Application effect of anticipatory care in postoperative infection and complication management in children with acute appendicitis

Abstract

BACKGROUND

Acute appendicitis is common among pediatric patients, and postoperative infections and complications are significant factors that affect recovery. As a “forward-looking” nursing model, anticipatory care may reduce the incidence of postoperative wound infections and complications.

AIM

To explore the effects of anticipatory care on the management of postoperative infections and complications in pediatric patients diagnosed with acute appendicitis.

METHODS

This prospective randomized controlled study included data from 78 pediatric patients who underwent acute appendicitis surgery at Shijiazhuang Sixth Hospital (Hebei Province, China) between February 2021 and March 2024. Patients were divided into two groups: The intervention and control groups (n = 39 each) were based on a random numbers table method. Both groups received routine postoperative nursing care, whereas the intervention group received additional anticipatory care. Statistical analyses were performed using independent sample t-tests, χ² tests, analysis of variance, and rank-sum tests.

RESULTS

Postoperative pain scores and hospital length of stay were significantly lower in the intervention group than those in the control group (P < 0.05 and P < 0.001, respectively). Postoperative wound infection and overall complication rates were significantly lower in the intervention group than those in the control group (5.13% vs 23.08%, P < 0.001; 15.38% vs 46.15%, P < 0.001, respectively). Furthermore, parental satisfaction scores were significantly higher in the intervention group than those in the control group (P < 0.05). Logistic regression identified high C-reactive protein level as a risk factor for postoperative infections and complications, whereas proactive (i.e. anticipatory) nursing intervention was a protective factor.

CONCLUSION

This study provided a scientific basis for the implementation of anticipatory care in the postoperative management of pediatric patients experiencing acute appendicitis.

Key Words: Acute appendicitis; Children; Anticipatory care; Postoperative infection; Complication

Core Tip: Anticipatory nursing care has important application value in the postoperative care of pediatric acute appendicitis. Anticipatory nursing care can significantly reduce the incidence of postoperative infection and complications and effectively improve the satisfaction of the parents of the pediatric patients with acute appendicitis.

INTRODUCTION

Acute appendicitis is one of the most common pediatric acute abdominal conditions, and its prevalence among children is approximately four times that in the total population[1,2]. Due to the incomplete development of physiological functions and anatomical structures in children, symptoms of appendicitis often present atypically. Moreover, acute appendicitis progresses rapidly, making it prone to perforation and pus formation as well as spreading and developing into sepsis or toxic shock[3]. Children have limited cognitive, comprehensive, and expressive capabilities; as such, they often fail or are unable to express their disease status accurately and promptly. In those with appendicitis, the appendix is frequently gangrenous or perforated, causing severe peritoneal adhesions that lead to increased surgical difficulty and a significantly higher possibility of postoperative residual peritoneal infections and intestinal obstruction[4].

Surgery remains the most common method for treating acute appendicitis; however, traditional open surgical incisions are relatively large and prone to postoperative scarring. Postoperative hyperplastic scarring is a common surgical complication that affects both esthetics and quality of life of patients[5]. The widespread use of laparoscopy plays an important role in alleviating postoperative pain and promoting early recovery, making it the procedure of choice[6]. However, the incidence of postoperative complications in pediatric acute appendicitis ranges from 5% to 30% and is higher in more complicated cases of appendicitis[7]. Therefore, diagnosis, treatment, and perioperative care for pediatric acute appendicitis requires a more delicate and comprehensive approach than those for adults.

Several preventive measures against postoperative infections and complications in pediatric acute appendicitis have been explored[6-8]. For example, strict aseptic techniques during surgery can reduce the risk for wound infections. Antibiotic prophylaxis is also commonly used; however, its effectiveness may vary depending on factors including antibiotic type, dosage, and timing of administration[6]. Some studies have reported that early mobilization and proper dietary management after surgery can help prevent intestinal adhesions and promote recovery of gastrointestinal function[5]. However, these measures alone may not be sufficient to fully address this issue, and the overall prevention effect still has room for improvement.

