Plasma Sodium and Age Are Important Markers of Risk of Perforation in Acute Appendicitis
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RESEARCH COMMUNICATION
Plasma Sodium and Age Are Important Markers of Risk of Perforation in Acute Appendicitis Adam Heymowski 1 & Lennart Boström 2 & Martin Dahlberg 2 Received: 3 July 2020 / Accepted: 17 July 2020 # 2020 The Society for Surgery of the Alimentary Tract
Keywords Risk prediction . Appendicitis . Hyponatremia
Introduction Acute appendicitis (AA) is the most common cause for emergency abdominal surgery worldwide.1 Although the risk of perforation is probably not increased by delays to surgery in stable patients,2 perforation is associated with an increase in postoperative complications including abscess formation, paralytic ileus, and in rare cases even death.1 Finding preoperative markers of perforation is important in allocating resources to those with perforated disease and in understanding the disease process. A negative correlation with strong negative predictive value between plasma sodium concentration and the rate of perforation in acute appendicitis and diverticulitis in patients over 50 years of age has been reported.3 Recent work has confirmed that even mild hyponatremia in patients presenting with AA is correlated with complicated appendicitis in adults.3,4 A recent study5 on children with appendicitis found a pronounced correlation (odds ratio 32) between hyponatremia at time of admission and the rate of perforation. To evaluate the relationship between plasma sodium concentration and perforation rate in a large urban hospital, we developed a model of the absolute risk of perforation in acute appendicitis, controlling for plasma sodium and age. We hypothesized an age-dependent correlation of increased effect of sodium imbalance in
* Martin Dahlberg [email protected] 1
Karolinska Institute, Stockholm, Sweden
2
Department of Surgery, Södersjukhuset, Karolinska Institute, Sjukhusbacken 10, 118 83 Stockholm, Sweden
the younger and elder patients, due to their higher sensitivity to hyponatremia.
Methods A quality register of all appendectomies for suspected acute appendicitis at Stockholm South General Hospital was available from January 2015 through December 2019. Plasma sodium levels were measured at the central laboratory on site with a potentiometry-based procedure. Perforation was defined by the operating surgeon and recorded on chart review in the 30-day follow-up done by two of the authors (MD, LB). A logistic multivariable model with perforation as the outcome and plasma sodium and age as covariables was constructed. Plasma sodium and age were modeled as restricted cubic splines with 3 knots placed at the quantiles of the respective distributions. Confidence intervals were constructed using a 1000-fold bootstrap. Patients with missing data were excluded from analysis. The study was approved by the Swedish Ethical Review Authority (Dnr 2019-05976).
Results The absolute risk of perforated appendicitis in the cohort of 2327 patients was 27.2%, and the baseline characteristics are presented in Table 1. There was a monotonous relationship between the risk of perforation an
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