title: Evaluating the effectiveness of a discharge protocol for children with advanced appendicitis.
abstract: BACKGROUND
  In 2006, an evidence-based protocol for the management of children with appendicitis was established at our institution. Discharge criteria for patients with advanced appendicitis were based on a combination of clinical parameters and laboratory values. The purpose of this study is to evaluate the utility of laboratory values in guiding patient management with a discharge protocol for advanced appendicitis.
  
  
  METHODS
  We reviewed charts of patients with advanced appendicitis as defined by the surgeon intraoperatively from 2008-2009. We evaluated the sensitivity and specificity of the laboratory values at discharge for predicting postoperative intra-abdominal abscess (IAA) formation using a receiver operator curve. A logistic regression analysis was performed to identify predictors of IAA formation.
  
  
  RESULTS
  We identified 450 patients (mean age 8.9 ± 3.9 y). The postoperative IAA rate was 25%. The sensitivity and specificity for developing an abscess with a white blood cell count >12,000/UL were 52% and 82%, respectively (AUC 0.72, 95% CI 0.67-0.78, P < 0.001). The sensitivity and specificity for bands >3% were 47% and 70% (AUC 0.60, 95% CI 0.53-0.67, P = 0.002), respectively. On logistic regression analysis, an elevated white blood cell count was independently associated with an increased likelihood of a postoperative IAA (OR 1.27, 95% CI 1.19-1.35, P < 0.001).
  
  
  CONCLUSIONS
  The absence of leukocytosis is useful for identifying children with a decreased risk of postappendectomy IAA formation who otherwise meet clinical discharge parameters. A band count is not as predictive of risk. The use of laboratory evaluation as a component of discharge criteria in advanced appendicitis can stratify a subset of patients who are at increased IAA risk and may benefit from continued antibiotic therapy.
authors.affiliation: Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas 77030, USA.
authors.forename: Sara C
authors.initials: SC
authors.lastname: Fallon
authors.forename: Mary L
authors.initials: ML
authors.lastname: Brandt
authors.forename: Saif F
authors.initials: SF
authors.lastname: Hassan
authors.forename: David E
authors.initials: DE
authors.lastname: Wesson
authors.forename: J Ruben
authors.initials: JR
authors.lastname: Rodriguez
authors.forename: Monica E
authors.initials: ME
authors.lastname: Lopez
mesh_terms: D018784:Abdominal Abscess / Q000175:diagnosis / Q000453:epidemiology; D000208:Acute Disease; D000465:Algorithms; D001062:Appendectomy; D001064:Appendicitis / Q000175:diagnosis* / Q000453:epidemiology / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D019091:Critical Pathways / Q000592:standards*; D019317:Evidence-Based Medicine; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D010351:Patient Discharge / Q000592:standards*; D017410:Practice Guidelines as Topic; D012372:ROC Curve; D012189:Retrospective Studies; D012307:Risk Factors; D012680:Sensitivity and Specificity; D013530:Surgical Wound Infection / Q000175:diagnosis / Q000453:epidemiology
keywords: Appendicitis; Evidence-based guidelines; Pediatric; Perforated appendicitis