Department of Pediatric General, Thoracic, and Minimally Invasive Surgery, Saint Christopher's Hospital for Children, Philadelphia, Pennsylvania, United States.
Department of Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania, United States.
Eur J Pediatr Surg. 2021 Feb;31(1):14-19. doi: 10.1055/s-0040-1715439. Epub 2020 Aug 23.
To standardize care and reduce resource utilization, we implemented a standardized protocol (SP) for the nonoperative treatment of complicated appendicitis.
We conducted a prospective, historically controlled, study of patients <21 years with complicated appendicitis managed nonoperatively using an SP from January 2017 to November 2018. The primary outcomes included length of stay (LOS), antibiotic days, peripheral inserted central catheter (PICC) utilization, discharge on intravenous antibiotics, and predischarge imaging. Secondary outcomes were protocol adherence and the rates of adverse events (AE) including return to emergency department (ED), readmission, failure of nonoperative treatment, and interval appendectomy complications.
Protocol adherence was 67.9%. In total, 741 children were treated for appendicitis of which 58 (30 pre-SP and 28 post-SP) were treated nonoperatively for complicated appendicitis at presentation. Patients were well matched for age, admission white blood cell, sex, body mass index, race, and the proportion requiring percutaneous drainage. After implementing the SP, fewer children had PICCs (100.0 vs. 57.1%, ≤ 0.001), fewer were discharged on intravenous antibiotics (90.0 vs. 42.9%, < 0.001), and total antibiotic days were reduced (14.0 vs. 10.0, = 0.006). There was no difference in LOS (5.5 vs. 6.0 days, = 0.790) or the proportion undergoing ultrasound (36.7 vs. 39.3%, = 0.837) or computed tomography scan (16.7 vs. 3.6%, = 0.195) prior to discharge. There were nonsignificant trends toward reduced AEs (46.7 vs. 35.7%, = 0.397), returns to ED (40.0 vs. 28.6%, = 0.360), and readmissions (26.7 vs. 17.9%, = 0.421). The proportion failing nonoperative treatment (10.0 vs. 3.6%, = 0.612) and experiencing complications of interval appendectomy (3.3 vs. 3.6%, = 0.918) were not significantly different.
Implementing an SP for treating complicated appendicitis nonoperatively reduced resource utilization without negatively affecting clinical outcomes.
为了规范治疗并减少资源利用，我们针对复杂性阑尾炎的非手术治疗制定了标准化方案（SP）。
我们对 2017 年 1 月至 2018 年 11 月期间使用 SP 接受非手术治疗的 21 岁以下复杂性阑尾炎患者进行了前瞻性、历史对照研究。主要结局指标包括住院时间（LOS）、抗生素使用天数、外周插入中心导管（PICC）使用、静脉抗生素出院和出院前影像学检查。次要结局指标为方案遵循率和不良事件（AE）发生率，包括返回急诊部（ED）、再入院、非手术治疗失败和间隔期阑尾切除术后并发症。
方案遵循率为 67.9%。共有 741 名儿童因阑尾炎接受治疗，其中 58 名（30 名在 SP 前，28 名在 SP 后）在就诊时患有复杂性阑尾炎，接受非手术治疗。患者在年龄、入院时白细胞计数、性别、体重指数、种族和需要经皮引流的比例方面匹配良好。实施 SP 后，接受 PICC 治疗的患儿减少（100.0% vs. 57.1%，≤0.001），静脉抗生素出院的患儿减少（90.0% vs. 42.9%，<0.001），抗生素总使用天数减少（14.0 天 vs. 10.0 天，=0.006）。 LOS（5.5 天 vs. 6.0 天，=0.790）或出院前超声（36.7% vs. 39.3%，=0.837）或 CT 扫描（16.7% vs. 3.6%，=0.195）的比例无差异。AE（46.7% vs. 35.7%，=0.397）、返回 ED（40.0% vs. 28.6%，=0.360）和再入院（26.7% vs. 17.9%，=0.421）的发生率有降低的趋势，但无统计学意义。非手术治疗失败（10.0% vs. 3.6%，=0.612）和间隔期阑尾切除术后并发症（3.3% vs. 3.6%，=0.918）的发生率无显著差异。
针对复杂性阑尾炎的非手术治疗实施 SP 可减少资源利用，而不会对临床结局产生负面影响。
