TOP 10 CPG in Our Hospital

2019 - TOP 10 CMH AMBULANCE
TRANSFER
ACUTE APPENDICITIS G1-P0 TO G5P4 PU 39
WEEKS AOG - PER
REQUEST
PREMATURE RUPTURE OF DENGUE FEVER
MEMBRANE SYNDROME
4% 4% 4% FOREIGN BODY FRACTURE (SKULL,
19% FOREARM)
4%
5% MULTIPLE LACERATED MULTIPLE PHYSICAL
18% WOUND INJURIES SEC VEHICULAR
5% ACCIDENT
5% 18%
AGE CHORNIC KIDNEY DISEAE
6%
6% DENGUE FEVER WITH PRE-ECLAMPSIA
WARNING SIGNS
ACUTE APPENDICITIS ok 31
OB PATIENTS IN LABOR - PER REQUEST ok 29
PREMATURE RUPTURE OF MEMBRANE ok 29
DENGUE FEVER WITH WARNING SIGNS 16
FOREIGN BODY 9
FRACTURE (SKULL, FOREARM) ok 8
MULTIPLE LACERATED WOUND ok 8
MULTIPLE PHYSICAL INJURIES SEC VEHICULAR ACCIDENT 8
AGE k 7
CHORNIC KIDNEY DISEAE 7
PRE-ECLAMPSIA 7
CLINICO-PATHOLOGICAL GUIDELINES
1. ACUTE APPENDICITIS
2. OB PATIENTS IN LABOR – TRANSFER PER REQUEST
3. PREMATURE RUPTURE OF MEMBRANE
4. DENGUE FEVER WITH WARNING SIGNS
5. FOREIGN BODY INGESTION AND INHALATION
6. FRACTURE
7. MULTIPLE LACERATED WOUND
8. MULTIPLE PHYSICAL INJURIES SECONDARY TO VEHICULAR ACCIDENTS
9. ACUTE GASTROENTERITIS
10. CHRONIC KIDNEY DISEASE
11. PRE-ECLAMPSIA
PREPARED BY JAMES L. JAVIER PTRP, MD, MHA

CMH – HOSPITAL ADMINISTRATOR
CMH – ER DEPARTMENT HEAD
ACUTE APPENDICITIS
INTRODUCTION
Acute appendicitis is the most common surgical emergency of the abdomen while appendectomy is one of the
most frequently performed surgical procedures. Quite fortunately, the mortality are particularly from perforated
appendicitis has improved from near certain death a century ago a 10-20 percent 50 years ago, 5 percent during
the 1960s and 1 percent o less from the 1970s to present. The morbidity rate, however, remains significant
especially with appediceal rupture where the incidence ranges from 17 percent to 40 percent with a median of 20
percent. To reduce the incidence of perforation, the surgical community traditionally accepts the approximately 15
percent of appendectomies over-all and 20 percent in women will yield a non-inflamed appendix. In certain
populations of patients, the rate of misdiagnosis may even reach 40 percent.
Despite gaining a century of clinical experience with acute appendicitis however, the rates of unnecessary
appendectomies and perforation have remained relatively high. The dramatic expansion of diagnostic testing
options and the introduction of innovative surgical approaches during the last decade have actually caused even
more debate and disagreement than resolultion of issues.
The clinical practice guidelines to be presented herein are statements that bring together the best clinical evidence
and other knowledge necessary for decision-making in the diagnosis and treatment of acute appendicitis. They
were formulated to identiofy the most efficacious interventions in order to maximize the benefits for individual
patients.
OPERATIONAL DEFINITIONS
 Uncomplicated Appendicitis – includes the acutely inflamed, phlegmonous, suppurative or mildly inflamed
with or without peritonitis.
 Complicated Appendicitis – includes gangrenous appendicitis, perforated appendicitis, localized purulent
collection at operation, generalized peritonitis and periappendiceal abscess.
 Equivocal Appendicitis – a patient with right lower quadrant abdominal pain who presents with an atypical
history and physical examination and the surgeon cannot decide whether to discharge or to operate on the
patient.
When should one suspect acute appendicitis?

- Consider the diagnosis of acute appendicitis when a patient with right lower quadrant abdominal pain.
What clinical findings are most helpful in diagnosis acute appendicitis?

- Acute appendicitis should be suspected in any patient (especially male) who presents with high intensity of
perceived abdominal pain of at least 7-12 hours duration, with migration to the right lower quadrant, and
followed by vomiting.
- Although symptoms alone have a low discriminating power, the diagnosis of acute appendicitis becomes more
certain when the physical examination findings include right lower quadrant tenderness, guarding, rebound
tenderness and other signs of peritoneal irritation
What diagnostic tests are helpful in the diagnosis of acute appendicitis?

