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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

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-------- 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:
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>



-- 
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


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