Difference between revisions of "Appendectomy"
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| airway = Endotracheal tube | | airway = Endotracheal tube | ||
| lines_access = Peripheral IV | | lines_access = Peripheral IV | ||
| monitors = Standard | | monitors = Standard | ||
| considerations_preoperative = Full stomach precautions | | considerations_preoperative = Full stomach precautions | ||
| considerations_intraoperative = Rapid sequence induction | | considerations_intraoperative = Rapid sequence induction | ||
| considerations_postoperative = PONV | | considerations_postoperative = PONV | ||
| image_file = | | image_file = | ||
}}An appendectomy is generally performed as an urgent or emergent procedure to treat appendicitis. Appendicitis can occur at any age, but is more common in patients 19-25 years old. Appendicitis is common, occurring in about 7% of the population. An appendectomy can be performed laparoscopically or as an open procedure. Surgical practice has largely transitioned to the laparoscopic approach<ref>{{Cite journal|last=Bhangu|first=Aneel|last2=Søreide|first2=Kjetil|last3=Di Saverio|first3=Salomone|last4=Assarsson|first4=Jeanette Hansson|last5=Drake|first5=Frederick Thurston|date=2015|title=Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management|url=https://linkinghub.elsevier.com/retrieve/pii/S0140673615002755|journal=The Lancet|language=en|volume=386|issue=10000|pages=1278–1287|doi=10.1016/S0140-6736(15)00275-5|via=}}</ref>. | }}An '''appendectomy''' is generally performed as an urgent or emergent procedure to treat appendicitis. Appendicitis can occur at any age, but is more common in patients 19-25 years old. Appendicitis is common, occurring in about 7% of the population. An appendectomy can be performed laparoscopically or as an open procedure. Surgical practice has largely transitioned to the laparoscopic approach<ref>{{Cite journal|last=Bhangu|first=Aneel|last2=Søreide|first2=Kjetil|last3=Di Saverio|first3=Salomone|last4=Assarsson|first4=Jeanette Hansson|last5=Drake|first5=Frederick Thurston|date=2015|title=Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management|url=https://linkinghub.elsevier.com/retrieve/pii/S0140673615002755|journal=The Lancet|language=en|volume=386|issue=10000|pages=1278–1287|doi=10.1016/S0140-6736(15)00275-5|via=}}</ref>. | ||
==Preoperative management== | ==Preoperative management== | ||
===Preoperative evaluation<!-- Provide a brief overview of the preoperative evaluation and optimization of patients for this case. Also list relevant labs, studies, or physical exam findings. If none, this section may be removed. -->=== | ===Preoperative evaluation<!-- Provide a brief overview of the preoperative evaluation and optimization of patients for this case. Also list relevant labs, studies, or physical exam findings. If none, this section may be removed. -->=== | ||
| Line 17: | Line 17: | ||
!Considerations | !Considerations | ||
|- | |- | ||
| | |Pulmonary | ||
| | | | ||
* Acute abdominal pain can cause respiratory impairment (respiratory splinting) resulting in atelectasis | * Acute abdominal pain can cause respiratory impairment (respiratory splinting) resulting in atelectasis | ||
|- | |- | ||
|Cardiovascular | |Cardiovascular | ||
| | | | ||
* May be dehydrated due to fever, emesis, and reduced oral intake | *May be dehydrated due to fever, emesis, and reduced oral intake | ||
* Assess volume status by checking vital signs, mucus membranes, skin turgor. | *Assess volume status by checking vital signs, mucus membranes, skin turgor. | ||
* IV hydration before anesthetic induction | *IV hydration before anesthetic induction | ||
|- | |- | ||
|Gastrointestinal | |Gastrointestinal | ||
| | | | ||
* Patients typically present with nausea and vomiting. | *Patients typically present with nausea and vomiting. | ||
* Patients with acute abdomen should be treated as if they have full stomachs. | *Patients with acute abdomen should be treated as if they have full stomachs. | ||
