ส่วนที่ 1 ข้อมูลเอกสาร

ส่วนที่ 2 Appendicitis Diagnosis

2.1 Clinical Features

• Periumbilical → RLQ pain (migration)
• Anorexia, nausea, vomiting
• Low-grade fever (37.5-38.5°C)
• McBurney's point tenderness
• Rebound tenderness, guarding
• Rovsing, psoas, obturator signs

2.2 Alvarado Score

Score: 0-4 unlikely | 5-6 possible | 7-10 probable

2.3 Imaging

• Ultrasound: First-line (children, pregnant, lean), wall > 6mm, non-compressible
• CT abdomen: Gold standard, sensitivity 94%
• MRI: Pregnancy, to avoid radiation

ส่วนที่ 3 Pre-operative Care

3.1 ERAS (Enhanced Recovery After Surgery) Pre-op

• NPO: 6 hr solids, 2 hr clear liquids (not overnight!)
• Carbohydrate loading: clear carb drink 2 hr before
• No routine bowel prep (unless colorectal)
• DVT prophylaxis: LMWH + mechanical
• Normothermia (warming)
• Antibiotic prophylaxis 30-60 min before incision:
  • Cefazolin 2g IV + Metronidazole 500mg
• Informed consent verification
• Site marking

3.2 Preoperative Assessment

• History: allergies, meds, prior surgeries, family anesthesia issues
• Airway assessment (Mallampati)
• Cardiovascular: ACS risk (RCRI)
• Labs: CBC, BMP, Coag, Type & Screen
• ECG (age > 50 or risk factors)
• CXR if indicated
• Pregnancy test (reproductive age women)

ส่วนที่ 4 Intra-operative (Nursing)

4.1 Safe Surgery Checklist (WHO)

• Sign In (before anesthesia): patient ID, site, consent, allergy, airway
• Time Out (before incision): team introduction, surgery/site confirmation, antibiotic given, imaging ready
• Sign Out (before leaving OR): procedure name, counts correct, specimens labeled, equipment issues

4.2 Counts

• Sponge count: before, before closing, after closing
• Instrument count
• Sharps count
• If count incorrect → X-ray before leaving OR

ส่วนที่ 5 Post-operative Care

5.1 PACU (Post-Anesthesia Care Unit)

• Airway: assess q 5-15 min
• V/S q 15 min × 1 hr, then q 30 min
• Aldrete Score: respiration, SpO₂, consciousness, circulation, activity (discharge ≥ 9)
• Pain: 0-10 scale, treat with opioid PRN
• Nausea: ondansetron 4 mg IV PRN
• Dressing check for bleeding
• Urine output
• Temperature (hypothermia common)

5.2 Ward — ERAS Postop

• Early feeding: clear liquids same day, advance as tolerated
• Early mobilization: out of bed within 24 hr, walk day 1
• Remove Foley early: POD 1-2
• Multimodal analgesia: scheduled acetaminophen + NSAID, opioid PRN only
• DVT prophylaxis: continue until discharge (longer if high-risk)
• Early discharge criteria:
  • Tolerating diet
  • Pain controlled on oral
  • Bowel function returning (flatus/BM)
  • Afebrile, stable V/S
  • Mobilizing safely

5.3 Wound Care

• Sterile dressing × 48 hr
• Daily inspection: redness, warmth, discharge, dehiscence
• Sutures/staples removed POD 7-10
• Patient education: signs of infection, when to call

ส่วนที่ 6 Complications

6.1 Early (< 48 hr)

• Hemorrhage — monitor Hb, V/S
• Atelectasis — incentive spirometry, early ambulation
• Nausea/vomiting
• Pain
• Urinary retention

6.2 Late

• SSI (Surgical Site Infection): POD 3-7, redness, drainage, fever
• Intra-abdominal abscess: persistent fever, ileus → CT
• Ileus vs obstruction: absent bowel sounds vs high-pitched
• DVT/PE: unilateral leg swelling, sudden SOB
• Wound dehiscence: POD 5-8, gush of serosanguinous fluid

6.3 SSI Management

• Open and drain wound
• Wound culture
• Antibiotics (depending on severity, organism)
• Packing and dressing changes
• Consider VAC (wound vac) for complex wounds

KPIs

References

• Di Saverio, S., et al. (2020). Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World Journal of Emergency Surgery, 15(1).
• Gustafsson, U.O., et al. (2019). Guidelines for Perioperative Care in Elective Colorectal Surgery: ERAS Society Recommendations.
• WHO. (2009). Safe Surgery Saves Lives.

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