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| considerations_postoperative = PONV
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}}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=2015-09|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}}</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. -->===
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** 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 norovolemia and normothermia
* 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. -->===
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<references />
<references />


[[Category:Surgical case reference]]
[[Category:Surgical procedures]]
[[Category:General surgery]]
[[Category:Intestinal surgery]]

Revision as of 14:52, 29 March 2021

Appendectomy
Anesthesia type

General

Airway

Endotracheal tube

Lines and access

Peripheral IV

Monitors

Standard ASA / 5-Lead EKG

Primary anesthetic considerations
Preoperative

Full stomach precautions

Intraoperative

Rapid sequence induction

Postoperative

PONV

Article quality
Editor rating
Certified
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
Respiratory
  • Acute abdominal pain can cause respiratory impairment (respiratory splinting) resulting in atelectasis
Cardiovascular
  • May be dehydrated due to fever, emesis, and reduced oral intake
  • Assess volume status by checking vital signs, mucus membranes, skin turgor.
  • IV hydration before anesthetic induction
Gastrointestinal
  • Patients typically present with nausea and vomiting.
  • 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.
Hematologic
  • Patients typically have moderate leukocytosis with left shift
  • Expect hemoconcentration if patient dehydrated
Labs
  • CBC
  • Chemistry Panel
  • Pregnancy test (for women of child bearing age)

Operating room preparation

  • NG Tube
  • 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 16-18 gauge)

Induction and airway management

  • Pre-oxygenate with 100% FiO2
  • Rapid Sequence Induction (RSI)
  • Intubation

Positioning

  • Supine
  • Secure or tuck the arms

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

  1. 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.