In past clinical practice, conventional nursing intervention measures were implemented after acute appendicitis surgery in pediatric patients. Although these measures could provide basic nursing measures for children, they lacked predictability and were difficult to effectively prevent complications. Proactive nursing intervention is capable of conducting predictive analysis and evaluation during the nursing process, enabling timely prediction of various potential safety hazards and the implementation of proactive intervention measures. It places greater emphasis on the predictability and systematic nature of nursing work[8]. Accordingly, the present study aimed to analyze the influence of anticipatory care on complications and nursing satisfaction in pediatric patients after acute appendicitis surgery.

MATERIALS AND METHODS

Study design

This prospective randomized controlled study enrolled data from 78 children who underwent surgery for acute appendicitis at our hospital between February 2021 and March 2024. Using a random numbers table method, the children were divided into two groups: Intervention (n = 39) and control (n = 39). Both groups received routine postoperative care, whereas the intervention group received predictive nursing interventions including preoperative risk assessment, close postoperative monitoring of vital signs, wound preventive care, pain management, dietary guidance, and psychological support. This study was approved by the Institutional Review Board of the Shijiazhuang Maternal and Child Health Hospital (No. 202122).

Inclusion criteria for the present study were as follows: (1) Age 6-12 years; (2) Diagnosed with acute appendicitis at our hospital and were surgically treated; (3) Signs, symptoms, imaging findings, and laboratory test results that fulfilled the diagnostic criteria for acute appendicitis; (4) Normal language and listening abilities; and (5) Informed consent obtained from all children and their parents/legal guardians.

Children < 6 years of age, those with acute gangrene, perforated appendicitis, or peri-appendiceal abscess, those with a history of severe organ dysfunction and other abdominal diseases, coagulation disorders or immunodeficiency, and those with incomplete clinical data were excluded.

Nursing methods

The control group underwent routine postoperative care, including abdominal ultrasonography, chest radiography, routine laboratory investigations, coagulation tests, inflammatory indicators, liver and kidney function tests, electrolytes, and other routine preoperative tests. Routine health education included disease introduction addressing postoperative pain, abdominal distension, vomiting, and other conditions, disease outcomes, treatment, and rehabilitation programs. The intervention group received proactive nursing interventions, including preoperative and postoperative nursing measures, described in the following sections.

Preoperative nursing measures

Preoperative risk assessment: A comprehensive preoperative risk assessment was performed within 24 h of hospital admission. This assessment covered aspects including the patient’s general health condition, severity of acute appendicitis, and potential risk factors for postoperative complications.

Explanation and emotional support: The nursing staff provided a detailed explanation of the surgery to the children and their parents within 12 h after admission. This included information about the surgical process, expected outcomes, and safety measures. Simultaneously, they provided comfort and encouragement to alleviate anxiety.

Oral glucose administration: The children were orally administered a glucose solution 4-6 h before the surgery to alleviate feelings of hunger.

Postoperative nursing measures

Close monitoring of vital signs: Continuous monitoring of vital signs (including body temperature, heart rate, blood pressure, and respiratory rate) was initiated immediately after the patient was returned to the ward from the operating room. Vital signs were monitored every 15-30 min for the first 2 h and subsequently adjusted according to the patient’s condition.

Preventive wound care: Preventive wound care was started within 1 h after the patient settled in the ward. This included observing the wound dressing for any signs of bleeding, swelling, or infection and changing the dressing according to physician instructions, usually every 1-2 days.

Pain management: Pain management was initiated immediately after the patient awakened from anesthesia. Pain levels were assessed using a visual analog scale (VAS) every 1-2 h for the first 24 h. Appropriate pain relief measures, such as medications or non-pharmacological methods (e.g., distraction techniques for children), were implemented according to pain level.

Dietary guidance: Parents were instructed to start feeding their child with fluids 6-8 h after surgery. Within 24-48 h after surgery, if the patient exhibited adequate tolerance to fluid intake with no signs of digestive problems (such as nausea, vomiting, or abdominal discomfort), diet was gradually transitioned to semi-fluids. As the patient continued to recover, a normal diet was slowly introduced, typically approximately 3-5 days after surgery, depending on the individual’s recovery progress.

Psychological support: Continuous psychological support was provided during the postoperative period. This was initiated by explaining the influence of psychology on acute appendicitis and providing psychological guidance within 2 h after the patient awakened. Offering books or storybooks to children was needed to ease crying and nervousness and to enhance compliance.

Postural care and mobility training: Postoperative postural care, sitting maintenance training, bed mobility training, and standing training was initiated 12-24 h after surgery, depending on patient condition. It began with simple postural adjustments and gradually progressed to more complex mobility training.

