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Note: controversies are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other!
You’re seeing a child with CT-confirmed uncomplicated appendicitis. The child has had symptoms for 12 hours, and pain is well controlled with medications. You’ve given IV antibiotics. You’re informed by utilization review that the child is not approved to stay at your hospital and must be transferred according to the insurance plan; the transfer will take 4-8 hours to coordinate.
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September 14, 2021 at 2:53 pm
On the one hand, a large multicenter study in New Zealand showed that transferred patients (median time to O.R. 20.8 hrs) vs those presenting to metropolitan centers (16 hrs) or regional centers capable of appendectomy (7.6 hrs) had higher perforation and complication rates (https://pubmed.ncbi.nlm.nih.gov/34405500/). On the other hand, 2 studies demonstrated that time from ED physician evaluation to operation was not associated with increased complication and perforation rate as long as the time was < 24 hours (https://pubmed.ncbi.nlm.nih.gov/28562252/, https://pubmed.ncbi.nlm.nih.gov/28628705/). A systematic review supports no increased risk as long as appendectomy is performed within 24 hours of presentation, but notes that evidence is limited (https://pubmed.ncbi.nlm.nih.gov/29241958/). Patients should receive broad-spectrum IV antibiotics as they await appendectomy (or as part of a trial of non-operative management, another controversy to tackle some other time!)