Management of Acute Appendicitis with Hypotension and Leukocytosis
Immediate surgical intervention with appropriate resuscitation and broad-spectrum antibiotics is required for this patient with acute appendicitis who has developed hypotension and marked leukocytosis (24,000), indicating likely complicated appendicitis with sepsis. 1, 2
Initial Resuscitation
- Begin aggressive fluid resuscitation to address hypotension, which likely indicates sepsis from complicated appendicitis 2
- Administer broad-spectrum antibiotics immediately, covering both aerobic and anaerobic bacteria 1, 2
- Appropriate antibiotic options include piperacillin-tazobactam, or combination therapy with cephalosporins plus metronidazole for complicated appendicitis 2
- Correct any electrolyte abnormalities and continue to monitor vital signs 2
Surgical Management
- Proceed to urgent surgical intervention as soon as the patient is hemodynamically stabilized 1, 2
- Laparoscopic appendectomy is preferred if the patient can tolerate it, but open approach may be necessary depending on the patient's condition 1
- Surgery should not be delayed as statement 11 indicates: "In elderly patient with acute appendicitis, once operation is indicated, we suggest to perform appendectomy as soon as possible" 1
- Consider placement of an abdominal drain if perforation, abscess, or peritonitis is found during surgery 1
Special Considerations for Complicated Appendicitis
- The marked leukocytosis (24,000) and hypotension strongly suggest complicated appendicitis with possible perforation 3, 4
- If a well-circumscribed periappendiceal abscess is found, consider percutaneous drainage as an adjunct to surgical management 1, 5
- For patients with peritonitis, adequate source control through surgery is essential 1
Post-operative Management
- Continue broad-spectrum antibiotics post-operatively for 3-5 days for complicated appendicitis 1
- Discontinuation of antimicrobial treatment should be based on clinical and laboratory criteria such as resolution of fever and normalization of leukocytosis 1, 2
- Monitor closely for signs of ongoing sepsis or development of intra-abdominal collections 2
Pitfalls to Avoid
- Delaying surgical intervention in a patient with hypotension and marked leukocytosis, as this indicates sepsis requiring urgent source control 1
- Inadequate fluid resuscitation before surgery, which could worsen the patient's hemodynamic status 2
- Using inappropriate antibiotic regimens that don't cover enteric gram-negative organisms and anaerobes 1, 2
- Discontinuing antibiotics too early in complicated appendicitis before clinical improvement 1
- Failing to place an abdominal drain in cases of complicated appendicitis with perforation or abscess 1
The combination of hypotension and significant leukocytosis (24,000) in a patient with acute appendicitis represents a surgical emergency requiring prompt intervention to prevent further deterioration and reduce mortality risk 1, 2.