporins

Class Summary

Cephalosporins are structurally and pharmacologically related to penicillins. They

inhibit bacterial cell wall synthesis resulting in bactericidal activity.


Cefoxitin (Mefoxin)

A second-generation cephalosporin, cefoxitin has activity against some gram-positive

organisms, gram-negative organisms (nonpseudomonal species), and anaerobic

bacteria. It inhibits bacterial cell wall synthesis during active multiplication by binding

1 or more penicillin-binding proteins.


Cefotetan (Cefotan)

Cefotetan is a second-generation cephalosporin indicated for infections caused by

susceptible gram-positive cocci and gram-negative rods.

Analgesics

Class Summary

Pain management is a contentious topic for some emergency physicians and surgeons.

Several classes of analgesic medications have proven to be safe and efficacious in the

preoperative pediatric patient.

It is ethical and prudent for emergency physicians, surgeons, anesthesiologists,

pediatricians, and pharmacists to agree on a plan for providing pain relief to the

pediatric patient. Topics to be agreed upon include type, route, dose, and frequency of

administration of analgesic drugs.


Ketorolac (Toradol)

Ketorolac inhibits prostaglandin synthesis by decreasing the activity of

cyclooxygenase, which results in decreased formation of prostaglandin precursors.

With proper dosing, it does not cause a significant decrease in hematocrit, increase in

creatinine, or overall complications. Its use can decrease hospital stay and narcotic

requirements in children who have undergone surgery.


Fentanyl citrate (Sublimaze)

Fentanyl is a synthetic opioid that is 75-200 times more potent and has a much shorter

half-life than morphine sulfate. It has less hypotensive effects and is safer in patients

with hyperactive airway disease than morphine because of minimal to no associated

histamine release. By itself, it causes little cardiovascular compromise, although the

addition of benzodiazepines or other sedatives may result in decreased cardiac output

and blood pressure.

Consider continuous infusion of fentanyl because of its short half-life (30-60 min).

Parenteral fentanyl is the drug of choice for conscious sedation analgesia. It is ideal for

analgesia of short duration during anesthesia and the immediate postoperative period. It

is readily titrated and is easily and quickly reversed by naloxone.

After the initial parenteral dose, subsequent parenteral doses should not be titrated more

frequently than every 3 or 6 hours. Fentanyl is highly lipophilic and protein bound.

Prolonged exposure leads to accumulation in fat and delays the weaning process.


Morphine

Morphine sulfate has the advantages of reliable and predictable effects, a favorable

safety profile, and ease of reversibility with naloxone. Various IV doses are used; it is

commonly titrated until the desired effect is obtained.

The Joint Commission on the Accreditation of Healthcare Organizations has placed

"MSO4" on the banned abbreviation list, because it can be mistaken for magnesium

sulfate. Therefore, in writing the prescription, spell out "morphine sulfate" in full,

legibly and clearly.

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