Tool Quickly Helps Predict Risk for Pediatric Appendicitis Complications

Research study background

Among the 60,000 to 80,000 children who are admitted to U.S. hospitals for acute appendicitis each year, approximately 35% have a perforated appendix. Perforation is linked to a greater risk of complications, longer hospital admission and need for ongoing IV antibiotics after the appendix is removed. However, it is often difficult to identify which children have perforated appendicitis based solely on presenting symptoms. Current tools are unable to predict how long a child with a perforation may need to be hospitalized after an appendectomy. This makes it challenging to provide families with accurate information, including what to expect in terms of the hospital course and outcomes after surgery.

A study conducted by a team of pediatric surgeons at Children’s Hospital Colorado sought to determine if an elevated shock index pediatric age-adjusted (SIPA) score at the time of presentation in patients with appendicitis and the time to normalization of SIPA could help identify perforated appendicitis and predict their length of stay (LOS) in the hospital. Initially created to identify severely injured pediatric trauma patients at risk for adverse outcomes, SIPA has been validated for its accuracy in identifying children in shock and has shown potential for broader utilization.

The study retrospectively reviewed 169 patients from ages 1 to 17 who underwent an appendectomy for appendicitis at Children’s Colorado between January and March of 2021. Of those, 53 had perforated appendicitis. Elevated SIPA was defined as >1.22 for ages 1 to 6, >1.0 for ages 7 to 12, and >0.9 for ages 13 to 17.

Children who presented with elevated SIPA were found to be 5.5 times more likely to have a perforated appendix, compared to those with normal SIPA. An elevated SIPA at presentation and increased time to return to a normal SIPA score after the appendectomy correlated with several adverse outcomes. On average, compared to those with normal SIPA at presentation, patient LOS was twice as long, it took 4.5 times longer to return to a regular diet, and antibiotics duration was 1.76 times longer.  

The research team also found that each additional hour a patient took to return to a normalized SIPA increased their LOS, delayed their return to a regular diet and extended their time on antibiotics.

Clinical implications 

The data presented in this study are the first to document an association between objective hemodynamic measures (SIPA) and greater risk of perforation. Unlike other existing predictors, the SIPA score can be calculated at ED presentation and does not require laboratory tests or imaging.

Study findings indicate that SIPA is a valuable presurgical tool for predicting longer hospital stays post-appendectomy. It can also be used to accurately guide family counseling about disease severity and the expected hospital course. While the sample size is small, the data support incorporating SIPA for initial evaluation and ongoing management of children with perforated appendicitis.