Medication management: The medication schedule was adjusted in accordance with physician instructions within 1 h after the patient was returned to the ward. The different effects and characteristics of various medications were explained to the patients and their parents during the first administration of each new medication.

Observational indicators

General demographic information (age, height, weight, body mass index, body temperature) and clinical data including systolic blood pressure, diastolic blood pressure, C-reactive protein (CRP), WBC, neutrophil, platelet, and lymphocyte counts, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, postoperative infection rate, complication rate, hospital length of stay, VAS score, and self-administered parent satisfaction questionnaire were collected and analyzed for the two patient groups.

A VAS developed by the Chinese Medical Pain Society[9] was used to evaluate the degree of pain in the two groups at 6 h, 12 h, 24 h, 48 h, and 72 h after surgery. Pain was rated on a scale of 0-10 using a 10 cm sliding ruler, with 0 indicating no pain and 10 indicating the most severe pain, with increased score(s) indicating worsening pain.

Statistical analysis

Data analysis was performed using SPSS version 27.0 (IBM Corporation, Armonk, NY, United States). Normally distributed continuous data were expressed as mean ± SD. Comparisons between the two groups were performed using an independent samples t-test. Multiple timepoint comparisons were performed using repeated-measures analyses. Count data were expressed as n (%), and comparisons between the two groups were performed using the χ² test. Postoperative infections and complications were transformed into dichotomous variables and their influencing factors were explored using a logistic regression model.

RESULTS

General characteristics

A comparison of the general characteristics of the intervention and control groups is presented in Table 1. No statistically significant differences were observed between the two groups in terms of sex, age, height, weight, body temperature, systolic blood pressure, diastolic blood pressure, or disease course (P > 0.05).

Table 1 Comparison of general characteristics between the two patient groups.

Characteristic	Intervention group (n = 39)	Control group (n = 39)	χ2/t	P value
Gender			0.710	0.354
Male	18 (46.15)	20 (51.28)
Female	21 (53.85)	19 (48.72)
Age	8.38 ± 1.46	8.56 ± 1.54	-0.529	0.599
Height	135.41 ± 10.11	137.56 ± 11.25	-0.888	0.378
Weight	30.10 ± 4.72	29.65 ± 5.36	0.385	0.701
Body temperature	37.25 ± 0.85	37.05 ± 0.85	1.013	0.314
SBP	112.50 ± 12.10	115.70 ± 11.20	-1.214	0.229
DBP	66.85 ± 8.15	67.25 ± 9.35	-0.201	0.841
Course of disease	13.54 ± 3.51	14.13 ± 4.53	-0.643	0.522

Data are presented as mean ± SD or n (%). Intervention group: Received routine postoperative nursing care and anticipatory nursing care. Control group: Received routine postoperative nursing care; SBP: Systolic blood pressure; DBP: Diastolic blood pressure.

Length of hospital stay and VAS scores

The VAS scores of the intervention group were lower than those of the control group at 6 h, 12 h, 24 h, 48 h, and 72 h after surgery (P < 0.05). The length of hospital stay was significantly shorter in the intervention group than that in the control group (P < 0.001) (Table 2).

Table 2 Comparison of length of hospital stay and visual analog scale scores between the two patient groups.

	Intervention group (n = 39)	Control group (n = 39)	t	P value
Hospital stay after surgery (hour)	107.03 ± 31.44	155.33 ± 34.52	-6.461	< 0.001
VAS scores
6 h after surgery	4.33 ± 0.66	4.79 ± 0.73	-2.920	0.005
12 h after surgery	3.46 ± 0.60	4.38 ± 0.75	-6.013	< 0.001
24 h after surgery	2.79 ± 0.41	3.64 ± 0.67	-6.743	< 0.001
48 h after surgery	2.23 ± 0.63	3.10 ± 0.55	-6.518	< 0.001
72 h after surgery	1.72 ± 0.72	2.62 ± 0.54	-6.192	< 0.001

Data are presented as mean ± SD. Intervention group: Received routine postoperative nursing care and anticipatory nursing care. Control group: Received routine postoperative nursing care; VAS: Visual analog scale.

