From the Guidelines
For a patient with cholecystitis who is on Levophed (norepinephrine), urgent surgical consultation is recommended for consideration of percutaneous cholecystostomy rather than immediate cholecystectomy. This approach is preferred because patients requiring vasopressor support like Levophed are typically hemodynamically unstable and at high risk for surgical complications 1. The 2020 World Society of Emergency Surgery guidelines suggest that early laparoscopic cholecystectomy (ELC) should be the standard of care whenever possible, but this may not be feasible in patients who are critically ill and require vasopressor support 1.
Key Considerations
- Start broad-spectrum antibiotics immediately, such as piperacillin-tazobactam 3.375g IV every 6 hours or ceftriaxone 2g IV daily plus metronidazole 500mg IV every 8 hours, adjusted for renal function.
- Provide adequate pain control with IV opioids like hydromorphone 0.5-1mg IV every 3-4 hours as needed.
- Continue NPO status and maintain IV fluid resuscitation while monitoring electrolytes and renal function.
- The rationale for this approach is that cholecystitis in critically ill patients on vasopressors represents a high-risk scenario where temporizing measures to control infection and stabilize the patient take precedence over definitive surgical management 1.
Surgical Management
- Once the patient is hemodynamically stable with vasopressors discontinued, definitive cholecystectomy can be considered, typically after 6-8 weeks of recovery.
- The decision to proceed with surgery should be made on a case-by-case basis, taking into account the patient's overall health status and risk factors for surgical complications 1.
- The 2020 World Society of Emergency Surgery guidelines suggest that ELC should be performed within 7 days of hospital admission and within 10 days of onset of symptoms, but this may not be possible in patients who are critically ill and require vasopressor support 1.
From the Research
Cholecystitis on Levophed
- There is no direct evidence in the provided studies regarding the use of Levophed in patients with cholecystitis.
- However, the studies discuss the diagnosis, treatment, and management of acute cholecystitis, including the use of antibiotics and surgical interventions 2, 3, 4, 5.
- Acute cholecystitis is typically treated with early laparoscopic cholecystectomy, and the use of antibiotics is recommended in certain cases, such as in patients with severe cholecystitis or those who are at high risk of complications 2, 3, 5.
- The choice of antibiotics should be based on the results of bile cultures and antibiotic susceptibility tests, as well as the patient's clinical presentation and medical history 4.
- In critically ill patients, percutaneous or endoscopic gallbladder drainage may be necessary as a rescue treatment 5, 6.
- The diagnosis of acute cholecystitis in the intensive care unit (ICU) can be challenging, and early diagnosis is essential to avoid high rates of morbidity and mortality 6.