What are the steps for preoperative preparation in a patient with acute appendicitis?

Preoperative Preparation for Acute Appendicitis

For patients with acute appendicitis requiring surgery, preoperative preparation should include a single dose of broad-spectrum antibiotics administered 0-60 minutes before surgical incision, along with appropriate pain management and fluid resuscitation. 1

Diagnosis Confirmation

• Confirm diagnosis using clinical scoring systems (Alvarado, AIR, or AAS scores) combined with appropriate imaging 1
• For adults, point-of-care ultrasound (POCUS) is recommended as first-line imaging when indicated based on clinical assessment 1
• If ultrasound is inconclusive, low-dose contrast-enhanced CT scan is preferred for adolescents and young adults 1
• For pregnant patients, graded compression trans-abdominal ultrasound is the preferred initial imaging method 1

Decision for Surgical Management

• Laparoscopic appendectomy is the preferred approach over open appendectomy for both uncomplicated and complicated acute appendicitis when laparoscopic equipment and expertise are available 1
• Surgery should be performed within 24 hours of admission to minimize complications 1
• For patients with complicated appendicitis (perforation, peritonitis), urgent surgical intervention is required for adequate source control 1

Preoperative Antibiotic Administration

• Administer a single preoperative dose of broad-spectrum antibiotics 0-60 minutes before surgical skin incision 1
• Appropriate antibiotic options include:
  • Second or third-generation cephalosporins (cefoxitin, cefotetan) for uncomplicated cases 1, 2, 3
  • For complicated appendicitis: broader-spectrum coverage with piperacillin-tazobactam, ampicillin-sulbactam, or combination therapy with cephalosporins or fluoroquinolones plus metronidazole 1, 4, 5

Fluid Resuscitation and Preoperative Optimization

• Ensure adequate intravenous hydration to correct fluid deficits from decreased oral intake, fever, and inflammatory response 1
• Correct electrolyte abnormalities if present 1
• Administer appropriate pain medication and antipyretics as indicated 1

Special Patient Populations

Pregnant Patients

• Use ultrasound as first-line imaging; if inconclusive, MRI is preferred over CT to avoid ionizing radiation 1
• If first trimester and imaging is inconclusive, consider laparoscopy or limited CT scanning 1

Pediatric Patients

• Imaging should be performed for all children, particularly those <3 years old, when diagnosis is uncertain 1
• Ultrasound is preferred over CT to avoid ionizing radiation 1
• A single preoperative dose of broad-spectrum antibiotics is recommended 1

Patients with Periappendiceal Abscess

• Consider percutaneous drainage before surgery if a well-circumscribed periappendiceal abscess is present 1
• Appendectomy may be deferred in such patients 1

Timing of Surgery

• For uncomplicated acute appendicitis, surgery should be performed as soon as reasonably feasible, minimizing delay wherever possible 1
• Delaying appendectomy beyond 24 hours from admission is associated with increased risk of adverse outcomes 1
• For pediatric patients with complicated appendicitis, early appendectomy within 8 hours should be performed 1

Considerations for Non-Operative Management

• In the context of specific situations (e.g., COVID-19 pandemic), non-operative management with antibiotics may be considered for uncomplicated appendicitis 1
• This approach should be discussed with the patient, advising of the possibility of failure and risk of misdiagnosing complicated appendicitis 1

Common Pitfalls to Avoid

• Delaying antibiotic administration until after surgery 1
• Prolonging preoperative preparation beyond 24 hours, which increases risk of perforation 1
• Failing to recognize complicated appendicitis requiring urgent intervention 1
• Inadequate fluid resuscitation before surgery 1
• Using inappropriate antibiotic regimens that don't cover enteric gram-negative organisms and anaerobes 1