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Eur J Pediatr Surg 2020; 30(04): 350-356
DOI: 10.1055/s-0039-1687870
Original Article
Georg Thieme Verlag KG Stuttgart · New York

Low Plasma Sodium Concentration Predicts Perforated Acute Appendicitis in Children: A Prospective Diagnostic Accuracy Study

Ulf Lindestam 
1   Department of Pediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children’s Hospital, Karolinska University Hospital Solna, Stockholm, Sweden
2   Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
,
Markus Almström
3   Department of Pediatric Surgery, Astrid Lindgren Children’s Hospital, Karolinska University Hospital Solna, Stockholm, Sweden
4   Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
,
Johannes Jacks
1   Department of Pediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children’s Hospital, Karolinska University Hospital Solna, Stockholm, Sweden
,
Pia Malmquist
5   Department of Pediatric Emergency Medicine, Astrid Lindgren Children’s Hospital, Karolinska University Hospital Solna, Stockholm, Sweden
,
Per-Arne Lönnqvist
1   Department of Pediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children’s Hospital, Karolinska University Hospital Solna, Stockholm, Sweden
2   Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
,
Boye Lagerbon Jensen
6   Department of Cardiovascular- and Renal Research, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
,
Mattias Carlström
2   Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
,
Rafael Tomas Krmar
2   Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
,
Jan Fredrik Svensson
3   Department of Pediatric Surgery, Astrid Lindgren Children’s Hospital, Karolinska University Hospital Solna, Stockholm, Sweden
4   Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
,
Åke Norberg
7   Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital Huddinge, Stockholm, Sweden
8   Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
,
Urban Fläring
1   Department of Pediatric Perioperative Medicine and Intensive Care, Astrid Lindgren Children’s Hospital, Karolinska University Hospital Solna, Stockholm, Sweden
2   Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
› Author Affiliations
Further Information

Publication History

21 December 2018

09 March 2019

Publication Date:
25 April 2019 (online)

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Abstract

Introduction Early differentiation between perforated and nonperforated acute appendicitis (AA) in children is of major benefit for the selection of proper treatment. Based on pilot study data, we hypothesized that plasma sodium concentration at hospital admission is a diagnostic marker for perforation in children with AA.

Materials and Methods This was a prospective diagnostic accuracy study, including previously healthy children, 1 to 14 years of age, with AA. Blood sampling included plasma sodium concentration, plasma glucose, base excess, white blood cell count, plasma arginine vasopressin (AVP), and C-reactive protein.

Results Eighty children with histopathologically confirmed AA were included in the study. Median plasma sodium concentration on admission in patients with perforated AA (134 mmol/L, [interquartile range 132–136]) was significantly lower than in children with nonperforated AA (139 mmol/L, [137–140]). The receiver operating characteristic curve of plasma sodium concentration identifying patients with perforated AA showed an area under the curve of 0.93 (95% confidence interval, 0.87–0.99), with a sensitivity and specificity of 0.82 (0.70–0.90) and 0.87 (0.60–0.98), respectively. Plasma sodium concentrations ≤136 mmol/L resulted in an odds ratio of 31.9 (6.3–161.9) for perforation. The association between low plasma sodium concentration and perforated AA was confirmed in a multivariate logistic regression analysis. Median plasma AVP on admission was higher in patients with perforated (8.6 pg/mL [5.0–14.6]) as compared with nonperforated AA (3.4 pg/mL [2.5–6.6]).

Conclusion In children with AA, there is a strong association between low plasma sodium concentration and perforation, a novel and not previously described finding.

Keywords

acute appendicitis - appendectomy - pediatric surgery - plasma sodium concentration - diagnostic accuracy
 