Postoperative infection and complication rates

Postoperative complications included nausea, vomiting, incision infections, intra-abdominal residual infections, and ileus. The postoperative infection and complication rates in the intervention group were 5.13% (2/39) and 15.38% (6/39), respectively, which was significantly lower than those in the control group (23.08% and 46.15%, respectively) (P < 0.001) (Table 3).

Table 3 Comparison of postoperative infection and complication rates between the two patient groups.

	Intervention group (n = 39)	Control group (n = 39)	χ2	P value
Nausea and vomiting	4 (10.26)	8 (20.51)
Incision infection	0	3 (7.69)
Intra-abdominal residual infection	2 (5.13)	6 (15.38)
Ileus	0	1 (2.56)
Postoperative infection rate	2 (5.13)	9 (23.08)	5.186	< 0.001
Complication rate	6 (15.38)	18 (46.15)	8.667	< 0.001

Data are presented as n (%). Intervention group: Received routine postoperative nursing care and anticipatory nursing care. Control group: Received routine postoperative nursing care.

Nursing satisfaction

Analysis of parent satisfaction with treatment revealed that the nursing satisfaction of the intervention group (92.31%) was significantly greater than that of the control group (79.49%) (χ² = 5.571, P < 0.05) (Table 4).

Table 4 Comparison of parent satisfaction between the two patient groups.

Group	Unsatisfied	Basically satisfied	Satisfied	Satisfaction
Intervention group (n = 39)	3 (7.69)	15 (38.46)	21 (53.85)	36 (92.31)
Control group (n = 39)	8 (20.51)	20 (51.28)	11 (28.21)	28 (79.49)
χ2				5.571
P value				< 0.05

Data are presented as n (%). Intervention group: Received routine postoperative nursing care and anticipatory nursing care. Control group: Received routine postoperative nursing care.

Univariate analysis of relevant clinical indexes

Postoperative infections and complications were transformed into binary variables and influencing factors were explored using logistic regression analysis. The results of univariate analysis revealed significant differences in terms of body mass index > 24 kg/m² (7.41% vs 33.33%; P < 0.001), body temperature ≥ 37.3 °C (11.11% vs 45.83%; P < 0.001), received anticipatory nursing (61.11% vs 25.00%; P < 0.001), CRP level (P < 0.001), neutrophil-to-lymphocyte ratio (P < 0.001), platelet-to-lymphocyte ratio (P < 0.001), and WBC count (P < 0.001). No statistically significant differences in age were observed between the two groups (Table 5).

Table 5 Univariate analysis of relevant clinical indexes of postoperative infections and complications.

	Non-complication group (n = 54)	Complication group (n = 24)	t/χ2	P value
Age (year)	8.28 ± 2.45	7.83 ± 2.16	0.765	0.447
BMI > 24	4 (7.41)	8 (33.33)	6.703	< 0.001
Body temperature ≥ 37.3 °C	6 (11.11)	11 (45.83)	11.753	< 0.001
Received anticipatory nursing	33 (61.11)	6 (25.00)	8.667	< 0.001
CRP level (mg/L)	38.35 ± 17.45	103.65 ± 42.35	-7.284	< 0.001
NLR	2.27 ± 0.54	3.00 ± 0.78	-4.145	< 0.001
PLR	151.55 ± 11.45	165.85 ± 13.07	-4.872	< 0.001
WBC (× 109/L)	13.55 ± 4.85	18.25 ± 5.36	-3.827	< 0.001

Data are presented as mean ± SD or n (%). Intervention group: Received routine postoperative nursing care and anticipatory nursing care. Control group: Received routine postoperative nursing care; BMI: Body mass index; CRP: C-reactive protein; NLR: Neutrophil-to-lymphocyte ratio; PLR: Platelet-to-lymphocyte ratio.

Multivariate logistic regression analysis

Multivariate logistic regression model revealed that the CRP level (odds ratio = 1.081; 95% confidence interval: 1.016-1.150; P = 0.013) was a risk factor for postoperative infection and complications, while receiving the anticipatory care intervention (odds ratio = 0.865; 95% confidence interval: 0.785-1.028; P = 0.025) was a favorable protective factor (Table 6).

Table 6 Results of multivariate logistic regression analysis.

