This handout is for acute appendicitis — pediatric (pas-stratified; nom-aware). Your care team identified this based on: child or adolescent with rlq abdominal pain + anorexia ± nausea/emesis ± migration from periumbilical region — classic peds appendicitis presentation (samuel 2002 pas scoring criteria).
Other reasons your team may use this plan: young child < 5 y with diffuse abdominal pain (atypical presentation; classic migration pattern often absent; ~ 80% perforation rate at presentation per pediatric surgery literature); child with rlq tenderness + fever ≥ 38 °c + leukocytosis wbc > 10k with neutrophilia — high pas components (samuel 2002; bhatt 2009); peritoneal signs — rigidity, guarding, rebound tenderness — raises perforation concern (lr+ ~ 3-5 for peritonitis); emergent surgical evaluation.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| normal saline / lactated Ringer's | 20 mL/kg IV bolus over 30-60 min, repeat × 1-2 PRN; max ~ 60 mL/kg total before reassessing for fluid overload | IV | bolus PRN with reassessment | AAP pediatric resuscitation principles; pre-op resuscitation REQUIRED if dehydration; lower bolus thresholds vs adult sepsis given pediatric fluid-overload risk; halt or slow if hepatomegaly / rales / no response |
| morphine | 0.05-0.1 mg/kg IV every 2-4 h PRN; titrate to comfort; does NOT obscure abdominal exam | IV | q2-4h PRN | Analgesia for visceral pain; titrate to comfort; AAP pediatric pain management — analgesia does NOT obscure abdominal exam |
| ondansetron | 0.15 mg/kg IV (max 4 mg per dose) q8h PRN | IV | q8h PRN | First-line pediatric antiemetic; minimal sedation; preferred over prochlorperazine in peds |
| ceftriaxone | 50 mg/kg IV (max 2 g) single dose at induction for uncomplicated; q24h for perforation × 5-7 d | IV | pre-op single dose; q24h for perforation | Pre-op antimicrobial prophylaxis for uncomplicated appendectomy; combination with metronidazole for perforation; alternative to single-agent pip-tazo |
| metronidazole | 10 mg/kg IV q8h (max 500 mg/dose); add to ceftriaxone for anaerobic cover | IV | q8h | Anaerobic cover combination with ceftriaxone for pre-op prophylaxis + post-perforation coverage per Solomkin IDSA intra-abdominal 2010 (peds-adapted) |
| piperacillin-tazobactam | 80-100 mg/kg IV q6-8h (piperacillin component) for confirmed perforation / peritonitis or single-agent NOM IV induction | IV | q6-8h | Broad Gram-positive + Gram-negative + anaerobe single-agent backbone for intra-abdominal contamination per Solomkin IDSA intra-abdominal 2010 (peds-adapted); also single-agent NOM IV induction per Minneci 2020 |
| amoxicillin-clavulanate | 25-45 mg/kg/day PO divided BID-TID (amoxicillin component; max 875 mg/dose) × 7 d for NOM | PO | BID-TID | PO step-down (or full outpatient course) for NOM per Minneci 2020 PMID 32730561; broad-spectrum oral coverage; standard pediatric dosing |
| meropenem | 20 mg/kg IV q8h (max 1 g per dose); for ESBL risk or MDRO concern or critically ill | IV | q8h | Broader Gram-negative + anaerobe + ESBL cover; reserved for ESBL risk or critically ill; alternative to pip-tazo |
| vancomycin | 15 mg/kg/dose IV q6-8h; target AUC 400-600 (Rybak IDSA 2020 PMID 32191793) | IV | q6-8h | Add-on for MRSA / CoNS / line-associated sepsis coinfection in perforated appendicitis; AUC target 400-600 (Rybak IDSA 2020) |
| ketamine | 1-2 mg/kg IV by pediatric sedation team for procedural sedation (e.g., MRI in young child); supplemental 0.5 mg/kg PRN | IV | procedural | Procedural-sedation agent for MRI in younger children unable to tolerate awake imaging; per institutional pediatric sedation protocol + AAP pediatric sedation guidance |
| midazolam | 0.05-0.1 mg/kg IV (max 2 mg single dose) for anxiolysis adjunct | IV | PRN procedural | Adjunct anxiolysis; not stand-alone procedural sedation in this context |
| acetaminophen | 10-15 mg/kg PO q4-6h PRN (max 75 mg/kg/day or 4 g/day adult-equivalent) | PO | q4-6h PRN | First-line PO analgesic-antipyretic in pediatrics; safe in all age bands at appropriate dose |
Plan: Pediatric appendicitis perioperative antibiotics + non-operative management (NOM) + analgesia (APSA 2020 + Minneci JAMA 2020 PMID 32730561 + Solomkin IDSA intra-abdominal 2010 peds-adapted)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Post-op uncomplicated: pediatric surgery follow-up at 2-4 weeks for wound check + scar inspection + bowel function review; activity progression per surgeon; school return typical 1-2 weeks. Post-op perforated: pediatric surgery follow-up at 2-4 weeks; pediatric infectious disease follow-up if prolonged antibiotic course; nutrition follow-up if extensive resection. NOM: structured pediatric surgery + pediatrician follow-up at 24-48 h, 7 d, 1-3 months; ~ 30% recurrence within 1 year (Minneci 2020) → re-presentation pathway with low threshold for surgical management; family education on recurrence signs (return of RLQ pain, fever, vomiting → ED). Interval appendectomy 6-8 weeks if abscess drained (no consensus on optimal timing; centers vary 4-12 weeks). Adolescent female: ongoing primary care + gyn follow-up if indicated. Pregnant patient: ongoing OB + MFM follow-up; preterm labor surveillance.
Guideline: APSA 2020 (American Pediatric Surgical Association) statement on pediatric appendicitis management + Minneci PC et al JAMA 2020 PMID 32730561 (NOM non-inferiority cohort) + Samuel M J Pediatr Surg 2002 (original Pediatric Appendicitis Score) + Bhatt M Acad Emerg Med 2009 (PAS prospective validation) + Doria AS Radiology 2006 (US vs CT meta-analysis) + Kollar A 2019 + Macco S 2020 (pAIR pediatric appendicitis inflammatory response) + ACR Appropriateness Criteria — Right Lower Quadrant Pain — Suspected Appendicitis + Solomkin IDSA Complicated Intra-Abdominal Infection 2010 PMID 20034345 (peds-adapted for perforation management) + CDC 2021 STI Treatment Guidelines (PID differential) + SSC peds 2020 (for shock physiology if perforation precipitates sepsis)