  • References

  • 1 Gale ME, Birnbaum S, Gerzof SG, Sloan G, Johnson WC, Robbins AH. CT appearance of appendicitis and its local complications. J Comput Assist Tomogr 1985; 9 (01) 34-37
    CrossrefPubMedGoogle Scholar
  • 2 Puylaert JB. Acute appendicitis: US evaluation using graded compression. Radiology 1986; 158 (02) 355-360
    CrossrefPubMedGoogle Scholar
  • 3 Incesu L, Coskun A, Selcuk MB, Akan H, Sozubir S, Bernay F. Acute appendicitis: MR imaging and sonographic correlation. AJR Am J Roentgenol 1997; 168 (03) 669-674
    CrossrefPubMedGoogle Scholar
  • 4 Blumfield E, Yang D, Grossman J. Scoring system for differentiating perforated and non-perforated pediatric appendicitis. Emerg Radiol 2017; 24 (05) 547-554
    CrossrefPubMedGoogle Scholar
  • 5 Yoon DY, Chu J, Chandler C, Hiyama S, Thompson JE, Hines OJ. Human cytokine levels in nonperforated versus perforated appendicitis: molecular serum markers for extent of disease?. Am Surg 2002; 68 (12) 1033-1037
    PubMedGoogle Scholar
  • 6 Gorter RR, Wassenaar ECE, de Boer OJ. , et al. Composition of the cellular infiltrate in patients with simple and complex appendicitis. J Surg Res 2017; 214: 190-196
    CrossrefPubMedGoogle Scholar
  • 7 Howie JG. Too few appendicectomies?. Lancet 1964; 1 (7345): 1240-1242
    PubMedGoogle Scholar
  • 8 Andersson RE. The natural history and traditional management of appendicitis revisited: spontaneous resolution and predominance of prehospital perforations imply that a correct diagnosis is more important than an early diagnosis. World J Surg 2007; 31 (01) 86-92
    CrossrefPubMedGoogle Scholar
  • 9 Fläring U, Lönnqvist PA, Frenckner B. , et al. The efficacy of hypotonic and near-isotonic saline for parenteral fluid therapy given at low maintenance rate in preventing significant change in plasma sodium in post-operative pediatric patients: protocol for a prospective randomized non-blinded study. BMC Pediatr 2011; 11: 61
    CrossrefPubMedGoogle Scholar
  • 10 Neville KA, Sandeman DJ, Rubinstein A, Henry GM, McGlynn M, Walker JL. Prevention of hyponatremia during maintenance intravenous fluid administration: a prospective randomized study of fluid type versus fluid rate. J Pediatr 2010; 156 (02) 313-319
    CrossrefPubMedGoogle Scholar
  • 11 Carr NJ. The pathology of acute appendicitis. Ann Diagn Pathol 2000; 4 (01) 46-58
    CrossrefPubMedGoogle Scholar
  • 12 Bie P, Sandgaard NC. Determinants of the natriuresis after acute, slow sodium loading in conscious dogs. Am J Physiol Regul Integr Comp Physiol 2000; 278 (01) R1-R10
    CrossrefPubMedGoogle Scholar
  • 13 Emmeluth C, Drummer C, Gerzer R, Bie P. Natriuresis in conscious dogs caused by increased carotid [Na+] during angiotensin II and aldosterone blockade. Acta Physiol Scand 1994; 151 (03) 403-411
    CrossrefPubMedGoogle Scholar
  • 14 ABL90 FLEX PLUS Instructions for use. 996–178, 201703L. Radiometer Medical ApS. 2017
    PubMed
  • 15 Cohen JF, Korevaar DA, Altman DG. , et al. STARD 2015 guidelines for reporting diagnostic accuracy studies: explanation and elaboration. BMJ Open 2016; 6 (11) e012799
    CrossrefPubMedGoogle Scholar
  • 16 St Peter SD. . Appendectomy Versus Non-Operative Treatment For Acute Non-Perforated Appendicitis in Children (APPY) Clinical Trials.gov NCT026874642016
    PubMed
  • 17 Pham XD, Sullins VF, Kim DY. , et al. Factors predictive of complicated appendicitis in children. J Surg Res 2016; 206 (01) 62-66
    CrossrefPubMedGoogle Scholar
  • 18 Kim DY, Nassiri N, de Virgilio C. , et al. Association between hyponatremia and complicated appendicitis. JAMA Surg 2015; 150 (09) 911-912
    CrossrefPubMedGoogle Scholar
  • 19 Käser SA, Furler R, Evequoz DC, Maurer CA. Hyponatremia is a specific marker of perforation in sigmoid diverticulitis or appendicitis in patients older than 50 years. Gastroenterol Res Pract 2013; 2013: 462891
    PubMedGoogle Scholar
  • 20 Kim HY, Park JH, Lee YJ, Lee SS, Jeon JJ, Lee KH. Systematic review and meta-analysis of CT features for differentiating complicated and uncomplicated appendicitis. Radiology 2017; 287 (01) 104-115
    PubMedGoogle Scholar
  • 21 Svensson JF, Patkova B, Almström M. , et al. Nonoperative treatment with antibiotics versus surgery for acute nonperforated appendicitis in children: a pilot randomized controlled trial. Ann Surg 2015; 261 (01) 67-71
    CrossrefPubMedGoogle Scholar
  • 22 Vons C, Barry C, Maitre S. , et al. Amoxicillin plus clavulanic acid versus appendicectomy for treatment of acute uncomplicated appendicitis: an open-label, non-inferiority, randomised controlled trial. Lancet 2011; 377 (9777): 1573-1579
    CrossrefPubMedGoogle Scholar
  • 23 Hansson J, Körner U, Khorram-Manesh A, Solberg A, Lundholm K. Randomized clinical trial of antibiotic therapy versus appendicectomy as primary treatment of acute appendicitis in unselected patients. Br J Surg 2009; 96 (05) 473-481
    CrossrefPubMedGoogle Scholar
  • 24 Hanna S, Tibby SM, Durward A, Murdoch IA. Incidence of hyponatraemia and hyponatraemic seizures in severe respiratory syncytial virus bronchiolitis. Acta Paediatr 2003; 92 (04) 430-434
    PubMedGoogle Scholar
  • 25 Moritz ML, Ayus JC. Preventing neurological complications from dysnatremias in children. Pediatr Nephrol 2005; 20 (12) 1687-1700
    CrossrefPubMedGoogle Scholar
  • 26 Steele A, Gowrishankar M, Abrahamson S, Mazer CD, Feldman RD, Halperin ML. Postoperative hyponatremia despite near-isotonic saline infusion: a phenomenon of desalination. Ann Intern Med 1997; 126 (01) 20-25
    PubMedGoogle Scholar
  • 27 Luu R, DeWitt PE, Reiter PD, Dobyns EL, Kaufman J. Hyponatremia in children with bronchiolitis admitted to the pediatric intensive care unit is associated with worse outcomes. J Pediatr 2013; 163 (06) 1652-1656.e1
    CrossrefPubMedGoogle Scholar
  • 28 van Steensel-Moll HA, Hazelzet JA, van der Voort E, Neijens HJ, Hackeng WH. Excessive secretion of antidiuretic hormone in infections with respiratory syncytial virus. Arch Dis Child 1990; 65 (11) 1237-1239
    CrossrefPubMedGoogle Scholar
  • 29 Robertson GL. Antidiuretic hormone. Normal and disordered function. Endocrinol Metab Clin North Am 2001; 30 (03) 671-694
    CrossrefPubMedGoogle Scholar
  • 30 Rosendahl W, Schulz U, Teufel T, Irtel von Brenndorf C, Gupta D. Surgical stress and neuroendocrine responses in infants and children. J Pediatr Endocrinol Metab 1995; 8 (03) 187-194
    PubMedGoogle Scholar