Metro Health: University of Michigan Health, Michigan State University College of Osteopathic Medicine, 5900 Byron Ave SW, Wyoming, MI 49519, USA.
Metro Health: University of Michigan Health, Michigan State University College of Osteopathic Medicine, 5900 Byron Ave SW, Wyoming, MI 49519, USA.
Am J Surg. 2018 Apr;215(4):593-598. doi: 10.1016/j.amjsurg.2017.06.003. Epub 2017 Jun 10.
We sought to decrease organ space infection (OSI) following appendectomy for perforated acute appendicitis (PAA) by minimizing variation in clinical management.
A postoperative treatment pathway was developed and four recommendations were implemented: 1) clear documentation of post-operative diagnosis, 2) patients with unknown perforation status to be treated as perforated pending definitive diagnosis, 3) antibiotic therapy to be continued post operatively for 4-7 days after SIRS resolution, and 4) judicious use of abdominal computed tomography (CT) scanning prior to post-operative day 5. Patient demographics and potential clinical predictors of OSI were captured. The primary end point was development of OSI within 30 days of discharge. Secondary endpoints included length of stay (LOS), readmission rate, other complications and secondary procedures performed.
A total of 1246 appendectomies were performed and we excluded patients <18 years (n = 205), interval appendectomies (n = 51) or appendectomies for other diagnosis (n = 37). Among the remaining 953 patients, 133 (14.0%) were perforated and 21 of these (15.8%) developed OSI. Comparing pre (n = 91) to post (n = 42) protocol patients, we saw similar rates of OSI (16.5 vs 14.3%, p = 0.75) with a peak in OSI development immediately prior to protocol implementation which dropped to baseline levels 1 year later based on CUSUM analysis. Readmission rates fell by 49.7% (14.3 vs 7.1%, p = 0.39) without increase in LOS (5.3 vs 5.7 days, p = 0.55) comparing patients pre and post protocol, although these results did not reach clinical significance.
The implementation of and compliance with a post-operative protocol status post appendectomy for PAA demonstrated a trend towards diminishing readmission rates and decreased utilization of CT imaging, but did not affect OSI rates. Additional approaches to diminishing OSI following management of perforated appendicitis need to be evaluated.
我们试图通过最小化临床管理中的变异性来降低穿孔性急性阑尾炎（PAA）阑尾切除术后的器官空间感染（OSI）。
制定了术后治疗途径，并实施了四项建议：1）明确记录术后诊断，2）对穿孔状态不明的患者，在明确诊断前应按穿孔处理，3）在全身炎症反应综合征（SIRS）消退后继续使用抗生素治疗 4-7 天，4）在术后第 5 天之前明智地使用腹部计算机断层扫描（CT）扫描。收集了患者的人口统计学和 OSI 的潜在临床预测因素。主要终点是出院后 30 天内发生 OSI。次要终点包括住院时间（LOS）、再入院率、其他并发症和进行的二次手术。
共进行了 1246 例阑尾切除术，排除了年龄<18 岁的患者（n=205）、间隔性阑尾切除术（n=51）或其他诊断性阑尾切除术（n=37）。在其余 953 例患者中，133 例（14.0%）为穿孔，其中 21 例（15.8%）发生 OSI。比较术前（n=91）和术后（n=42）组患者，我们发现 OSI 发生率相似（16.5%比 14.3%，p=0.75），在方案实施前的高峰期立即下降，并根据累积和分析，1 年后降至基线水平。再入院率下降了 49.7%（14.3%比 7.1%，p=0.39），而 LOS 没有增加（5.3 天比 5.7 天，p=0.55），与术前和术后的患者相比，但这些结果没有达到临床意义。
在 PAA 阑尾切除术后实施和遵守术后方案状态，显示出降低再入院率和减少 CT 成像使用率的趋势，但并未影响 OSI 发生率。需要评估其他减少穿孔性阑尾炎管理后 OSI 的方法。
