Association for Academic Surgery Evaluating the effectiveness of a discharge protocol for children with advanced appendicitis Sara C. Fallon, MD, Mary L. Brandt, MD, Saif F. Hassan, MD, David E. Wesson, MD, J. Ruben Rodriguez, MD, MMSc, and Monica E. Lopez, MD* Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas article info Article history: Received 5 January 2013 Received in revised form 12 April 2013 Accepted 30 April 2013 Available online 22 May 2013 Keywords: Pediatric Appendicitis Perforated appendicitis Evidence-based guidelines 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. Materials and methods: We reviewed charts of patients with advanced appendicitis as defined by the surgeon intraoperatively from 2008e2009. 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 Æ 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 0.67e0.78, P < 0.001). The sensitivity and specificity for bands >3% were 47% and 70% (AUC 0.60, 95% CI 0.53e0.67, P ¼ 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 1.19e1.35, 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 parame- ters. 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. ª 2013 Elsevier Inc. All rights reserved. 1. Introduction The postoperative management of pediatric patients with advanced appendicitis is highly variable between tertiary care centers [1,2]. A survey of North American pediatric surgeons from 2004 demonstrated a lack of consensus regarding postoperative antibiotic use and discharge criteria in advanced appendicitis, with only half of the respondents reporting the use of inflammatory markers to determine the time of discharge [1]. Optimizing discharge criteria * Corresponding author. Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 6701 Fannin Street CC1210.00, Houston, TX 77030. Tel.: þ1 832 822 3135; fax: þ1 832 825 3141. E-mail address: melopez@texaschildrens.org (M.E. Lopez). Available online at www.sciencedirect.com journal homepage: www.JournalofSurgicalResearch.com journal of surgical research 184 (2013) 347 e351 0022-4804/$ e see front matter ª 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2013.04.081