From the Guidelines
Cholecystitis in a patient on Levophed requires immediate stabilization with broad-spectrum antibiotics and fluid resuscitation, followed by early laparoscopic cholecystectomy (ELC) when the patient is hemodynamically stable, as ELC is the standard of care for acute cholecystitis whenever possible, even in high-risk patients 1.
Initial Management
The patient should be started on broad-spectrum antibiotics such as piperacillin-tazobactam 3.375g IV every 6 hours or ceftriaxone 2g IV daily plus metronidazole 500mg IV every 8 hours for 4-7 days, as recommended by the 2020 World Society of Emergency Surgery guidelines for the diagnosis and treatment of acute calculus cholecystitis 1.
- Maintain adequate fluid resuscitation while continuing vasopressor support as needed to ensure hemodynamic stability.
- Pain should be managed with IV opioids titrated carefully to avoid hypotension.
Definitive Surgical Management
Once the patient is hemodynamically stable with Levophed weaned off, definitive laparoscopic cholecystectomy can be performed, typically within 6-8 weeks after initial stabilization, as ELC is superior to delayed laparoscopic cholecystectomy (DLC) in terms of shorter hospital stay and faster return to work 1.
- The timing of ELC is crucial, and it should be performed within 7 days of hospital admission and within 10 days of onset of symptoms, as recommended by the guidelines 1.
- Subtotal cholecystectomy is a safe and valuable option in cases of difficult gallbladder removal, as stated in the 2020 guidelines 1.
Considerations
- Patients on vasopressors have significantly higher mortality rates with emergency surgery due to their compromised perfusion status and potential for end-organ damage.
- Percutaneous cholecystostomy tube placement may be considered as a less invasive drainage procedure for initial management, but ELC remains the standard of care for definitive treatment.
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 can be challenging, and early diagnosis is essential to avoid high rates of morbidity and mortality 6.