Medication Summary
Administer 1 dose of preoperative antibiotics to children with suspected appendicitis. Antibiotics can be discontinued after surgery if no perforation is noted.
Antibiotics are selected to provide coverage for aerobic and anaerobic organisms. The most widely used regimen is the combination of ampicillin, clindamycin (or metronidazole), and gentamicin. Alternative regimens include the following:
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Ampicillin/sulbactam
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Cefoxitin
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Cefotetan
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Piperacillin/tazobactam
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Ticarcillin/clavulanate
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Imipenem/cilastatin
Resistant organisms develop in 15% of patients with a ruptured appendix. Antibiotic substitutions are made for patient allergies, poor clinical improvement or deterioration on current regimen, or culture-proven antibiotic resistance.
Patients with appendicitis also require medication for pain control. Antiemetic and antipyretic agents may also be indicated.
Antibiotic regimens should cover the most commonly encountered organisms, including Escherichia coli and Bacteroides, Klebsiella, Enterococcus, and Pseudomonas species.
Penicillins
Class Summary
The penicillins are bactericidal antibiotics that work against sensitive organisms at adequate concentrations and inhibit the biosynthesis of cell wall mucopeptide. Examples of extended-spectrum penicillins include ticarcillin and clavulanate (Timentin) and ampicillin and sulbactam (Unasyn).
Ampicillin (Marcillin, Omnipen, Polycillin, Principen)
Ampicillin is a beta-lactam antibiotic with activity against some gram-positive and gram-negative organisms. It inhibits bacterial cell wall synthesis during active multiplication.
Ampicillin/sulbactam (Unasyn)
A combination of ampicillin with a beta-lactamase inhibitor, this agent has activity against some gram-positive organisms, gram-negative organisms (nonpseudomonal species), and anaerobic bacteria.
Piperacillin/tazobactam (Zosyn)
A combination of a beta-lactamase inhibitor with piperacillin, this agent has activity against some gram-positive organisms, gram-negative organisms, and anaerobic bacteria. It inhibits biosynthesis of bacterial cell wall mucopeptide and is effective during the stage of active multiplication.
Ticarcillin and clavulanate potassium (Timentin)
This combination of an antipseudomonal penicillin plus a beta-lactamase inhibitor provides coverage against most gram-positive and gram-negative organisms and most anaerobes. It inhibits biosynthesis of cell wall mucopeptide and is effective during the stage of active growth.
Imipenem and cilastatin (Primaxin)
This combination agent is indicated for treatment of multiple organism infections in which other agents do not have wide-spectrum coverage or are contraindicated because of potential for toxicity.
Aminoglycosides
Class Summary
Aminoglycosides are bactericidal antibiotics used to primarily treat gram-negative infections. They interfere with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits.
Gentamicin (Garamycin, Gentacidin)
Gentamicin is an aminoglycoside antibiotic with activity against gram-negative bacteria, including Pseudomonas species. It is synergistic with beta-lactams against enterococci. Gentamicin interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits. Dosing regimens are numerous; adjust the dose based on creatinine clearance and changes in volume of distribution. Gentamicin may be administered intravenously or intramuscularly.
Anti-Infectives
Class Summary
Anti-infectives such as metronidazole and clindamycin are effective against some types of bacteria that have become resistant to other antibiotics.
Clindamycin (Cleocin)
Clindamycin is a lincosamide effective against gram-positive aerobic and anaerobic bacteria (except enterococci). It inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Metronidazole (Flagyl)
Metronidazole is often used in combination with an aminoglycoside, such as gentamycin. It provides broad gram-negative and anaerobic coverage. It appears to be absorbed into cells, and the intermediate-metabolized compounds that are formed bind DNA and inhibit protein synthesis, causing cell death. Metronidazole is a synthetic, nitroimidazole-derivative antibacterial and antiprotozoal agent. Metronidazole may be administered intravenously or orally.
Cephalosporins
Class Summary
Cephalosporins are structurally and pharmacologically related to penicillins. They inhibit bacterial cell wall synthesis resulting in bactericidal activity.
Cefoxitin (Mefoxin)
A second-generation cephalosporin, cefoxitin has activity against some gram-positive organisms, gram-negative organisms (nonpseudomonal species), and anaerobic bacteria. It inhibits bacterial cell wall synthesis during active multiplication by binding 1 or more penicillin-binding proteins.
Cefotetan (Cefotan)
Cefotetan is a second-generation cephalosporin indicated for infections caused by susceptible gram-positive cocci and gram-negative rods.
Analgesics
Class Summary
Pain management is a contentious topic for some emergency physicians and surgeons. Several classes of analgesic medications have proven to be safe and efficacious in the preoperative pediatric patient.
It is ethical and prudent for emergency physicians, surgeons, anesthesiologists, pediatricians, and pharmacists to agree on a plan for providing pain relief to the pediatric patient. Topics to be agreed upon include type, route, dose, and frequency of administration of analgesic drugs.
Ketorolac (Toradol)
Ketorolac inhibits prostaglandin synthesis by decreasing the activity of cyclooxygenase, which results in decreased formation of prostaglandin precursors.
With proper dosing, it does not cause a significant decrease in hematocrit, increase in creatinine, or overall complications. Its use can decrease hospital stay and narcotic requirements in children who have undergone surgery.
Fentanyl citrate (Sublimaze)
Fentanyl is a synthetic opioid that is 75-200 times more potent and has a much shorter half-life than morphine sulfate. It has less hypotensive effects and is safer in patients with hyperactive airway disease than morphine because of minimal to no associated histamine release. By itself, it causes little cardiovascular compromise, although the addition of benzodiazepines or other sedatives may result in decreased cardiac output and blood pressure.
Consider continuous infusion of fentanyl because of its short half-life (30-60 min). Parenteral fentanyl is the drug of choice for conscious sedation analgesia. It is ideal for analgesia of short duration during anesthesia and the immediate postoperative period. It is readily titrated and is easily and quickly reversed by naloxone.
After the initial parenteral dose, subsequent parenteral doses should not be titrated more frequently than every 3 or 6 hours. Fentanyl is highly lipophilic and protein bound. Prolonged exposure leads to accumulation in fat and delays the weaning process.
Morphine
Morphine sulfate has the advantages of reliable and predictable effects, a favorable safety profile, and ease of reversibility with naloxone. Various IV doses are used; it is commonly titrated until the desired effect is obtained.
The Joint Commission on the Accreditation of Healthcare Organizations has placed "MSO4" on the banned abbreviation list, because it can be mistaken for magnesium sulfate. Therefore, in writing the prescription, spell out "morphine sulfate" in full, legibly and clearly.
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Ultrasonographic examination of the right lower quadrant reveals a greater than 6-mm noncompressible tubular structure shown in cross section. Discomfort was noted as the probe was depressed over this structure. A small amount of free fluid is also noted surrounding the appendix.
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Ultrasonographic examination of the right lower quadrant reveals a greater than 6-mm noncompressible tubular structure shown in cross section. Discomfort was noted as the probe was depressed over this structure. A small amount of free fluid is also noted surrounding the appendix.
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CT scan depicting a distended tubular structure descending into the pelvis and containing a round calcification (ie, an appendicolith).
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CT scan revealing an enhancing tubular structure descending into the pelvis. Periappendiceal inflammation and streaking, so-called dirty fat, is noted surrounding the appendix.
