What are the initial hospital admission orders for a patient with acute appendicitis?

Hospital Admission Orders for Acute Appendicitis

For patients admitted with acute appendicitis, immediately initiate broad-spectrum intravenous antibiotics covering gram-negative organisms and anaerobes, keep NPO with IV hydration, obtain surgical consultation for appendectomy within 24 hours, and provide adequate analgesia without concern for masking physical findings. 1, 2

Immediate Orders Upon Admission

NPO Status and IV Access

• Make patient NPO (nothing by mouth) with IV hydration to prepare for urgent/emergent surgery and maintain fluid balance 1, 2
• Establish large-bore IV access for antibiotic administration and potential surgical preparation 1

Antibiotic Therapy

• Administer broad-spectrum IV antibiotics immediately upon diagnosis, covering enteric gram-negative organisms and anaerobes 1, 3
• Preferred regimens include:
  • Piperacillin-tazobactam 3.375 grams IV every 6 hours (monotherapy) 1, 4, 5
  • Alternatively: cephalosporin or fluoroquinolone PLUS metronidazole 1, 5
  • Ampicillin-sulbactam, ticarcillin-clavulanate, or imipenem-cilastatin are acceptable alternatives 1, 3
• Timing is critical: antibiotics should be given 0-60 minutes before surgical incision for optimal prophylaxis 2
• Note that metronidazole is not needed when using broad-spectrum agents like aminopenicillins with β-lactam inhibitors or carbapenems 3

Pain Management

• Provide adequate analgesia with opioids (morphine 0.15 mg/kg IV, maximum 20 mg) without concern for masking physical examination findings 6
• Evidence demonstrates morphine relieves pain and improves patient cooperation without altering physical signs in acute appendicitis 6
• Administer antipyretics as indicated for fever 1

Laboratory Studies

• Complete blood count (CBC) with differential - expect leukocytosis ≥16,000/mL as predictor of appendicitis 1
• C-reactive protein (CRP) - levels ≥10 mg/L are strong predictive factors 1
• Basic metabolic panel to assess hydration status and electrolytes 1
• Pregnancy test for all females of childbearing potential prior to any imaging 1
• Blood type and screen in preparation for potential surgery 1

Imaging Confirmation

• If diagnosis not already confirmed by imaging, obtain appropriate studies based on clinical risk stratification 1
• CT scan is preferred for diagnostic accuracy in adults, though ultrasound is reasonable to avoid radiation in children and pregnant patients 1
• For pregnant patients in first trimester: ultrasound or MRI instead of CT 1
• Contrast-enhanced low-dose CT is preferred over standard-dose CT when indicated 1

Surgical Consultation and Timing

Immediate Surgical Consultation

• Obtain urgent surgical consultation for appendectomy planning 1, 2
• Surgery should be performed within 24 hours of admission for uncomplicated appendicitis 1, 2
• For complicated appendicitis (perforation, peritonitis), early appendectomy within 8 hours is recommended 1
• Delaying appendectomy beyond 24 hours increases risk of adverse outcomes including surgical site infections 1

Special Considerations for Surgical Timing

• For perforated appendicitis with diffuse peritonitis: urgent appendectomy is mandatory and should not be delayed 3
• For well-circumscribed periappendiceal abscess: percutaneous drainage may be considered with deferred appendectomy 1, 3
• High-risk populations (elderly, immunosuppressed, transplant recipients) require expedited surgical intervention 1, 3, 2

Monitoring and Supportive Care

Vital Signs and Clinical Monitoring

• Continuous monitoring of vital signs every 4 hours minimum 1
• Serial abdominal examinations to detect progression to perforation or peritonitis 1
• For patients with equivocal imaging or intermediate risk: close observation with repeat imaging at 24 hours if symptoms persist 1

Risk Stratification

• Elderly patients (>65 years) have 55-70% perforation rates and threefold mortality increase per decade, requiring heightened vigilance 1, 3
• Mortality risk stratifies dramatically: perforated appendicitis carries ~5% mortality versus <0.1% for non-gangrenous appendicitis 3
• Patients with hidden appendix locations (retrocecal, pelvic, retroperitoneal) are at higher risk for delayed diagnosis and perforation 7

Critical Pitfalls to Avoid

Common Errors

• Do not delay antibiotics waiting for surgical scheduling - antibiotics must be initiated immediately upon diagnosis 1, 3
• Do not withhold adequate analgesia - morphine does not mask physical findings and improves patient cooperation 6
• Do not delay surgery beyond 24 hours in standard cases - this increases complications and perforation risk 1
• Do not skip pregnancy testing in females of childbearing age - this determines appropriate imaging modality 1

High-Risk Scenarios Requiring Immediate Surgery

• Perforated appendicitis with diffuse peritonitis requires urgent operative intervention 3
• Immunosuppressed patients, transplant recipients, and pregnant patients should proceed directly to surgery 3, 2, 8
• CT findings of appendicolith, mass effect, or appendiceal diameter >13 mm predict higher failure rates (~40%) with antibiotic-only management 5

Disposition Planning

Admission Orders Summary

• Admit to surgical service 1
• NPO status with IV hydration 1
• Broad-spectrum IV antibiotics (piperacillin-tazobactam 3.375g IV q6h or equivalent) 1, 4
• IV opioid analgesia as needed 6
• Surgical consultation for appendectomy within 24 hours 1, 2
• Serial abdominal examinations 1
• Antiemetics and antipyretics as needed 1

Postoperative Antibiotic Duration

• For uncomplicated appendicitis: discontinue antibiotics postoperatively 2
• For perforated appendicitis: continue antibiotics for 5-7 days total based on clinical response 3
• Do not prolong antibiotics beyond 3-5 days with adequate source control 2