Disclaimer: This article is intended solely for informational and educational purposes only. It does not constitute medical advice.
Acute appendicitis remains one of the most common indications for emergency abdominal surgery, and anesthesiologists managing these cases must balance the competing priorities of airway protection, hemodynamic stability, and effective analgesia in a population that typically does not meet standard nil per os (NPO) requirements (1). In procedures for patients with a full or potentially full stomach, anesthetic management for urgent appendectomy must protect against elevated aspiration risk.
At most facilities, general anesthesia with rapid sequence induction (RSI) is the default approach for the anesthetic management of appendectomy patients. A retrospective review of 250 patients found that RSI was recorded in 81% of cases, typically combining an opioid, propofol, and succinylcholine, with rocuronium precurarization used in the large majority of succinylcholine cases (1). Difficult intubation occurred in only 1.2% of patients, and no aspiration events were documented, though hypotension was observed in over a quarter of patients in the twenty minutes following induction (1). These findings suggest that while airway complications with RSI are infrequent, clinicians should anticipate and be prepared to manage hemodynamic perturbation (1).
Regional and neuraxial techniques have been increasingly explored as alternatives or adjuncts to general anesthesia. A prospective feasibility study of combined spinal-epidural anesthesia (CSEA) in 33 ASA class I patients undergoing laparoscopic appendectomy demonstrated that a T2–T4 sensory block could be achieved safely, with intraoperative shoulder pain and abdominal discomfort as the most common adverse events, and postoperative nausea and vomiting notably absent (2). Hypotension occurred in only 6.1% of patients, an outcome the investigators attributed to adequate volume preloading and the hemodynamic effects of a modest 10 mmHg pneumoperitoneum pressure (2). Notably, two patients with perforated appendicitis required conversion to general anesthesia because of insufficient abdominal wall relaxation, underscoring that CSEA may be best reserved for uncomplicated, non-perforated presentations in healthy patients rather than more complex intra-abdominal pathology (2).
Postoperative analgesia is another consideration in the anesthetic management of appendectomy, with strategies having evolved over time. A randomized, double-blind trial in children undergoing open appendectomy found that a unilateral transversus abdominis plane (TAP) block with ropivacaine, performed after induction and before incision, reduced 48-hour morphine consumption by approximately 50% and delayed time to first opioid request compared with placebo, without increasing sedation or nausea (3). These results support incorporation of regional blockade into a multimodal analgesic regimen even when general anesthesia with tracheal intubation is employed (3).
Some research suggests that the non-urgent treatment of appendicitis may be appropriate in select cases. A randomized trial comparing immediate laparoscopic appendectomy with initial nonoperative management (percutaneous drainage and antibiotics followed by interval appendectomy) in children with perforated appendicitis and abscess found no significant difference in total hospitalization or charges between strategies, though immediate operation trended toward a longer operative time (4). Non-urgent surgery allows for patients to present NPO, reducing aspiration risk. However, many cases are not suitable for nonoperative care and do require urgent surgery.
Taken together, the literature indicates that anesthetic management of urgent appendectomy should involve RSI as the default. Combined spinal-epidural anesthesia may be a viable alternative in carefully selected, uncomplicated patients, and regional blocks such as the TAP block can offer meaningful opioid-sparing benefits in postoperative analgesia. Individualized decision-making, informed by disease severity, patient comorbidity, and institutional expertise, remains essential.
References
- Istvan, J.; Belliveau, M.; Donati, F. Rapid Sequence Induction for Appendectomies: A Retrospective Case-Review Analysis. Can. J. Anesth. 2010, 57, 330–336. https://doi.org/10.1007/s12630-009-9260-1.
- Uzman, S.; Donmez, T.; Erdem, V. M.; Hut, A.; Yildirim, D.; Akinci, M. Combined Spinal-Epidural Anesthesia in Laparoscopic Appendectomy: A Prospective Feasibility Study. Ann. Surg. Treat. Res. 2017, 92 (4), 208–213. https://doi.org/10.4174/astr.2017.92.4.208.
- Carney, J.; Finnerty, O.; Rauf, J.; Curley, G.; McDonnell, J. G.; Laffey, J. G. Ipsilateral Transversus Abdominis Plane Block Provides Effective Analgesia After Appendectomy in Children: A Randomized Controlled Trial. Anesth. Analg. 2010, 111 (4), 998–1003. https://doi.org/10.1213/ANE.0b013e3181ee7bba.
- St. Peter, S. D.; Aguayo, P.; Fraser, J. D.; Keckler, S. J.; Sharp, S. W.; Leys, C. M.; Murphy, J. P.; Snyder, C. L.; Sharp, R. J.; Andrews, W. S.; Holcomb, G. W., III; Ostlie, D. J. Initial Laparoscopic Appendectomy Versus Initial Nonoperative Management and Interval Appendectomy for Perforated Appendicitis with Abscess: A Prospective, Randomized Trial. J. Pediatr. Surg. 2010, 45 (1), 236–240. https://doi.org/10.1016/j.jpedsurg.2009.10.039.
