Intubation Protocol for Acute Cholecystitis Requiring Emergency Surgery
Standard Rapid Sequence Intubation (RSI) Protocol
For patients with acute cholecystitis requiring emergency surgery, use standard rapid sequence intubation with the six-step algorithm: pre-oxygenation, premedication, muscle relaxation and induction, intubation, primary and secondary confirmation, and post-intubation management. 1
Pre-Oxygenation
- Administer 100% oxygen for 3-5 minutes prior to induction 1
- This is critical as RSI is indicated when fasting status cannot be determined, which applies to emergency cholecystitis cases 1
Induction Agent Selection
Propofol is the first-line intravenous hypnotic agent for hemodynamically stable patients. 1
- For hypotensive or hemodynamically unstable patients, use ketamine as the induction agent instead. 1
- This is particularly relevant in acute cholecystitis with sepsis or gallbladder perforation, where mortality reaches 12-16% 2
Neuromuscular Blockade
Succinylcholine remains the most common neuromuscular relaxant for RSI due to its rapid onset. 1
- Rocuronium (1.2 mg/kg) is the preferred alternative when succinylcholine is contraindicated, with onset in 1-2 minutes. 1
- The longer duration of rocuronium (45-70 minutes) can be reversed with sugammadex if needed 1
Critical Pre-Intubation Considerations
Hemodynamic Optimization
Aggressively correct intravascular volume depletion and acidosis before induction, as these conditions significantly increase the risk of hypotension and cardiovascular collapse during RSI. 1
- Patients with acute cholecystitis often present with dehydration and require intravenous fluid resuscitation 3, 4
- Severe acidosis, heart failure, and severe pulmonary disease are relative contraindications that complicate both pre-induction and induction phases 1
Risk Stratification for Complications
Identify high-risk patients who may decompensate during intubation:
- Elderly patients (>65 years) 2
- Patients with diabetes mellitus 2
- Those with cardiac disease or renal disease 5
- Patients with gallbladder perforation (2-11% of acute cholecystitis cases) who have higher mortality risk 2
- Critically ill patients with septic shock from cholecystitis 2
Common Pitfalls to Avoid
Do not delay intubation in patients with worsening peritonitis or sepsis, as early surgical intervention substantially decreases morbidity and mortality. 5, 2
- Vasodilatation and hypotension during induction are the primary complications in volume-depleted or acidotic patients 1
- Hypoxemia during the intubation maneuver is another major complication that must be anticipated 1
Post-Intubation Management
After successful intubation, proceed immediately with:
- Primary confirmation (end-tidal CO2 monitoring) 1
- Secondary confirmation (auscultation, chest rise) 1
- Ongoing hemodynamic support as needed for the surgical procedure 1
The goal is to proceed to early laparoscopic cholecystectomy within 7 days of hospital admission and within 10 days of symptom onset to minimize complications. 5, 3, 2