bedah journal reading
DESCRIPTION
apendicTRANSCRIPT
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5/21/2018 Bedah Journal Reading
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Pembimbing :dr. Wijiono, Sp.OT
Di presentasikan oleh :
Mudhita kurnia syarifa
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Abstract
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Background
Initial antibiotics with planned interval appendectomy (interval AP) have beenused to treat patients with complicated perforated appendicitis
however, little experience exists with this approach in
children with suspected acute perforated appendicitis (SAPA)
We sought to determine the outcome of initial
antibiotics and interval AP in children with SAPA.
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Methods
a prospective observational
time
Over an 18-month period, between February2007 and August 2008
place Miami Children's Hospital
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age
751105 .Therewere 63 males and 42
females with a meanage of 9.8 years(range, 218 years)
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For the purposes of this study, SAPA was defined
by
Duration of symptoms less than 96 hours
Generalized abdominal tenderness on physical exam
Laboratory studies including an elevated white bloodcell count (WBC) N12,000
Diagnostic imaging findings on ultrasound (US) orcomputerized tomography (CT).
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Freeintraabdominal
fluid
Enlarged appendixdiameter greaterthan
7 mm
Diagnostic
imagingfinding
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Criteria excludePatients
withsymptoms
greater than96 hours
Palpablemass onphysical
examination
Imagesshowing a
wellformed
abscess
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PICC was placed for antibiotic administration and patients were treated with aminimum 7-day course
Patients afebrile for 24 hours, tolerating a regular diet and having adequate paincontrol with oral analgesics
Intravenous antibiotics
Piperacillin/tazobactam (100 mg/kg/dose) dosed every 6 hourswas
used primarily
Gentamycin (7.5 mg/kg/day) and clindamycin
(30 mg/kg/day) were used in combination if the patient had a
penicillin allergy
All eligible patients were initially treated
intravenous fluids analgesics intravenous antibioticsoperation planned for
approximately 8 weeks afterdiagnosis
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They weredischarged with a
PICC and home healthcare, undergoingreevaluation on anoutpatient basis
Criteria fordiscontinuingantibiotics
-absence oftenderness on physicalexam
-no temperatureabove 100 F for 48hours
- a normal WBC
About 2 weeks after the cessation of
antibiotic treatment, patients wereseen in the clinic for reevaluation andscheduling of surgery
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Result
(89%) of patients underwent planned interval AP.
(11%) had early appendectomies.
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All SAPA patients were admitted to thehospital for initiation of the nonoperativeprotocol.
Children were treated with antibiotictherapy for a mean duration of 12.9days (range 529).
Ninety-five percent of patients weretreated with piperacillin/tazobactam
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Discussion
All four criteria outlined in the Methods section had to have
been met. Any patient with symptoms longer than 4 days or with
mass or abscess was excluded from the study
Multiple studies have identified the characteristics of children
more likely to present with ruptured appendicitis; these include
younger age, pain longer than 2 to 3 days, generalized abdominal
tenderness and fever over 38 C
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Comparison of clinical characteristics of SAPA
patients to published reports of ruptured
appendicitis presenting with mass or abscess
and treated on an interval managementpathway reveals that SAPA patients tended to
have a shorter duration of symptoms and
lower temperature on admission
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St. Peter et al
evaluated children who over a 2-year span
presented with a well defined abdominal
abscess by CT scan
Forty patients were enrolled and randomized
to either immediate AP or nonoperative
medical management after abscess drainage
followed by interval AP
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Blakely et al
looked at early (64 patients) versus delayed AP
(67 patients) in those patients with acute
perforated appendicitis who did not have a
well-formed abscess or mass on exam
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Early AP
It was shown to have lower adverseevent rates overall, notably lower
occurrence of intraabdominal abscess
Hospital charges and costs weresignificantly lower
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Conclusions
Treatment of SAPA with antibiotics andplanned interval AP is successful in the
majority of patients
complications such as abscess formationand/or readmission prior to planned interval
AP occur in up to one-third of patients
Certain clinical variables are associated withincreased treatment complications.