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Risk score improves care in patients with suspected appendicitis
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Risk stratifying patients with suspected appendicitis using the Appendicitis Inflammatory Response score based on patient symptoms and lab parameters reduced the need for diagnostic imaging, hospital admissions, and surgery in a randomized clinical trial.
The risk score stratifies patients based on right iliac fossa pain, vomiting history, rebound tenderness or muscular guarding, body temperature, white blood cell count, neutrophil granulocyte proportion, and C-reactive protein concentration.
To determine if using the AIR score would improve outcomes, investigators evaluated patients who presented with suspected appendicitis between September 2009 and January 2012 at 21 emergency surgical centers and three university pediatric centers in Sweden.
During a baseline phase, the investigators prospectively recorded the clinical characteristics, treatments and outcomes of 1,152 patients. Then during the intervention period, they implemented an AIR score-based algorithm for 2,639 patients. From this cohort, researchers deemed 1,068 patients as intermediate-risk and randomly assigned them to either prompt diagnostic imaging or admission and repeat AIR scoring after a 4- to 8-hour observation period. Patients deemed low risk underwent outpatient observation and patients deemed high risk underwent surgical exploration.
For low-risk patients, use of the AIR score reduced imaging (19.2% vs. 34.5%; P < .001), admissions (29.5% vs. 42.8%; P < .001), negative explorations (1.6% vs. 3.2%; P = .03) and operations for non-perforated appendicitis (6.8% vs. 9.7%; P = .034).
Further, the intermediate-risk patients in both the imaging and observation groups showed comparable proportions of negative appendicectomies (6.4% vs. 6.7%), numbers of admissions and perforations, and duration of hospital stay. However, those who received routine imaging were more likely to receive treatment for appendicitis (53.4% vs. 46.3%; P = .02).
“These data suggest that AIR score-based risk stratification of patients with suspected appendicitis has the potential to reduce admissions to hospital, use of diagnostic imaging, unnecessary surgery and costs compared with standard management,” the investigators wrote. “In-hospital observation with repeated clinical assessment and selective diagnostic imaging is as safe and efficient as routine diagnostic imaging in patients with an equivocal clinical diagnosis of appendicitis,” they concluded. – by Adam Leitenberger
Disclosures: The researchers report no relevant financial disclosures.
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