2/08/01, 4pm
| Admit: | To recovery room |
| Diagnosis: | Acute cholecystitis s/p laproscopic cholecystectomy |
| Condition: | Stable |
| Vitals: | per routine |
| Activity: | Out of bed to chair as tolerated |
| Allergies: | None |
| Nursing: | per routine, incentive spirometry x10 q1h while awake |
| Diet: | Clears |
| IVF: | D51/3NS@100cc/hr |
| Meds: | Cefoxitin 1g IV q8h |
| Demerol 75mg IM q4h prn pain x24h | |
| Vistaril 25mg IM q4h prn pain x24h (to be given with Demerol) | |
| Tylenol #3 1 tab PO q6h prn pain | |
| Compazine 10mg IM q8h prn nausea, may repeat x1 | |
| Labs: | CBC, SMA |
Vitals, Activity, Nursing, Diet: Following laparoscopic cholecystectomy all patients are monitored in the recovery room for several hours. Patients are encouraged to get out of bed as soon as tolerated as early mobilization is demonstrated to decrease the risk of post-operative complications such as pneumonia, fever secondary to atelectasis, and deep venous thrombosis. Incentive spirometry also aids in the prevention of atelectasis and pneumonia. Patients may begin consumption of clears as soon as tolerated and as PO intake increases intravenous fluid administration may be tapered.
Intravenous Fluids: Following laparoscopic cholecystectomy patients are typically given hypotonic maintenance fluids rather than isotonic resuscitation fluids because intravascular volume loss is usually negligible. Open cholecystectomy and other intrabdominal procedures involving broader dissection result in larger interstitial (third space) fluid shifts and thus require isotonic fluids to replace the intravascular loss. The degree of intravascular fluid loss through third spacing or hemmorhage is the major determinant of the intravenous fluids administered in the immediate postoperative period. In this case, there is negligible bleeding and minimal third spacing so maintenance fluids are an appropriate choice.
Medications: As soon as the diagnosis of acute cholecystitis is made, the patient should be started on an antibiotic that covers common biliary pathogens. A second generation cephalosporin with good gram negative and anerobic coverage such as cefoxitin is ideal. Cholecystectomy for acute cholecystitis is a clean-contaminated case and as such demands 24 hours of post-operative antibiotic coverage. If the patient is afebrile with resolution of leukocytosis after 24 hours, antibiotics can then be discontinued.
Pain control is crucial postoperatively, providing comfort to patients and encouraging early mobilization and full respiratory excursion. In biliary tract disease morphine and other opiates should be avoided because they increase the tone of the sphincter of Oddi and can thus inhibit free flow of bile. Many patients will achieve adequate pain control with aceiteminophen with codeine alone, though provision should be made for more potent analgesia during the first 24 postoperative hours. In this case, Demerol and Vistaril were chosen. Nausea is a common sequelae of anesthesia and prn compazine can help to control it.
Labs: Postoperative laboratory evaluation depends on the patient and procedure. After a laparoscopic cholecystectomy for acute cholecystitis a CBC is indicated to allow serial evaluation of hematocrit and WBC count permitting detection of postoperative bleeding or ongoing infection. An SMA is optional though commonly obtained to help determine volume status by evaluation of BUN and createnine and to assure there are no electrolyte anomalies. Liver function tests are not necessary after an uncomplicated laparoscopic cholecystectomy.