Pediatric Appendicitis Practice Guidelines

Reena Blanco, MD
rnarwan@emory.edu

Alesia Fleming, MD, MPH
aflemi2@emory.edu

 

Acute appendicitis is the most common, non-traumatic surgical emergency encountered in children. Early identification can lead to timely removal preventing perforation and its complications.  Abdominal pain is a common symptom in the emergency department.  To help differentiate the surgical from medical emergencies, CHOA emergency medicine, surgery and radiology teams collaborated to develop the suspected appendicitis clinical guideline.

The broad goals of the team were to:

  • Identify children with the highest risk of appendicitis
  • decrease utilization of abdominal CT to diagnose appendicitis
  • Increase utilization of the Pediatric Appendicitis Score (PAS).
  • Streamline and standardize clinical evaluation
  • Decrease time to diagnosis and definitive care

 

The guideline was implemented in 2013 using the PAS as a common language tool to better communicate across services.  Patients 5 years and older with abdominal pain for less than 72 hours** suspected of having appendicitis are evaluated according to the pathway with screening labs, given an initial IV fluid bolus and pain medication.  After this, the PAS score is calculated and used to further guide care and communicate across services for next steps.

Patients with a PAS of 0-4 have a low suspicion for appendicitis. The physician should consider other diagnoses. There is always a risk that the patient may develop further symptoms as disease progresses therefore if discharged home, these patients need to be seen by their PCP within 24 hours for re-evaluation.

A PAS of 5-7 is equivocal for appendicitis and diagnostic imaging or surgical consult is warranted.  The guideline promotes US as the exam of choice for initial evaluation.  Ultrasound has a sensitivity is 98% and specificity is 92% in identifying appendicitis in those where the appendix was clearly seen. In addition to eliminating exposure to ionizing radiation ultrasound can evaluate female patients for ovarian torsion which is part of the differential of appendicitis.  The exact correlations between radiation exposure and cancer in children is not known, and utilizing alternative imaging modalities such as ultrasound limit exposure to ionizing radiation.

If the patient has a PAS >8 there is a high suspicion for appendicitis, imaging is not required, and surgery should be immediately consulted.

The guideline does not represent a professional care standard and physicians will need to be prudent in determining most appropriate care, but it does offer an approach to abdominal pain that should help with efficiency of care and ultimate outcome of our patients.

 

**exclusions outlined in clinical practice guidelines on md.choa.org under

clinical excellence->clinical practice guidelines

 

 

Bronchiolitis Update 2015

By Maggie Kilgore and Javier Tejedor-Sojo

Margaret.Killgore@choa.org

javier.tejedor-sojo@choa.org

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As we move into bronchiolitis season, we wanted to remind you all of the new recommendations for inpatient and outpatient bronchiolitis treatment published by the AAP in 2014. These new recommendations were incorporated into Children’s Healthcare of Atlanta’s updated guidelines in the fall of 2014. Bronchiolitis is one of the top three admission diagnoses at Children’s. The 2014 Children’s guideline fosters patient-centered, value-based outcomes, more closely supports evidence-based therapies and interventions, and recommends that care providers deliver a consistent message to families.

Some of the key elements of the 2014 AAP guideline are that:

  • Clinicians should diagnose bronchiolitis and assess disease severity on the basis of history and physical examination. Chest X-Rays or laboratory studies should not be obtained routinely
  • Clinicians should not routinely administer albuterol or epinephrine to patients with a diagnosis of bronchiolitis
  • Clinicians should not administer antibacterial medications to infants and children with a diagnosis of bronchiolitis unless there is a concomitant bacterial infection, or a strong suspicion of one
  • In infants with bronchiolitis, clinicians may choose not to administer supplemental oxygen if the O2 saturation exceeds 90%

It can be difficult to explain to families that the best treatment for their child is supportive care. The evidence and the new recommendations support that supportive care is what patients benefit from the most. In regards to albuterol, current recommendations discouraging its use in bronchiolitis are derived from the 2010 Cochrane review which included 10 inpatient and 10 outpatient trials. There was no statistical difference in the rate of hospitalization, length of hospitalization, oximetry nor time to resolution of illness at home between albuterol and placebo treated children. Some brief improvement in clinical respiratory scores was noted among outpatient and hospitalized patients but the standard mean difference was very small and no impact on clinical care would be expected.

There may be a sub-group of children with an underlying predisposition to asthma who may exhibit a response to albuterol. These children are generally older (>12 months) and have either a previous history of wheezing or atopy or a strong family history of asthma in first degree relatives. In the bronchiolitis guideline, these children may receive a single trial of albuterol without other concurrent interventions to determine whether they exhibit a positive clinical response to it. If they indeed have a positive documented response to albuterol these children would be managed under the ED/Inpatient asthma pathway.

Families should be educated that bronchiolitis is a disease that may last for two to three weeks. Many parents present for care because they are concerned their child is not feeding as usual. During the acute illness it is common and expected that children will feed less than their baseline. We need to help parents understand that if their child can sustain their basic fluid needs (even if they take sometimes half of what they typically drink), they are not likely to get dehydrated. Patients who maintain saturations >90% on room air, are able to handle secretions, and can maintain acceptable hydration and activity can generally be treated at home with supportive therapy.

On October 1, 2014 Children’s implemented the guidelines in the ED, Urgent Care, and Inpatient Settings. During the Sept 2014—April 2015 season, we decreased albuterol usage in 1-12 month olds with bronchiolitis from 45% to 25% in the ED and from 40% to 11% for patients who were admitted. We were able to achieve these results without negatively impacting our length of stay or 7 day readmission rate. Reducing the use of therapies that have not demonstrated benefit to our patients and helping them return home sooner if medically stable, is an example of delivering value to them and their families.

If there are any questions about the guideline, feel free to contact :

Dr Shabnam Jain sjain@emory.edu

Dr Tejedor-Sojo  javier.tejedor-sojo@choa.org

Please see the link below to the clinical guideline page on the physician portal for access to our guidelines, link to the AAP 2014 recommendations, and see Children’s full evidence summary that is posted on the physician portal:

https://md.choa.org/clinical-excellence/clinical-practice-guidelines/bronchiolitis