Pediatric Appendicitis A Clinical Pathway James Reingold, M.D. November 3,4 2011.

Pediatric AppendicitisPediatric AppendicitisA Clinical PathwayA Clinical Pathway

James Reingold, M.D.James Reingold, M.D.

November 3,4 2011November 3,4 2011

James Reingold, M.D.James Reingold, M.D.

• Medical Director, Cardon Children’s EDMedical Director, Cardon Children’s ED• Board Certified, PEM (Peds, Peds ER)Board Certified, PEM (Peds, Peds ER)• Member of the defunct ED Order Set Member of the defunct ED Order Set

WorkgroupWorkgroup– Goals of standardizing care to “best Goals of standardizing care to “best

practice” and reducing riskpractice” and reducing risk

• Member of Peds CCGMember of Peds CCG• 4+ years with “The Bannerman”4+ years with “The Bannerman”

Risk ConsiderationsRisk Considerations

• ““The ED is often crowded, waits are The ED is often crowded, waits are long and privacy is limited. The ED long and privacy is limited. The ED environment is often one of excessive environment is often one of excessive noise, high volume, and extreme noise, high volume, and extreme pressure and stress.”pressure and stress.”

• Especially weekends, holidays, evenings Especially weekends, holidays, evenings and nights spawn litigation (80%!)and nights spawn litigation (80%!)

• The ED accounts for 45% of peds casesThe ED accounts for 45% of peds cases

Risk ConsiderationsRisk Considerations

• By age 6 yrs, appendicitis is the 2By age 6 yrs, appendicitis is the 2ndnd most common diagnosis claimmost common diagnosis claim

• Insurance co. complaints about Insurance co. complaints about Banner prolonged LOS and Banner prolonged LOS and perforation rateperforation rate

• Testicular Torsion is #3 for boys 12-Testicular Torsion is #3 for boys 12-17 yrs, do your TSG course!17 yrs, do your TSG course!

Pediatric AppendicitisPediatric Appendicitis

• The most common surgical emergency The most common surgical emergency in childrenin children

• 70K appendectomies each yr in the US70K appendectomies each yr in the US

• Appendicitis is rare before age 1, when Appendicitis is rare before age 1, when the appendix is “funnel shaped”the appendix is “funnel shaped”

• Appendicitis under age 4 results in Appendicitis under age 4 results in perforation rates of 80-100%perforation rates of 80-100%

Pediatric AppendicitisPediatric Appendicitis

• Appendicitis incidence peaks at age Appendicitis incidence peaks at age 10-20 yrs because of lymphoid 10-20 yrs because of lymphoid follicle hyperplasia, but perforation follicle hyperplasia, but perforation rate is only 10-20%rate is only 10-20%

• Taken together, children 0-17 have Taken together, children 0-17 have perforation rate of 33%perforation rate of 33%

Radiation ConcernsRadiation Concerns

• Concern over missed appendicitis led Concern over missed appendicitis led to widespread use of CTto widespread use of CT

• A clinical guideline at Harvard A clinical guideline at Harvard pushing CT imaging decreased both pushing CT imaging decreased both the negative appendectomy rate and the negative appendectomy rate and admission for serial abdominal admission for serial abdominal examsexams– Perforation rate was unchangedPerforation rate was unchanged– CT rate increased from 5% to 60%CT rate increased from 5% to 60%


• Adult CT is more common but the Adult CT is more common but the rate of increase is larger among rate of increase is larger among children, primarily because CT is now children, primarily because CT is now faster and does not require sedationfaster and does not require sedation

• ““The major growth area in CT use for The major growth area in CT use for children has been the presurgical children has been the presurgical diagnosis of appendicitis.”diagnosis of appendicitis.”


• Children are at higher risk of radiation-Children are at higher risk of radiation-induced carcinogenesis because of greater induced carcinogenesis because of greater sensitivity to radiation as well as a longer sensitivity to radiation as well as a longer life span to allow cancers to developlife span to allow cancers to develop– They are also more likely to undergo further CT They are also more likely to undergo further CT

imaging as they ageimaging as they age– Lifetime attributable risk of death from cancer Lifetime attributable risk of death from cancer

from a SINGLE abd CT for a 5 y/o is 0.09%from a SINGLE abd CT for a 5 y/o is 0.09%– Of 600K children/yr who undergo CT, 500 will Of 600K children/yr who undergo CT, 500 will

develop cancer (slightly less than 1/10,000 develop cancer (slightly less than 1/10,000 risk)risk)


• Atomic Bomb dataAtomic Bomb data– 25,000 survivors received a dose less 25,000 survivors received a dose less

than 50 mSv, mean dose 40 mSVthan 50 mSv, mean dose 40 mSV– A single CT Abd study delivers 45-90 A single CT Abd study delivers 45-90

mSv radiation depending on agemSv radiation depending on age– 1.5-2% of all cancer in the US now 1.5-2% of all cancer in the US now

attributable to CT imagingattributable to CT imaging


• Is there a difference between “clean” Is there a difference between “clean” radiation from GE and “dirty” radiation from GE and “dirty” radiation from an atomic bomb?radiation from an atomic bomb?

