Optimizing Value in Perioperative Medicine and the High Value Practice Academic Alliance: A Case-Based Study on Preoperative Assessment

Clinical Case Example

Mrs. Reyes is a 51-year-old woman, who is admitted to a hospital with abdominal pain. She is diagnosed, after her initial laboratory evaluation and imaging findings return, with acute cholecystitis. She has a 5-pack per year history of cigarette use; however, she quit 25 years ago. She has hyperlipidemia and well-controlled essential hypertension. She can walk up two flights of stairs and exercises daily, walking 3 miles per day without chest pain. Her only medication is a high potency statin. Her vital signs are within normal limits. On examination, her respiratory and cardiovascular system are normal. She is managed conservatively with intravenous (IV) fluid hydration and parenteral antibiotics and does well. A surgical consultation is obtained, and she is scheduled for a cholecystectomy once she has fully recovered from the acute episode. The surgical consultant writes in the consult note, “Obtain preop labs and studies, clearance for surgery per medicine.”

Using the admission ECG and labs, you perform a revised risk cardiac index (RCRI) risk stratification ( https://www.mdcalc.com/revised-cardiac-risk-index-pre-operative-risk ) and the patient scores 0 points, which places her in the lowest risk category with a 3.9% risk of perioperative major adverse cardiac events (MACE). She is now eating and drinking normally.

On the day of surgery, the case is cancelled, and the patient is sent back to the floor. You are called by the anesthesiologist who informs you that the case was cancelled because the patient needs to have a preoperative chest radiograph.

You order a two-view chest radiograph, which shows no cardiopulmonary abnormalities.

The patient was able to have a successful laparoscopic cholecystectomy on the next day and was discharged.