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Most of these kids with RLQ pain feel better after fluids and pain control,
by the time the US comes back negative for appendicitis, the child is
feeling better and then goes home, or they are usually constipated so we
discharged them with a stool softener, if the child continues in pain, then
we take it from there. If the US did not find the appendix, then we discuss
the case with surgery and take it from there.

On Thu, Aug 10, 2017 at 6:43 AM, trzim29 <[log in to unmask]> wrote:

> If US is negative they go home?
> But you than go on with a different process, can you expound?
> I would never rely my dispo on a negative US, hence, although I still do
> them, I am starting to shy away from them. Could be institutional related,
> I get it...
>
> Todd Z
>
>
> Sent from my Verizon, Samsung Galaxy smartphone
>
> -------- Original message --------
> From: Daniel Thimann <[log in to unmask]>
> Date: 8/9/17 6:00 PM (GMT-06:00)
> To: [log in to unmask]
> Subject: Re: WBC counts for appy workup
>
> In my experience, the PAS is driving by your surgeons and your system. In
> our institution, our process is that in a kid with suspicion for
> appendicitis, we order blood work, IV, IVF and send the child for an US, if
> the child US is negative, he goes home, if +, he goes to the OR, if
> equivocal (appy not identified) then we talk to the surgeons, based on
> their assessment and our consultation, the kid gets admitted, goes to the
> OR or gets a CT scan. The problem is that if you send the child for US
> first and comes back equivocal, then you may or may not do labs, if it
> comes back positive, surgeons want a CBC, chemistry and a UA (This is a LOS
> issue, it takes time for these studies to come back). We do not use a white
> count to determine if the child needs an US, we use my PE findings for
> that.
>
> Where I trained, if the US was positive, no one cared about the white count
> and they would take the kid to the OR. In a world of decreasing re
> imbursement and cost containment, it would be interesting to know how much
> does a CBC actually cost, you could even do it without the differential but
> the differential is also part of the PAS. I had several kids with
> appendicitis and normal white count which demonstrated how good of a test
> it is. I would prefer to perform just an US and then send the kid to the
> OR, but the surgeons want to know since they take the kid to the OR. In my
> experience PAS is rarely useful, maybe is a good thing to document on a
> child with constipation were your suspicion is already low.
>
> Hope this helps
>
> Daniel Thimann MD
> Pediatric Emergency Medicine
> Jacksonville Florida
>
> On Wed, Aug 9, 2017 at 12:32 PM, christian Rocholl <
> [log in to unmask]> wrote:
>
> > I am interested to know, if you routinely use a WBC count to determine if
> > you would perform an US to look for appendicitis. Many times I perform a
> > RLQ US based on clinical suspicion and thus I don't perform a CBC on many
> > children before imaging. I usually order a CBC if I think a child has
> > enough pain to warrant IV fluids and medication but in these cases I will
> > admit that I typically order the CBC with the US. We have US available
> 24/7
> > and I think that anecdotally our technicians are pretty good. We rarely,
> > almost never, do CT before US but if US is equivocal and suspicion is
> high
> > then will proceed to CT. I work at a hospital that is part of a larger
> > system where other hospitals (without 24/7 Pediatric EM) are doing
> > appendicitis scoring on all abdominal pain. Obviously not everyone has
> high
> > enough suspicion of appendicitis to warrant a score and I would assume
> that
> > many patients with abdominal pain are discharged without a work up.
> > However, the healthcare system can not compare data of appendicitis
> outcome
> > comparing pre diagnosis low, moderate, and high suspicion cases because
> the
> > providers at my hospital are not completing a pediatric appendicitis
> score.
> > A CBC is required for the score to be completed in the EMR and thus for
> it
> > to be retrievable in a report without a chart review.
> > It has been questioned whether our process adds cost and I am in the
> > process of obtaining cost for US compared to lab. I take into
> consideration
> > that we rarely perform blood work without an IV on children and I am sure
> > this can be questioned but we try not to "poke" a child for a CBC only to
> > return and "poke" for an IV. Our turn around time for US is vey good. And
> > also this may be questionable but I feel that US for appy is very
> operator
> > dependent and the process has helped in that our rates of US where the
> > appendix can not be visualized has improved. I know this previous
> sentence
> > is not a justification for US on children but I would also say that we
> have
> > many patients referred to our hospital with inconclusive or borderline
> > measurements of an appendix where an US at our hospital sometimes
> provides
> > clarity.
> >
> > Thank You for your thoughts
> >
> > Christian Rocholl MD
> >
> > For more information, send mail to [log in to unmask] with the
> > message: info PED-EM-L
> > The URL for the PED-EM-L Web Page is:
> >                  http://listserv.brown.edu/ped-em-l.html
> >
>
>
>
> --
> Thank you
>
> Daniel Thimann
>
> For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                  http://listserv.brown.edu/ped-em-l.html
>



-- 
Thank you

Daniel Thimann

For more information, send mail to [log in to unmask] with the message: info PED-EM-L
The URL for the PED-EM-L Web Page is:
                 http://listserv.brown.edu/ped-em-l.html