Management of complicated appendicitis: A rational approach based on clinical course

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 $224 000 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.'