* Muscular resistance to palpation (muscle guarding) can correlate with severity of the inflammatory process. | *Muscular resistance to palpation (muscle guarding) can correlate with severity of the inflammatory process. | ||
|- | |- | ||
|Hematologic | |Hematologic | ||
| | | | ||
* Patients typically have moderate leukocytosis with left shift | *Patients typically have moderate leukocytosis with left shift | ||
* Expect hemoconcentration if patient dehydrated | *Expect hemoconcentration if patient dehydrated | ||
|- | |- | ||
|Labs | |Labs | ||
| | | | ||
* CBC | * CBC | ||
* Chemistry Panel | *Chemistry Panel | ||
* Pregnancy test (for women of child bearing age) | *Pregnancy test (for women of child bearing age) | ||
|} | |} | ||
===Operating room preparation<!-- List any special, non-standard equipment, medications, fluids, or other preparations that should be made prior to surgery. If none, this section may be removed. -->=== | ===Operating room preparation<!-- List any special, non-standard equipment, medications, fluids, or other preparations that should be made prior to surgery. If none, this section may be removed. -->=== | ||
* NG | *OG Tube (or NG if going to be left post-op) | ||
* Verify pre-incisions antibiotics required | *Verify pre-incisions antibiotics required | ||
=== Regional and neuraxial techniques === | ===Regional and neuraxial techniques=== | ||
* Consider pre-incision nerve blocks | *Consider pre-incision nerve blocks | ||
==Intraoperative management== | ==Intraoperative management== | ||
===Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. -->=== | ===Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. -->=== | ||
* Standard ASA monitors | *Standard ASA monitors | ||
* 5-lead EKG | *5-lead EKG | ||
* Urinary catheter | *Urinary catheter | ||
* 1 peripheral IV (typically | *1 peripheral IV (typically 18-20 gauge) | ||
===Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. -->=== | ===Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. -->=== | ||
* Pre-oxygenate with 100% FiO2 | *Pre-oxygenate with 100% FiO2 | ||
* Rapid Sequence Induction (RSI) | *Rapid Sequence Induction (RSI) | ||
* Intubation | *Intubation | ||
===Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. -->=== | ===Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. -->=== | ||
* Supine | *Supine | ||
* Secure or tuck the arms | *Secure or tuck the arms / Check IV | ||
===Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. -->=== | ===Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. -->=== | ||
* Standard maintenance | *Standard maintenance | ||
** Consider avoiding nitrous oxide given potential for bowel dissension and increased risk of PONV | **Consider avoiding nitrous oxide given potential for bowel dissension and increased risk of PONV | ||
* Place OG/NG before surgical incision to decompress the stomach | * Place OG/NG before surgical incision to decompress the stomach | ||
* Maintain | *Maintain normovolemia and normothermia | ||
===Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->=== | ===Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->=== | ||
* Extubate when patient awake and able to protect airway | *Extubate when patient awake and able to protect airway | ||
* PONV prophylaxis | *PONV prophylaxis | ||
==Postoperative management== | ==Postoperative management== | ||
===Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. -->=== | ===Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. -->=== | ||
* PACU | *PACU | ||
** Patients undergoing laparoscopic appendectomy can often be discharged home from PACU | **Patients undergoing laparoscopic appendectomy can often be discharged home from PACU | ||
* Encourage early post-operative ambulation | *Encourage early post-operative ambulation | ||
===Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->=== | ===Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->=== | ||
* Oral analgesics | *Oral analgesics | ||
