Treatment of cholelithiasis in children with sickle cell disease - Home Study Program

AORN Journal,  June, 2003  by Verna Hendricks-Ferguson,  Martha A. Nelson

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CASE STUDY

Sarah, a 10-year-old African-American female with a history of SCD, was admitted to the pediatric unit at St Louis Children's Hospital with a suspected diagnosis of acute cholecystitis. After undergoing numerous diagnostic examinations, the physician confirmed diagnoses of acute cholecystitis, prolonged prothrombrin time, and multiple pigmented stones in the gallbladder. Hematology-oncology team members evaluated Sarah and initiated medical interventions, including pain management and vitamin K administration. Sarah recovered from the acute painful episode and was scheduled for elective laparoscopic cholecystectomy.

Sarah's pediatric nurse started an IV in Sarah's left anticubital fossa and began administering IV fluids (ie, 5% dextrose in 0.45% normal saline with 20 mEq potassium chloride) at 80 mL per hour in preparation for the scheduled surgical procedure. The nurse also administered prophylactic antibiotic therapy (ie, 1 g IV cefoxitin sodium) every eight hours for three doses in preparation for the surgical procedure.

The elective laparoscopic cholecystectomy procedure proceeded uneventfully, and although the surgeon identified some adhesions from the omentum to the gallbladder, she detected no other abnormalities except for mild hepatomegaly. The surgeon bluntly dissected all detected adhesions from the omentum on the duodenum into the gallbladder and dissected the gallbladder free. She was unable to locate Sarah's dominant artery; however, small branches of this artery were identified. While mobilizing and transecting the cystic duct, the surgeon determined that one of the distally placed clips appeared not to have approximated appropriately; therefore, the surgeon placed an endoloop proximal to the clips on the cystic duct stump. She removed the gallbladder without difficulty and closed the incisions.

Sarah was transferred via pediatric stretcher to the PACU, and after she recovered for 60 minutes, PACU nurses transferred Sarah to the pediatric surgical unit. Sarah's pediatric surgical unit nurse completed an admission assessment and then monitored Sarah's vital signs every four hours until discharge. During the surgical procedure and the postoperative phase, the nurse managed Sarah's pain with a continuous IV infusion via a computerized patient-controlled anesthesia (PCA) pump of 1 mg per mL of morphine sulfate (MS) at a rate if 0.5 mg per hour. In the event that Sarah experienced MS-associated side effects, such as pruritus, the nurse had orders to administer 25 mg diphenhydramine hydrochloride IV or by mouth (PO) every six hours as needed. If the pruritus was unresponsive to diphenhydramine, Sarah's nurse could administer 2 mg of IV nalbuphine every one to two hours as needed. Additionally, the nurse had orders to treat other side effects associated with MS therapy, such as nausea and vomiting, with 4 mg IV ondansetron every six hours or 6 mg IV metaclopramide hydrochloride every six hours as needed. Fortunately, Sarah did not experience side effects typically associated with MS.