- Although the diagnosis of acute appendicitis is primarily based on the clinical findings, the following
examinations may be helpful:
A. All Cases
 White Blood Cell with differential count
B. Equivocal Appendicitis in Adults.
 CT scan
 Ultrasound
 Whenever feasible, CT scan should be preferred over ultrasonography in clinically equivocal
appendicitis in adults because of its superior accuracy. (Level I Evidence)
C. Equivocal Appendicitis in the Pediatric Age Group
 Ultrasound (Graded Compression)
 CT scan
 Although CT scan and ultrasound have comparable accuracy in the diagnosis of appendicitis in
the pediatric age group, ultrasound is preferred because of its lack of radiation, cost effectiveness
and availability compared to CT scan.
D. Selected Cases
 Diagnostic Laparoscopy
 Despite its statistically significant favourable effects, diagnostic laparoscopy should be viewed as an
invasive procedure requiring anesthesia and having risks similar to appendectomy. It should be
utilized at this time only in selected cases.
 The following examinations are generally not useful in the diagnosis of acute appendicitis:
 Plain Abdominal X-ray
 Barium Enema
 Scintigraphy
What is the appropriate treatment for acute appendicitis?

- Appendectomy is the appropriate treatment for acute appendicitis.
What is the recommended approach to the surgical; management of acute appendicitis?

- Open appendectomy is the recommended primary approach to the treatment of acute appendicitis in our setting.
Therapeutic laparoscopic appendectomy is an alternative for selected cases.
What is the role of laparoscopic appendectomy in the management of acute appendicitis in children?
- Laparoscopic appendectomy may be recommended as an alternative to open appendectomy in the pediatric age
group.
What is the role of antibiotics in the management of acute appendicitis?

A. Is antibiotic prophylaxis indicated for uncomplicated appendicitis?
 Yes, Antibiotic prophylaxis is effective in the prevention of surgical site infection for patients who undergo
appendectomy and should be considered for routine use.
B. What antibiotic/s is/are recommended for prophylaxis in uncomplicated appendicitis and what is the appropriate
dose and route of administration?
 The following antibiotics are recommended for prophylaxis in uncomplicated appendicitis:
 Cefoxitin 2 gms IV single dose (Adults)
 Cefoxitin 40mg/kg single dose (Children)
 Alternative agents:
 Ampicillin-sulbactam
o 1.5 – 3 grams IV single dose (Adults)
o 75 mg/kg IV single dose (Children)
 Amoxicillin-clavulanate
o 1.2 – 2.4 gram IV single dose (Adults)
o 45 mg/kg IV single dose (Children)
 For patients with allergy to beta-lactam antibiotics:
 Gentamycin 80 – 120 mg IV single dose plus Clindmycin 600 mg IV single dose (Adults)
 Gentamycin 2.5 mg/kg IV single dose plus CLindamycin 7.5 – 10 mg/kg IV single dose (Children)
C. What antibiotic/s is/are recommended for the treatment of complicated appendicitis and what is the appropriate
dose, route and duration of administration?
 The recommended antibiotics for therapy of complicated appendicitis in adults are
o Ertapenem 1 gm IV every 24 hours
o Tazobactam-piperacillin 3.375 grams IV every 6 hours or 4.5 grams IV every 8 hours.
 For adults with beta-lactam allergy:
o Ciprofloxacin 400 mg IV every 12 hours plus Metronidazole 500 mg IV every 6 hours
 The recommended antibiotic for therapy of complicated appendicitis in pediatric patients is
o Ticarcillin-Clavulanic acid 75 mg/kg IV every 6 hours.
 For children with beta-lactam allergy:
o Gentamicin 5 mg/kg IV every 24 hours plus Clindamycin 7.5 – 10 mg/kg IV every 6 hours.
 For gangrenous appendicitis, the recommended form of management is to treat in the same manner as
uncomplicated appendicitis.
 The duration of therapy may vary depending on the clinician’s assessment after the operation. The therapy
may be maintained for 5-7 days. Sequential therapy to oral antibiotics may be considered when
gastrointestinal function has returned.
 The absence of fever 24 hours (temperature < 38 C), the ability to tolerate oral intake, and a normal WBC
count with 3 percent or less band forms are useful parameters for the discontinuation of antibiotic therapy.
 Should gram stain and culture and sensitivity be routinely done?
o Gram stain and culture with sensitivity testing of intra-operative specimens (purulent peritoneal fluid
or tissue) should not be routinely performed except in high-risk and immune-compromised patients
 How should localized peritonitis ne managed?
o No necrotic tissue or purulent material should be left behind as much as possible. General peritoneal
lavage is not recommended for localized peritonitis. Intra-perironeal drain, while most useful in
patients with a well-established and localized abscess cavity, should be selectively utilized.
 What is the appropriate method of wound closure in patients with complicated appendicitis?
o The incision may be closed primarily in patients with complicated appendicitis.
 What is the optimal timing of surgery for patients with periappendiceal abscess?
o A patient with a peri-appendiceal abscess should undergo surgery as soon as the diagnosis is made.

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2019 - TOP 10 CMH AMBULANCE

PREPARED BY JAMES L. JAVIER PTRP, MD, MHA

When should one suspect acute appendicitis?

What clinical findings are most helpful in diagnosis acute appendicitis?

What diagnostic tests are helpful in the diagnosis of acute appendicitis?

What is the appropriate treatment for acute appendicitis?

What is the recommended approach to the surgical; management of acute appendicitis?

What is the role of antibiotics in the management of acute appendicitis?

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