Bedah Journal Reading

5/21/2018 Bedah Journal Reading

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Pembimbing :dr. Wijiono, Sp.OT

Di presentasikan oleh :

Mudhita kurnia syarifa


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Abstract


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Background

Initial antibiotics with planned interval appendectomy (interval AP) have beenused to treat patients with complicated perforated appendicitis

however, little experience exists with this approach in

children with suspected acute perforated appendicitis (SAPA)

We sought to determine the outcome of initial

antibiotics and interval AP in children with SAPA.


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Methods

a prospective observational

time

Over an 18-month period, between February2007 and August 2008

place Miami Children's Hospital


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age

751105 .Therewere 63 males and 42

females with a meanage of 9.8 years(range, 218 years)


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For the purposes of this study, SAPA was defined

by

Duration of symptoms less than 96 hours

Generalized abdominal tenderness on physical exam

Laboratory studies including an elevated white bloodcell count (WBC) N12,000

Diagnostic imaging findings on ultrasound (US) orcomputerized tomography (CT).


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Freeintraabdominal

fluid

Enlarged appendixdiameter greaterthan

7 mm

Diagnostic

imagingfinding


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Criteria excludePatients

withsymptoms

greater than96 hours

Palpablemass onphysical

examination

Imagesshowing a

wellformed

abscess


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PICC was placed for antibiotic administration and patients were treated with aminimum 7-day course

Patients afebrile for 24 hours, tolerating a regular diet and having adequate paincontrol with oral analgesics

Intravenous antibiotics

Piperacillin/tazobactam (100 mg/kg/dose) dosed every 6 hourswas

used primarily

Gentamycin (7.5 mg/kg/day) and clindamycin

(30 mg/kg/day) were used in combination if the patient had a

penicillin allergy

All eligible patients were initially treated

intravenous fluids analgesics intravenous antibioticsoperation planned for

approximately 8 weeks afterdiagnosis


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They weredischarged with a

PICC and home healthcare, undergoingreevaluation on anoutpatient basis

Criteria fordiscontinuingantibiotics

-absence oftenderness on physicalexam

-no temperatureabove 100 F for 48hours

- a normal WBC

About 2 weeks after the cessation of

antibiotic treatment, patients wereseen in the clinic for reevaluation andscheduling of surgery


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Result

(89%) of patients underwent planned interval AP.

(11%) had early appendectomies.


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All SAPA patients were admitted to thehospital for initiation of the nonoperativeprotocol.

Children were treated with antibiotictherapy for a mean duration of 12.9days (range 529).

Ninety-five percent of patients weretreated with piperacillin/tazobactam


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Discussion

All four criteria outlined in the Methods section had to have

been met. Any patient with symptoms longer than 4 days or with

mass or abscess was excluded from the study

Multiple studies have identified the characteristics of children

more likely to present with ruptured appendicitis; these include

younger age, pain longer than 2 to 3 days, generalized abdominal

tenderness and fever over 38 C


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Comparison of clinical characteristics of SAPA

patients to published reports of ruptured

appendicitis presenting with mass or abscess

and treated on an interval managementpathway reveals that SAPA patients tended to

have a shorter duration of symptoms and

lower temperature on admission


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St. Peter et al

evaluated children who over a 2-year span

presented with a well defined abdominal

abscess by CT scan

Forty patients were enrolled and randomized

to either immediate AP or nonoperative

medical management after abscess drainage

followed by interval AP


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Blakely et al

looked at early (64 patients) versus delayed AP

(67 patients) in those patients with acute

perforated appendicitis who did not have a

well-formed abscess or mass on exam


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Early AP

It was shown to have lower adverseevent rates overall, notably lower

occurrence of intraabdominal abscess

Hospital charges and costs weresignificantly lower


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Conclusions

Treatment of SAPA with antibiotics andplanned interval AP is successful in the

majority of patients

complications such as abscess formationand/or readmission prior to planned interval

AP occur in up to one-third of patients

Certain clinical variables are associated withincreased treatment complications.

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