• 400,000 radiation workers exposed 400,000 radiation workers exposed to 20 mSvto 20 mSv– Mortality from cancer correlated to Mortality from cancer correlated to

radiation dose within 5-150 mSvradiation dose within 5-150 mSv– Correlated with A-bomb dataCorrelated with A-bomb data

Alvarado ScoreAlvarado Score

• This study from 1986 published in Annals This study from 1986 published in Annals of Emergency Medicine was a retrospective of Emergency Medicine was a retrospective review of 305 surgical admissions to review of 305 surgical admissions to Nazareth Hospital in PhiladelphiaNazareth Hospital in Philadelphia– Charts pulled over 24 mos, 1975-76Charts pulled over 24 mos, 1975-76

• 74% prevalence of appendicitis!74% prevalence of appendicitis!• Study Goal: Approach pts in a rational Study Goal: Approach pts in a rational

manner using a simple diagnostic score for manner using a simple diagnostic score for observation vs surgeryobservation vs surgery

• Discussed a MANTRELS score to aid in Discussed a MANTRELS score to aid in diagnosisdiagnosis

MANTRELSMANTRELS

• MMigration of pain to the RLQigration of pain to the RLQ

• AAnorexianorexia

• NNausea/vomitingausea/vomiting

• TTenderness in the RLQenderness in the RLQ

• RRebound tendernessebound tenderness

• EElevation of templevation of temp

• LLeukocytosiseukocytosis

• SShfit of WBC counthfit of WBC count

Evaluation of Alvarado Evaluation of Alvarado ScoreScore• Bond, et al. Annals of Emergency Bond, et al. Annals of Emergency

Medicine, 1990Medicine, 1990– 11stst to stratify the score to specified risk levels to stratify the score to specified risk levels– Among children with a score of 4 or lower, Among children with a score of 4 or lower,

none had appendicitisnone had appendicitis– Other studies report negative likelihood ratio Other studies report negative likelihood ratio

of 0.05of 0.05•(9% x 0.05=0.45%)(9% x 0.05=0.45%)

– Score performed best among older children. Score performed best among older children.

Evaluation of Alvarado Evaluation of Alvarado ScoreScore• Three prospective studies show a score of Three prospective studies show a score of

7 or higher increases the likelihood of 7 or higher increases the likelihood of appendicitis 4x (95% CI=3-5)appendicitis 4x (95% CI=3-5)– So 9% x 4=36%So 9% x 4=36%

• Macklin, et al. Annals of the Royal College Macklin, et al. Annals of the Royal College of Surgeons of England.of Surgeons of England.– Performance unchanged by dropping Performance unchanged by dropping SS (left (left

shift)shift)– ““Modified Alvarado,” this is what we are usingModified Alvarado,” this is what we are using

Clinical Practice GuidelinesClinical Practice Guidelines

• Harvard has received the most Harvard has received the most attentionattention

• Surgical consultation BEFORE imagingSurgical consultation BEFORE imaging– The Heidi Cox, MD memorial ED consultThe Heidi Cox, MD memorial ED consult

• If classic, to OR without labsIf classic, to OR without labs

• If concerning, labsIf concerning, labs

• If imaging negative, homeIf imaging negative, home

• Age <4 excludedAge <4 excluded

Clinical Practice GuidelinesClinical Practice Guidelines

• Harvard ResultsHarvard Results– 34% appendicitis prevalence34% appendicitis prevalence– 60% presented in 24 hours (earlier, was 60% presented in 24 hours (earlier, was

36 hours for Alvarado)36 hours for Alvarado)– Sensitivity and specificity were >95%Sensitivity and specificity were >95%– 60% use of CT, 18% use of CT + US60% use of CT, 18% use of CT + US

UltrasonographyUltrasonography

• Annals of Emergency Medicine, Clinical Annals of Emergency Medicine, Clinical Policy on Suspected Appendicitis, 2010Policy on Suspected Appendicitis, 2010– Level B recommendation, use US “to Level B recommendation, use US “to

confirm acute appy but not to definitively confirm acute appy but not to definitively exclude it.”exclude it.”

