Hi Dr. F,
I am wondering if you could help me answer a question for one of the RN's in PACU. Tuesday April 8th a laparoscopic cholecystectomy was performed on nightshift, the pt's name was TB, HF 2****24. In speaking with Carol PCM of PACU it was agreed that this procedure was deemed Emergent Type A. Alex PCM OR also agreed, stating that research has suggested that these types of patients need to be treated acutely and recover quickly. I am wondering if you have access to this research that I can pass on to the RN's in PACU to clarify questions that they have regarding the emergent nature of this procedure.
Thank you so much,
Ramona
Were the nurses in the recovery room unhappy with a patient with acute cholecystitis being done in the evening?
darlene
A question did arise as to how emergent it was, and so I'm trying to clarify it. The PCM's are satisfied that it was an A2 case, and I'd like to be able to get back to the RN's with the correct information so that there is no future confusion or questions regarding chole patients being operated on after hours.
Other than sepsis, what might be some of the critical diseases that might warrent the gallbladder to be removed sooner than later? Extra-large stones? Intractable pain? Multiple gallbladder attacks?
I'd like to give the RN's a clear understanding as to the importance of this procedure being done emergently.
Thanks again!
Ramona
Hi,
No problem. I will do my best to help clarify.
Stones in the CBD - choledocolithiasis (which this patient had)
Acute cholecystitis (which she also had) which includes patients with normal WBC who have had pain longer than 6 hours.
GS pancreatitis.
Ascending cholangitis.
In acute cholecystitis, it is better for the patient, fewer hospital visits, pain, and fewer complications to have the GB removed within 72 hour of the onset of pain. I would have to double check the chart, but this woman's pain started at noon on Sunday I believe. So, the GB should be removed within 72 hour of the onset of pain. It can wait until the morning or the following night...but it can't wait on the B list because it is unlikely to get done at night and then would be done at 48 hours which would be too late. Not to mention the fact that she had evidence of biochemical choledocolithiasis and would still be waiting on the ward today with more cases being cancelled and instead she will go home today or tomorrow.
I am happy to discuss this with Andy or Alexandra. I am sure this has been reviewed in the past but maybe I am not aware of the history.
I believe I followed all of the rules and did my best to give the patient the best care possible.
I hope this helps.
darlene
An excerpt From Dr. S's email:
1. Dr. F should be congratulated on her decision making and judgement re the medical management and logistics of this case.
2. We feel that in the era of ACCESS service logistics will be easier.
3. We are in fact critical of surgeons who, if operation is possible, pursue a non-operative course in such cases as this approach is outmoded, associated with longer LOS and impaired patient flow.
Dr. B pursued this in a evidence based manner with OR management some time ago.
I am happy to discuss as you see fit-
ajs
And my Response:
I would be happy to share Dr. B's information with the PACU staff. It is my sincere hope that by sharing knowledge with the nurses, and providing updates regularly, we can all work together more effectively as a team and provide the best care for our patients.
FYI:
The OR Booking Policy, with Appendix II (Emergent Type A Cases) can be found here. Please look under Sepsis.
http://mysb/data/1/rec_docs/630_I_O_1300.pdf
Also, I did a little Google search, and found multiple abstracts with the following conclusion:
The impact of patient delay and physician delay on the outcome of laparoscopic cholecystectomy for acute cholecystitis
Conclusions: In acute cholecystitis, patient delay is associated with a high conversion rate. Early timing of laparoscopic cholecystectomy tends to reduce the conversion rate, as well as the total and the infectious complication rates. Male gender, a history of biliary disease, and advanced cholecystitis are associated with conversion. Male and older patients are associated with a high total and infectious complication rates.
If I should get a response from Dr. B, I will let you know!
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