P35
EMERGENCY PAEDIATRIC APPENDICETOMIES - ARE WE BLOCKING IT?
I.Tribe, M. Boampomaa, S. Aravindan
Royal London Hospital, UK
Background:
Multimodal analgesia has been established as beneficial for emergency appendectomies (1), and our institution's practice involves the use of paracetamol, ibuprofen, and opioids through nurse-controlled analgesia (NCA) or patient-controlled analgesia (PCA). An audit in 2019 revealed the incorporation of abdominal wall blocks into postoperative analgesic management, but their comparative efficacy versus infiltration in morphine usage, PCA duration, and length of stay remained unclear. Challenges such as sporadic teaching due to the COVID-19 pandemic and logistical constraints of busy emergency lists potentially has led to fewer blocks, coinciding with an increased incidence of cases with perforated appendices.
Problem:
Perforated appendices often result in postoperative nil by mouth status and reliance on IV morphine. This prompted a review of regional block usage in emergency appendectomies to assess its impact on reducing opioid usage and related side effects.
Strategies:
1) A paediatric scanning club was established for regular regional block teaching to enhance skills and confidence in ultrasound scanning.
2) Implement the updated anaesthetic curriculum (which specifies competency of abdominal wall blocks) through fostering a cultural shift for trainers to support trainees in developing regional block skills.
3) Re-audit emergency appendectomies to determine the proportion of cases with performed blocks and assess any differences in postoperative outcomes.
Measure of Improvement:
Conduct a re-audit to understand departmental practices in performing regional blocks for emergency appendectomies. Gather data to assess the potential benefits of blocks, including IV morphine usage (mcg/kg) and its impact on nausea, vomiting, constipation, mobilization, trial without catheter (TWOC), and hospital discharge.
Lessons Learned:
Compared to 2019, there was a 9% increase in cases (58 vs. 53) involving a younger population with a higher proportion of perforated appendices (43% vs. 30%). Interestingly, laparoscopic management saw a higher proportion of perforated appendectomies.
Most cases (91%) utilised either an NCA/PCA and a third of cases had a regional block which included transversus abdominal plane, quadratus lumborum, or rectus sheath blocks. Despite fewer abdominal wall blocks, 24-hour morphine requirement, NCA/PCA duration, and length of stay were similar to 2019, with notable differences between open and laparoscopic cases. The laparoscopic results are consistent with adult data and previous audits, showing the impact of blocks has little clinically significant difference compared to infiltration (See Table 1). Limitations from retrospective data, means a focussed prospective audit on open appendicectomies is planned.
Message:
The trend indicates an increase in perforated appendices in younger patients, potentially influencing regional block outcomes. Infiltration may be as beneficial, but further research is needed for a comprehensive evaluation. As expected, laparoscopic cases appear to have better postoperative outcomes comparative to open cases. As such, our departmental guidance will rationalise blocks to open appendicectomies.
Reference:
(1) Liu, Y., Seipel, C., Lopez, M.E., Nuchtern, J.G., Brandt, M.L., Fallon, S.C., Manyang, P.A., Tjia, I.M., Baijal, R.G. and Watcha, M.F. (2013), A retrospective study of multimodal analgesic treatment after laparoscopic appendectomy in children. Paediatr Anaesth, 23: 1187-1192. doi:10.1111/pan.12271