1. Time from initial emergency department evaluation to appendectomy onset was not associated with increased odds of appendiceal perforation (AP).
2. Increased perforation risk was most significantly associated with longer duration of time from onset of abdominal pain and presentation to the emergency department.
Study Rundown: Diagnosing appendicitis is particularly challenging in the pediatric population. Previous studies have shown an association between increased risk of postoperative complications and AP, yet surveys have indicated that the majority of pediatric surgeons do not believe postponing appendectomies overnight for nonperforated appendicitis increases the risk of AP. Using data on time from emergency department (ED) evaluation to operative intervention in children who present with abdominal pain, this study attempted to determine if delaying appendectomies is an independent risk factor for AP. To answer this question, researchers conducted a secondary analysis of data collected in a prospective, cross-sectional, multi-center trial validating a clinical decision rule for pediatric appendicitis. Results showed that longer delays between ED exam and appendectomy (≤ 24 hours) were not associated with higher odds of AP, even after adjusting for those patients who may have had AP at the time of ED presentation. Longer duration of abdominal pain before presentation to the ED, moderate and severe abdominal tenderness, and fever ≥100.4°F were all associated with increased odds of AP. Due to the observational nature of this study, results may be confounded by factors influencing surgeons’ decisions on when to operate, which would limit the accuracy of detecting the impact of post-evaluation delay times on perforation risk.
Relevant reading: Pediatric appendectomy: optimal surgical timing and risk assessment
In-depth [cross-sectional study]: Researchers analyzed data from 955 patients (mean age = 10.8 years, 60% male) aged 3 to 18 years diagnosed with appendicitis after emergency department evaluation for abdominal pain. Data was originally collected as part of a prospective, cross-sectional, 10-center study looking at clinical decision making for pediatric appendicitis. Of those studied, 25.8% had AP, the median time from ED exam to appendectomy was 7.2 hours, and 22% of participants did not have surgery until ≥12 hours after initial ED exam. Results showed no significant association between time from evaluation in the ED to appendectomy and AP among children who underwent operation 12 to 23 hours after evaluation (OR 0.93, 95%CI 0.79-1.08). This study also found no increased odds of AP with increasing time from exam to surgery when looking at only children without evidence of perforation on computed tomography (CT) in the ED (n = 403, OR 0.95, 95%CI 0.89-1.02). Patients who received imaging in the ED (CTor ultrasound) had a longer average time from exam to operation than those without imaging (8.2 vs. 4.9 hours, p = .001), but performance of imaging was not associated with increased odds of AP (OR 1.39, 95%CI 0.86-2.26). This analysis showed longer duration of abdominal pain prior to presentation at the ED was associated with increased odds of perforation (36-47 hours: OR 9.35, 95%CI 4.16-21.0; 48-71 hours: OR 14.3 95%CI 6.32-32.4. Fever ≥100.4°F (OR 3.66, 95%CI 2.36-5.66) and severity of abdominal pain (severe pain, OR 7.36, 95%CI 2.87-18.9) were also associated with an increased risk of AP
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