**Question:** A 73-year-old woman with a long history of heavy smoking undergoes femoral-popliteal arterial bypass for rest pain in her left leg. Because of serious underlying respiratory insufficiency, she continues to require ventilatory support for 4 days after her operation. As soon as her endotracheal tube is removed, she begins complaining of vague upper abdominal pain. She has daily fever spikes of 39°C (102.2°F) and a leukocyte count of 18,000/mL. An upper abdominal ultrasonogram reveals a dilated gallbladder, but no stones are seen. A presumptive diagnosis of acalculous cholecystitis is made. Which of the following is the next best step in her treatment?

A. Initiate antibiotics
B. Perform a cholecystectomy
C. Assess for sepsis and manage accordingly
D. Monitor and manage her respiratory condition

**Correct Answer:**

**Core Concept:** Acalculous cholecystitis is a type of acute inflammation of the gallbladder, which is not associated with gallstones. It is often triggered by stress, trauma, or infections, such as those seen in critically ill patients requiring intensive care unit (ICU) support.

**Why the Correct Answer is Right:**

In this scenario, the patient is suffering from acalculous cholecystitis, which is a severe inflammation of the gallbladder without gallstones. Given her history of respiratory insufficiency, critical illness, and need for prolonged ventilatory support, it is reasonable to assume that her acalculous cholecystitis is a consequence of her critical condition rather than an independent cause, such as cholelithiasis.

**Why Other Options Are Incorrect:**

A) Initiating antibiotics (Option A) may not be specific to the patient's condition as the inflammation is not caused by infection.

B) Performing a cholecystectomy (Option B) would not be appropriate due to the critical condition and need for ventilatory support.

C) Assessing for sepsis (Option C) and managing it is important, but the focus should be on treating the primary cause (respiratory insufficiency) rather than managing sepsis.

D) Monitoring and managing the patient's respiratory condition (Option D) is crucial, given the patient's critical illness and need for prolonged ventilatory support. Managing her respiratory condition should be the primary focus, as it is likely the root cause of her acalculous cholecystitis.

**Clinical Pearls:**

The patient's respiratory condition is the primary concern in this case. Acalculous cholecystitis is a secondary complication due to her critical illness. Therefore, the next best step would be to manage her respiratory distress (Option D) and monitor her condition closely. The options A, B, and C are not directly addressing the patient's primary problem.