– Use CT “to confirm or exclude acute appy.”Use CT “to confirm or exclude acute appy.”– Level C, “consider using US as the initial Level C, “consider using US as the initial

imaging modality. In cases in which the dx imaging modality. In cases in which the dx remains uncertain, CT may be performed.”remains uncertain, CT may be performed.”

UltrasoundUltrasound

• What is a (+) US?What is a (+) US?– Diagnostic criteria for appendicitis are an Diagnostic criteria for appendicitis are an

appendix greater than 6 mm in diameterappendix greater than 6 mm in diameter– A noncompressible appendix A noncompressible appendix – Appendiceal tenderness. Appendiceal tenderness.

• LimitationsLimitations– the appendix may be obscured (by bowel the appendix may be obscured (by bowel

gas or overlying fat) or difficult to find gas or overlying fat) or difficult to find (eg, retrocecal position)(eg, retrocecal position)


• The 7 studies that evaluate the diagnostic The 7 studies that evaluate the diagnostic accuracy of ultrasound in pediatric accuracy of ultrasound in pediatric appendicitis support the idea that appendicitis support the idea that ultrasound is better at positively ultrasound is better at positively identifying appendicitis than excluding itidentifying appendicitis than excluding it

• Although 3 of the 7 studies report negative Although 3 of the 7 studies report negative likelihood ratios for US less than 0.1, 5 of likelihood ratios for US less than 0.1, 5 of these 7 studies report positive likelihood these 7 studies report positive likelihood ratios greater than 10 ratios greater than 10


• Sensitivity likely in the 88% rangeSensitivity likely in the 88% range

• Specificity in the 95% rangeSpecificity in the 95% range

• Operator specific, accuracy improves Operator specific, accuracy improves with the volume of studies performedwith the volume of studies performed– High volume centers report less High volume centers report less

“appendix not visualized”“appendix not visualized”

Combining US and CTCombining US and CT

• Harvard warningHarvard warning– Karakas, et al, 1999. 633 children. Karakas, et al, 1999. 633 children.

Perforation rate increased “substantially” Perforation rate increased “substantially” among pts who underwent both US and CTamong pts who underwent both US and CT

– This is presumed to be due to a delay in This is presumed to be due to a delay in reaching the ORreaching the OR

– In rural Canada, prolonged transfer to a In rural Canada, prolonged transfer to a pediatric surgeon correlated with pediatric surgeon correlated with perforatoinperforatoin


• Future Research: A study evaluating Future Research: A study evaluating a Bayesian approach using a Bayesian approach using ultrasound to diagnose appendicitis ultrasound to diagnose appendicitis in children would be very helpful. For in children would be very helpful. For example, such a study would identify example, such a study would identify the probabilities of appendicitis in the probabilities of appendicitis in children with low, moderate, and children with low, moderate, and high pre-test clinical suspicion.high pre-test clinical suspicion.


• From Schneider, et al (Annals, 2007) “One From Schneider, et al (Annals, 2007) “One editorial argues that both ultrasonography editorial argues that both ultrasonography and CT can have a role in diagnosisand CT can have a role in diagnosis

• According to the editorial, the main goal of According to the editorial, the main goal of imaging should be rational use of imaging imaging should be rational use of imaging resources and radiation dose reduction.resources and radiation dose reduction.

• Perhaps the ideal scoring system could Perhaps the ideal scoring system could clearly stratify patients into those who can clearly stratify patients into those who can go directly to the operating room, those go directly to the operating room, those who should have radiologic imaging, and who should have radiologic imaging, and those who can be observed.”those who can be observed.”

Banner CPG (Finally!)Banner CPG (Finally!)

• Assign a modified Alvarado ScoreAssign a modified Alvarado Score– RLQ Pain (1 point)RLQ Pain (1 point)– Anorexia (1 point)Anorexia (1 point)– N/V (1 point)N/V (1 point)– RLQ TTP (1 point)RLQ TTP (1 point)– Rebound in RLQ (2 points)Rebound in RLQ (2 points)– Fever >37.5C (1 point)Fever >37.5C (1 point)– WBC >10K (2 points)WBC >10K (2 points)

Banner CPGBanner CPG

• Stratify risk according to scoreStratify risk according to score– 0-3 low risk, send home with good follow-up0-3 low risk, send home with good follow-up– 4-6 intermediate risk, will require imaging4-6 intermediate risk, will require imaging– 7-9, high risk, send to Peds ER for surgical 7-9, high risk, send to Peds ER for surgical

consultation, may be able to avoid imaging consultation, may be able to avoid imaging and speed time to OR, reduce risk of ruptureand speed time to OR, reduce risk of rupture•Avoid the radiation and delay of “confirming the Avoid the radiation and delay of “confirming the

diagnosis”diagnosis”