* Non-opioid analgesics | *Non-opioid analgesics | ||
** Ketoralac (Toradol) | **Ketoralac (Toradol) | ||
** Acetaminophen (Tylenol) | **Acetaminophen (Tylenol) | ||
* IV narcotics for breakthrough pain | *IV narcotics for breakthrough pain | ||
===Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->=== | ===Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->=== | ||
* PONV | *PONV | ||
* Urinary retention (consider straight catheterization of bladder prior to emergence) | *Urinary retention (consider straight catheterization of bladder prior to emergence) | ||
==Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). -->== | ==Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). -->== | ||
{| class="wikitable" | {| class="wikitable" | ||
| Line 165: | Line 158: | ||
Conversion to Open | Conversion to Open | ||
|- | |- | ||
| Pain | |Pain | ||
|5-7 | |5-7 | ||
|4 | |4 | ||
Latest revision as of 21:57, 4 April 2022
Appendectomy
| Anesthesia type |
General |
|---|---|
| Airway |
Endotracheal tube |
| Lines and access |
Peripheral IV |
| Monitors |
Standard |
| Primary anesthetic considerations | |
| Preoperative |
Full stomach precautions |
| Intraoperative |
Rapid sequence induction |
| Postoperative |
PONV |
| Article quality | |
| Editor rating | |
| User likes | 2 |
An appendectomy is generally performed as an urgent or emergent procedure to treat appendicitis. Appendicitis can occur at any age, but is more common in patients 19-25 years old. Appendicitis is common, occurring in about 7% of the population. An appendectomy can be performed laparoscopically or as an open procedure. Surgical practice has largely transitioned to the laparoscopic approach[1].
Preoperative management
Preoperative evaluation
| System | Considerations |
|---|---|
| Pulmonary |
|
| Cardiovascular |
|
| Gastrointestinal |
|
| Hematologic |
|
| Labs |
|
Operating room preparation
- OG Tube (or NG if going to be left post-op)
- Verify pre-incisions antibiotics required
Regional and neuraxial techniques
- Consider pre-incision nerve blocks
Intraoperative management
Monitoring and access
- Standard ASA monitors
- 5-lead EKG
- Urinary catheter
- 1 peripheral IV (typically 18-20 gauge)
Induction and airway management
- Pre-oxygenate with 100% FiO2
- Rapid Sequence Induction (RSI)
- Intubation
Positioning
- Supine
- Secure or tuck the arms / Check IV
Maintenance and surgical considerations
- Standard maintenance
- Consider avoiding nitrous oxide given potential for bowel dissension and increased risk of PONV
- Place OG/NG before surgical incision to decompress the stomach
- Maintain normovolemia and normothermia
Emergence
- Extubate when patient awake and able to protect airway
- PONV prophylaxis
Postoperative management
Disposition
- PACU
- Patients undergoing laparoscopic appendectomy can often be discharged home from PACU
- Encourage early post-operative ambulation
Pain management
- Oral analgesics
- Non-opioid analgesics
- Ketoralac (Toradol)
- Acetaminophen (Tylenol)
- IV narcotics for breakthrough pain
Potential complications
- PONV
- Urinary retention (consider straight catheterization of bladder prior to emergence)
Procedure variants
| Open Appendectomy | Laparoscopic Appendectomy | |
|---|---|---|
| Position | Supine | Supine |
| Surgical time | 1 hour | 30-90 mins |
| EBL | <75 mL | <75 mL |
| Postoperative disposition | PACU | PACU |
| Mortality | Perforated: 2%
Non-perforated: <0.1% |
Perforated: 2%
Non-perforated: <0.1% |
| Complications | Perforation
Abscess Fistula Hematoma Illeus |
Perforation
Abscess Fistula Hematoma Illeus Conversion to Open |
| Pain | 5-7 | 4 |
References
- ↑ Bhangu, Aneel; Søreide, Kjetil; Di Saverio, Salomone; Assarsson, Jeanette Hansson; Drake, Frederick Thurston (2015). "Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management". The Lancet. 386 (10000): 1278–1287. doi:10.1016/S0140-6736(15)00275-5.
Top contributors: Barrett Larson, Chris Rishel, Tony Wang and Olivia Sutton