Neurologic

Carotid bruits

Consider carotid Doppler exam or referral.

Pulmonary

At risk for tuberculosis

TB skin test. Consider CXR

History of malignancy

Consider CBC, CXR, hepatic, renal, electrolyte, coagulation tests

Significant asthma or COPD

Consider CXR, and ECG. Consider PFTs/ABGs before upper abdominal or cardiothoracic surgery

Anterior mediastinal mass

CXR. Flow volume loops. If large mass: consider Echo

Cardiac

(see ischemia flowchart)

Significant acquired or congenital cardiac disease

The patient's cardiologist or primary care giver MUST be informed that the patient is to have surgery/anesthesia.

MUST know recent device check, exact make & model + manufacturer's recommendations on intraop use with electrosurgical interference. Pacemaker nurse may need to interrogate/innactivate/reprogram device preop & reactivate postop.

Read the UWHC perioperative policy here! (pdf)

An adult with a significant (> II/VI) systolic murmur, or any diastolic heart murmur

ECG, consider CXR. Consider Echo2. Does the patient need SBE prophylaxis?

Hypertension

ECG, BUN/Cr, Electrolytes

Significant palpitations, history of syncope

ECG, consider Holter & cardiology consult, consider long QT syndrome.

Undiagnosed chest pain or changing angina pattern

Hgb, ECG, CXR. Consider stress testing. Cardiology consult.

Known stable angina

Hgb, ECG. Patients' Cardiologist or Internist MUST be aware of proposed surgery. Consider quantitative stress imaging to assess amount of myocardium at risk before major procedures.

Congestive heart failure

Hgb, ECG, CXR, BUN/Cr, Electrolytes. Patient's Cardiologist/Internist MUST be aware of proposed surgery. Consider estimate of ejection fraction before major procedures or when CHF is severe, unstable.

Patient has a condition known to be associated with cardiac disease.

Consider ECG, CXR, and/or Echo

Oncologic: Adriamycin Therapy

Consider stress MUGA/Echo if > 400mg/M2, symptoms, or physical findings of reduced myocardial function.

Hepatic

Known or suspected hepatic disease

Hepatic Enzymes, Bilirubin, Albumin, INR, Plts, BUN/Cr

Renal

Known or suspected renal disease

Diuretic or digoxin use

Hgb, Bun/Cr, ECG, Electrolytes (if on dialysis, blood [K+] on day of surgery is essential)

Endocrine

Diabetes

Hgb, Bun/Cr, Electrolytes, Glucose, consider HgbA1c and ECG (in long-standing DM)

Adrenal disease

Hgb, Bun/Cr, Electrolytes, Glucose, ECG

Heme

Known anemia

CBC. Consider retic count, Coag tests, etc., as indicated.

Personal/Family history of bleeding problems Anticoagulant drug use Severe hepatic disease Malnutrition Extended antibiotic use

Chemotherapy

INR, APTT, Platelets (consider Bleeding Time if platelet defect suspected). Consider Hematology consult.

African heritage
(Sickle status not known)

CBC & RBC morphology; or Sickle Test. May substitute a Hgb alone only by permission of Anesthesia Clinic. If findings or history suggest SS/SC disease: add hemoglobin electrophoresis.

Caution advised when S+ and tourniquets are used.

Misc.

Latex allergy

Allergy consult. ±Preop steroid & H1 + H2 blockers may be used. Must notify OR of latex avoidance before day of surgery.

Neck Pain complaints or patients with Down's/T21, Rheumatoid Arthritis, or Dwarf Syndromes that may have unstable C-Spines

Flexion/extension X-ray of neck strongly suggested.

Malignancy/Chemotherapy

Adriamycin, doxorubicin, daunorubicin

CBC, Coag tests, Hepatic and renal function tests, CXR & ECG as indicated