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

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
  • Acute abdominal pain can cause respiratory impairment (respiratory splinting) resulting in atelectasis
  • 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
  • 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.
  • Patients typically have moderate leukocytosis with left shift
  • Expect hemoconcentration if patient dehydrated
  • CBC
  • Chemistry Panel
  • Pregnancy test (for women of child bearing age)

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


  • 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


  • Extubate when patient awake and able to protect airway
  • PONV prophylaxis

Postoperative management


  • 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










Conversion to Open

Pain 5-7 4


  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.