P67
APPROPRIATE IV SELECTION IN COMPLICATED ACUTE APPENDICITIS
A.N. O'Donoghue, S. Farrelly, R. O'Connor
Cork University Hospital, Ireland
Background/Context
Acute appendicitis in children is reported to be complicated (gangrenous or perforated viscera) in as high as 35-40% of cases(1, 2). Management is predominantly surgical, with adjunct intravenous antimicrobial therapy. PIVC (Peripheral Intravenous Catheter) failure of 36-69% is described, commonly due to vessel injury and irritation. Up to 26% of antimicrobial doses are missed due to PIVC failure secondary to inappropriate device selection for duration of therapy and infusate characteristics(3). The GIRFT guideline provides guidance on appropriate IV selection, suggesting mid- or non-central long line for complicated appendix with medium post-operative antibiotic course(4).
Problem
Our institution does not have a standard operating procedure (SOP) with respect to definitive IV access for prolonged antimicrobial therapy following complicated appendicectomy. We hypothesise that this has resulted in inappropriate device selection, leading to PIVC failure and treatment interruption.
Methods
We conducted an anonymous retrospective chart review of all paediatric laparoscopic appendicectomies (<16 years) during an 18-month period in our institution: a tertiary hospital providing paediatric acute and elective surgery to over 2500 children per year. We aimed to assess:
- Appropriate IV position and device in complicated appendicitis (as per GIRFT)
- Number of IV access procedures performed in first seven days post appendicectomy
- Requirement for central access
- Duration of IV antibiotics
While this chart review did not require ethical approval, the project was registered with the hospital's audit department.
Results
Data consisted of 75 patients. Mean age was 11 years. 37% were complicated. 65% received a new PIVC placed in theatre. Most commonly a 20G (42%). Most commonly in the hand (52%). No mid- or non-central long line was placed for complicated appendix with medium antibiotic course. In only four cases was further IV access required. In three of these, 2 further PIVCs were required, and in one case, a single further cannula was required. In no case was central access required. Approximately half of all complicated appendices required > 5 days antibiotics.
Lessons Learned
We found that we are not compliant with GIRFT guidance on PIVC selection. While the percentage of complicated acute appendicitis in our institution mirrors published data, this sample did not demonstrate PIVC failure to be the issue described in our literature review. This may be a more significant issue in paediatric institutions serving a more complex population and children under one. A larger sample size may have mirrored published data more closely.
Message to others
Our institution is representative of many tertiary facilities providing care to children outside of paediatric referral centres. We recognise that there is no SOP for appropriate PIVC selection in this cohort. We will be implementing this SOP and are providing training in ultrasound-guided paediatric IV access within our department.
References:
- Bethell GS, Rees CM, Sutcliffe JR, Hall NJ. Management and early outcomes of children with
appendicitis in the UK and Ireland during the COVID-19 pandemic: a survey of surgeons and
observational study. BMJ Paediatrics Open. 2020;4(1):e000831.
- Collaborative RSGobotWMR. Appendicitis risk prediction models in children presenting with
right iliac fossa pain (RIFT study): a prospective, multicentre validation study. Lancet Child Adolesc Health. 2020;4(4):271-80.
- Larsen EN, Marsh N, Mihala G, King M, Zunk M, Ullman AJ, Keogh S, Kleidon TM, Rickard CM. Intravenous antimicrobial administration through peripheral venous catheters - establishing risk profiles from an analysis of 5252 devices. Int J Antimicrob Agents. 2022 Apr;59(4):106552. doi: 10.1016/j.ijantimicag.2022.106552. Epub 2022 Feb 17. PMID: 35183678.
- GIRFT. Acute paediatric abdominal pain pathway. Royal National Orthopaedic Hospital NHS
Trust, NHS England and NHS Improvement.; 2022.