APPENDICITIS: ROUTINE PRE-DISCHARGE LABS DON’T PREDICT COMPLICATIONS

Infographic · Apr 2023 · 1 min read

In brief

This multicenter study of 1,264 children found that routine pre-discharge white blood cell counts have poor predictive value for identifying post-discharge organ space infections after appendectomy for complicated appendicitis. The findings challenge the clinical utility of routine lab monitoring before discharge in this population.

Pre-discharge WBC has poor predictive value for post-discharge organ space infection after complicated appendicitis (PPV 3.9-9.8%).
50% of children who developed post-discharge OSI had normal pre-discharge WBC, limiting its clinical utility as a screening tool.
Hospital practice varied widely: 0.8-100% obtained routine pre-discharge WBC, suggesting lack of evidence-based consensus.
Neither persistent leukocytosis (≥9.0) nor increasing WBC predicted complications better than clinical assessment alone.
Routine pre-discharge labs can be safely omitted in afebrile children without surgical site infection after complicated appendicitis.

Written by the GCMD Library team from the infographic.

Red and white infographic with three main sections. Left panel shows study design details with an intestine icon and warning symbol. Center panel displays a house icon above two sets of test tubes (one with checkmark, one with prohibition symbol) representing the comparison groups. Right panel shows two outcome metrics with human figure icons and bacterial symbol.

Infographic by Jose Campos and the Chilean society of pediatric surgery

"Predictive Value of Routine White Blood Cell Count Obtained Prior to Discharge for Organ Space Infection in Children with Complicated Appendicitis: Results from the Eastern Pediatric Surgery Network"

Authors: Shannon L Cramm, Dionne A Graham, Myron Allukian, Martin L Blakely, Nicole M Chandler, Robert A Cowles, Christina Feng, Shaun M Kunisaki, Robert T Russell, Shawn J Rangel; Eastern Pediatric Surgery Network (EPSN)

Full article: https://pubmed.ncbi.nlm.nih.gov/36503868/

Abstract

Background: The objective of this study was to evaluate the clinical utility of a routine pre-discharge white blood cell count (RPD-WBC) for predicting post-discharge organ space infection (OSI) in children with complicated appendicitis.

Study design: This was a multicenter study using NSQIP-Pediatric data from 14 hospitals augmented with RPD-WBC data obtained through supplemental chart review. Children with fever or surgical site infection diagnosed during the index admission were excluded. Positive predictive value (PPV) for post-discharge OSI was calculated for RPD-WBC values of persistent leukocytosis (≥9.0x103 cells per microliter), increasing leukocytosis (RPD-WBC>preoperative WBC), quartiles of absolute RPD-WBC, and quartiles of relative proportional change from preoperative WBC. Logistic regression was used to calculate predictive values adjusted for patient age, appendicitis severity, and use of post-discharge antibiotics.

Results: 1264 children were included, of which 348 (27.5%) had a RPD-WBC obtained (hospital range: 0.8-100%, P<0.01). Median RPD-WBC was similar between children who did and did not develop a post-discharge OSI (9.0 vs. 8.9; p=0.57), and leukocytosis was absent in 50% of children who developed a post-discharge OSI. The PPV of RPD-WBC was poor for both persistent and increasing leukocytosis (3.9% and 9.8%, respectively), and for thresholds based on the quartiles of highest RPD-WBC values (>11.1, PPV: 6.4%) and greatest proportional change (<32% decrease from preoperative WBC; PPV: 7.8%).

Conclusions: Routine pre-discharge WBC data have poor predictive value for identifying children at risk for post-discharge OSI following appendectomy for complicated appendicitis.

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