Variables	OR	95%CI	P value
BMI > 24	0.771	0.004-150.425	0.923
Body temperature ≥ 37.3 °C	1.997	0.141-28.289	0.609
Received anticipatory care	0.865	0.785-1.028	0.025
CRP level (mg/L)	1.081	1.016-1.150	0.013
NLR	2.305	0.292-18.180	0.428
PLR	1.113	0.973-1.273	0.119
WBC (× 109/L)	1.191	0.950-1.494	0.130

BMI: Body mass index; CRP: C-reactive protein; NLR: Neutrophil-to-lymphocyte ratio; PLR: Platelet-to-lymphocyte ratio; OR: Odds ratio; CI: Confidence interval.

DISCUSSION

Results of the present study demonstrated that the postoperative VAS score for the intervention group was lower than that of the control group at multiple time points, and the length of hospital stay was significantly shorter in the intervention group than that in the control group. The incidence of postoperative infection and total incidence of complications were significantly lower in the intervention group than those in the control group. In addition, parents’ satisfaction scores were significantly higher in the intervention group. Logistic regression analysis revealed that a high CRP level was a risk factor for postoperative infections and complications, whereas the proactive nursing intervention was a protective factor.

Anticipatory care is a novel nursing concept; the core of which lies in predicting and identifying possible risks and problems that patients may encounter in advance to inform the design of targeted nursing plans[10]. Anticipatory care enables nurses to detect early signs of complications and implement timely intervention measures, thereby reducing the incidence of complications[11,12]. Anticipatory care focuses on individual patient characteristics. After patients are admitted to the hospital, a comprehensive assessment of their actual condition is performed to determine the risk for complications to design personalized nursing plans, thus enhancing the effectiveness of nursing care[13]. Furthermore, anticipatory care emphasizes devoting attention to the psychological and social needs of patients. Providing all-round nursing services improves patients’ negative emotions and enables them to obtain more social support, thereby improving their satisfaction and quality of life[14,15]. In this study, we found that anticipatory care had a significant effect on the management of postoperative infections and complications in pediatric patients treated for acute appendicitis. It reduced the rates of postoperative wound infections and complications, shortened the length of hospital stay, and improved nursing satisfaction.

Postoperative infections pose a challenge to surgeons. The overall incidence of postoperative infection in pediatric acute appendicitis is 3%-6% for both laparoscopic and conventional open procedures, although this rate increases with appendiceal perforation[16]. Postoperative complications increase patient distress, especially among children, and the number of readmissions and impose an additional economic burden on families and society[17,18]. A retrospective analysis suggested that CRP and WBC values not only reflected the degree of inflammation but also indicated the presence or absence of postoperative complications, with the CRP level exhibiting the highest diagnostic utility followed by WBC count[19]. Many domestic and foreign studies have reported that blood markers at the time of hospitalization reflect, to some extent, the degree of infection and recovery[19-21]. Our study also found that the CRP level was a risk factor for postoperative infection and complications in patients diagnosed with acute appendicitis.

Anticipatory care involves targeted preventive care with the patient as the main focus. The patient’s preoperative, perioperative, and postoperative periods are protected from special circumstances through scientifically based nursing interventions to improve safety. Strict monitoring of patient intraoperative and postoperative vital signs effectively mitigates potential complications and reduces their occurrence. Postoperative guidance for patients to get out of bed as soon as possible and resume a normal diet helps to accelerate the postoperative recovery process. In summary, anticipatory care demonstrates significant clinical utility.

The present study had several limitations, the first of which was its single center design, which restricts the generalizability of the results. Hospitals have different patient populations, surgical techniques, and nursing practices. For example, large tertiary hospitals may have more advanced medical resources and more diverse patient groups than community hospitals. In future investigations, therefore, multicenter studies should be conducted to include a broader range of patients and healthcare settings to make the results more representative and applicable. Second, the sample size was relatively small. With only 78 participants, the study may not have had sufficient statistical power to accurately detect all possible relationships and effects. A larger sample size would provide more reliable data and reduce error margins. Future studies should recruit a larger number of pediatric patients with acute appendicitis to strengthen the validity of our findings.

CONCLUSION

Anticipatory nursing care has important application value in the postoperative care of pediatric patients undergoing surgery for acute appendicitis. It can significantly reduce the incidence of postoperative infection and complications and effectively improve the satisfaction of children and their parents. More studies are needed to further explore specific implementation methods and the effects of anticipatory care to provide more scientific and comprehensive guidance for clinical nursing.