Fluid Resuscitation in Acute Cholecystitis
Begin fluid resuscitation immediately with an initial bolus of 30 mL/kg of intravenous crystalloid within the first 3 hours, followed by goal-directed therapy with frequent reassessment of hemodynamic status. 1
Initial Resuscitation Protocol
Acute cholecystitis should be treated as a medical emergency requiring immediate fluid resuscitation. 1 The approach mirrors sepsis management principles, as cholecystitis can progress to septic shock:
- Administer at least 30 mL/kg of IV crystalloid fluid within the first 3 hours as your initial fixed volume while obtaining more detailed patient information 1
- Use either normal saline or balanced crystalloids (such as Ringer's lactate) as the fluid of choice for initial resuscitation 1
- Target a mean arterial pressure (MAP) of ≥65 mmHg if the patient develops hypotension requiring vasopressors 1
Ongoing Fluid Management
After the initial bolus, continue fluid administration based on frequent reassessment of hemodynamic status rather than fixed protocols: 1
- Perform thorough clinical examination including heart rate, blood pressure, arterial oxygen saturation, respiratory rate, temperature, and urine output (target >0.5 mL/kg/hr) 1
- Use dynamic variables over static variables (such as pulse pressure variation, stroke volume variation, or passive leg raises) to predict fluid responsiveness when available 1
- Avoid relying on central venous pressure (CVP) alone to guide fluid resuscitation, as it has limited ability to predict fluid responsiveness 1
Monitoring and Resuscitation Targets
Guide resuscitation to normalize lactate levels in patients with elevated lactate as a marker of tissue hypoperfusion 1. Key monitoring parameters include:
- Lactate normalization as a primary resuscitation endpoint 1
- Urine output ≥0.5 mL/kg/hr as a marker of adequate perfusion 1
- Hemodynamic improvement based on both dynamic and static variables 1
Critical Pitfalls to Avoid
Do not use hydroxyethyl starch (HES) fluids for resuscitation in acute cholecystitis, as they are associated with increased mortality and organ failure without benefit 1. The Surviving Sepsis Campaign provides a strong recommendation against HES use based on high-quality evidence 1.
Avoid fluid overload by using a fluid challenge technique where administration continues only as long as hemodynamic factors continue to improve 1. This prevents complications associated with excessive fluid administration.
Special Considerations for Source Control
Recognize that definitive treatment requires source control through early laparoscopic cholecystectomy (ideally within 72 hours to 7 days of symptom onset), as fluid resuscitation alone does not address the underlying pathology 1. However, ensure hemodynamic stabilization with adequate fluid resuscitation before proceeding to surgery 1.
For critically ill patients unfit for surgery, consider percutaneous cholecystostomy as a rescue treatment after initial fluid resuscitation 1, 2.