• Those children requiring imaging will Those children requiring imaging will undergo US if their body habitus is undergo US if their body habitus is amenableamenable

• This will require transferring children to a This will require transferring children to a Peds ED where experienced US techs and Peds ED where experienced US techs and radiologists are presentradiologists are present

• Those children undergoing CT can stay putThose children undergoing CT can stay put– This includes slim children whose pain has This includes slim children whose pain has

been >48 hours in durationbeen >48 hours in duration

Limited CT Appendicitis Limited CT Appendicitis ProtocolProtocol• T-Bird developed a “Limited” CT for T-Bird developed a “Limited” CT for

pediatric r/o appypediatric r/o appy

• From L1 to symphysis pubis (pelvis From L1 to symphysis pubis (pelvis only)only)

• IV contrast onlyIV contrast only

• Significantly reduced radiation and Significantly reduced radiation and time to study completiontime to study completion

• Indicated for pain <48 hoursIndicated for pain <48 hours

CT with PO and IV contrastCT with PO and IV contrast

• Because of the increased rate of Because of the increased rate of perforation and abscess formation, perforation and abscess formation, as well obstruction, children with as well obstruction, children with pain >48 hours will still undergo CT pain >48 hours will still undergo CT Abd/Pelvis with both PO and IV Abd/Pelvis with both PO and IV contrastcontrast


• Children with (+) CT may be transferred to Children with (+) CT may be transferred to the inpatient pediatric service to await the inpatient pediatric service to await appendectomyappendectomy

• Children with a negative CT may be sent Children with a negative CT may be sent home or observed if neededhome or observed if needed

• Children with a negative US should Children with a negative US should proceed to CT if there is high suspicionproceed to CT if there is high suspicion

• Children with a (+) CT after US will go to Children with a (+) CT after US will go to OROR

Cerner Clinical Decision Cerner Clinical Decision SupportSupport• Cerner will apply these rules “behind Cerner will apply these rules “behind

the scenes” so that you can answer the scenes” so that you can answer questions after the labs are back and questions after the labs are back and appropriate orders will be suggestedappropriate orders will be suggested

• This will allow Cerner to track the This will allow Cerner to track the Alvarado score and the resulting Alvarado score and the resulting physician orderphysician order

• Finally, Outcomes Research!!Finally, Outcomes Research!!

Cerner Clinical Decision Cerner Clinical Decision SupportSupport• Do I need to use Decision Support?Do I need to use Decision Support?

– Yes!Yes!

• Simplifies use of the new guidelineSimplifies use of the new guideline

• Allows quality control and tracking of Allows quality control and tracking of expenseexpense

• You must hit “done” to record the You must hit “done” to record the score but can delete orders from score but can delete orders from scratchpadscratchpad

What will need to be What will need to be tracked?tracked?• Use of CT (desired direction=less)Use of CT (desired direction=less)• Rate of perforation (less)Rate of perforation (less)• Rate of negative appendectomy (stable)Rate of negative appendectomy (stable)• Number of patients transferred and Number of patients transferred and

attendant cost (qualitative)attendant cost (qualitative)• Number of children undergoing dual Number of children undergoing dual

imaging (false negative rate of US)imaging (false negative rate of US)• Total cost of imaging (qualitative)Total cost of imaging (qualitative)

Expected OutcomesExpected Outcomes

• Less use of CT in low pretest probability Less use of CT in low pretest probability childrenchildren

• Increased use of US in mid-pretest Increased use of US in mid-pretest probability childrenprobability children

• Decreased use of any imaging in high Decreased use of any imaging in high pretest children, faster time to ORpretest children, faster time to OR

• Faster transfer to peds surgeon (less Faster transfer to peds surgeon (less time at referral center), faster arrival in time at referral center), faster arrival in OROR

Expected OutcomesExpected Outcomes

• More children completing their More children completing their evaluation in the Peds ED (being sent evaluation in the Peds ED (being sent without imaging)without imaging)

• More chlidren moving to the Peds EDMore chlidren moving to the Peds ED– Some children will have negative US and Some children will have negative US and

will be sent back home, but may have will be sent back home, but may have been spared CT or unnecessary direct been spared CT or unnecessary direct admitadmit

Pediatric Appendicitis A Clinical Pathway James Reingold, M.D. November 3,4 2011.

Documents

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