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. While the patient is hemodynamically unstable on vasopressors, the focus should be on source control with the least invasive approach possible. According to the 2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis 1, early laparoscopic cholecystectomy (ELC) is the standard of care whenever possible, but in this case, the patient's instability on vasopressors makes it a high-risk procedure. 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, as recommended by the guidelines 1. Provide adequate fluid resuscitation while carefully monitoring hemodynamic parameters. Pain management with IV opioids like fentanyl or hydromorphone is appropriate, avoiding NSAIDs due to potential renal effects in a hypotensive patient. Keep the patient NPO (nothing by mouth) and place a nasogastric tube if there is significant nausea or vomiting. This approach is necessary because cholecystectomy during vasopressor-dependent shock carries extremely high mortality risk, while drainage procedures can stabilize the patient until definitive surgery can be performed after hemodynamic stability is achieved. Once the patient is weaned off Levophed, reassess for interval cholecystectomy, typically within 6-8 weeks after the acute episode resolves.
Some key points to consider in the management of this patient include:
- The importance of urgent surgical consultation for consideration of percutaneous cholecystostomy
- The need for broad-spectrum antibiotics and adequate fluid resuscitation
- The avoidance of NSAIDs due to potential renal effects in a hypotensive patient
- The importance of monitoring hemodynamic parameters and adjusting management as needed
- The consideration of interval cholecystectomy once the patient is stable and weaned off vasopressors.
It is also important to note that the guidelines recommend ELC as the standard of care whenever possible, but in this case, the patient's instability on vasopressors makes it a high-risk procedure, and a more conservative approach may be necessary 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, 6.
- The treatment of acute cholecystitis typically involves early laparoscopic cholecystectomy, as well as supportive care such as fasting, intravenous fluid infusion, and antimicrobial therapy 3, 5.
- The choice of empirical antibiotics for acute cholecystitis is still a topic of debate, with some studies suggesting that first-generation cephalosporins may be sufficient for mild-to-moderate cases 6, while others recommend second-generation cephalosporins or other antibiotics based on bile microbiology and antibiotic susceptibility 4.
- It is essential to note that the management of cholecystitis should be individualized based on the patient's specific condition, including the severity of the disease, the presence of comorbidities, and the risk of complications 2, 3, 5.