RESUMO
Appendicitis is the most common condition requiring emergency surgery in children. We implemented a standardized protocol (SP) for treating children with appendicitis to provide more uniform care and reduce resource utilization. METHODS: All patients younger than 21 years were managed with the SP beginning in January 2017. We compared data from 22 months before and after implementation. The primary outcomes included the length of stay (LOS), antibiotic days, discharge on intravenous antibiotics, utilization of peripherally inserted central catheters lines, and postoperative imaging. Secondary outcomes were protocol adherence and the rates adverse events, including postoperative abscess, return to emergency department or operating room, surgical site infection, and readmission. RESULTS: Protocol adherence was 92.3%. For uncomplicated cases (n = 412), LOS (P = 0.010) and postoperative antibiotic days (P < 0.001) were significantly reduced. There was no difference in the rates of any adverse event (6.7% versus 2.7%; P = 0.058), postoperative abscess (0.4% versus 0.0%; P = 0.544), return to emergency department (6.3% versus 2.7%; P = 0.084), readmission (1.8% versus 0.5%; P = 0.245), or postoperative ultrasound (0.4% versus 0.5%; P = 0.705) and computed tomography (0.0% versus 0.5%; P = 0.456). For complicated cases (n = 229), the post-SP cohort had a shorter LOS (P = 0.015), fewer peripherally inserted central catheters lines (26.9% versus 2.7%; P < 0.001), fewer postoperative ultrasounds (8.4% versus 1.8%; P = 0.027), and fewer discharges on intravenous antibiotics (17.6% versus 0.9%; P < 0.001). There were no differences in adverse events before and after the SP (16.0% versus 18.3%; P = 0.633). CONCLUSION: Implementing an SP for appendicitis in children reduced resource utilization, and by inference healthcare costs, for both uncomplicated and complicated cases without adversely affecting clinical outcomes.
RESUMO
BACKGROUND/PURPOSE: The incidence of choledocholithiasis is increasing. The diagnosis of common bile duct (CBD) obstruction is based on abnormal CBD size. Establishing norms for CBD size in children would improve diagnostic accuracy. We analyzed ultrasounds (US) to determine normal pediatric CBD size based on age and then validated this against patients with choledocholithiasis. METHODS: A retrospective review was conducted for children less than 21 years of age with US defined CBD size. Patients were stratified into age groups by ANOVA statistical analysis. Secondary analysis included patients with confirmed choledocholithiasis in comparison to the normal cohort. RESULTS: A total of 778 patients had US without pathology. Group 1 (<1 year) had a mean CBD of 1.24±0.54 mm, group 2 (1-10 years) 1.97±0.71 mm, and group 3 (>10 years) 2.98±1.17 mm, p<0.05. Fourteen additional patients were found to have choledocholithiasis with a mean CBD size of 8.1 mm. All patients with choledocholithiasis had CBD sizes outside of our normal range, but only 50% of patients had enlarged CBD size based on adult normal range of values. CONCLUSION: Normal CBD size in children is less than a normal adult patient. More accurate normal values will aid in determining if a child needs further evaluation for possible obstruction of the CBD. TYPE OF STUDY: diagnostic Level of evidence: III.