Chapter 4: Preoperative

Evaluation
Screening Procedures
Summary of Perioperative Laboratory Testing
 THE PREOPERATIVE EVALUATION
An adequate pre-op preparation of the surgical patient is of the utmost
importance. The quality of pre-anesthetic care largely determines the
outcome, especially in patients with significant medical problems. What will
constitute proper pre-anesthetic screening will vary from patient to patient
according to their physical status and chronological age. The anesthetic
technique applicable to healthy patients for simple procedures will differ from
a more complex technique for major procedures.

Screening Procedures
1. The History: A medical history obtaining relevant information:
a. DOES THE PATIENT HAVE AN M.D. AND IS HE/SHE PRESENTLY TREATING
THIS PATIENT
b. PRESENT or PAST MEDICAL PROBLEMS
c. PREVIOUS HOSPITALIZATIONS/SURGERY & PROBLEMS WITH ANESTHESIA
OR CLOTTING OR SCAR FORMATION
d. TAKING ANY MEDICATIONS FOR ANYTHING (RX OR OTC'S)
e. ANY KNOWN ALLERGIES
f. FAMILY HISTORY ( SICKLE CELL, DIABETES, HYPERTENSION, REACTION TO
ANESTHESIA, ETC.)
g. SOCIAL HISTORY (SMOKING, DRINKING, DRUGS ETC.)
h. REVIEW OF SYSTEMS

2. The Physical Examination:

a. Vital Signs: B.P., TEMP, PULSE, AND RESPIRATIONS
b. Review of systems: HEAD AND NECK, LUNGS AND HEART (AUSCULTATION),
ABDOMINAL, GI, GU, EXTREMITIES, NEUROLOGICAL, DERMATOLOGICAL,
VASCULAR, AND ORTHOPEDIC/BIOMECHANICAL

NOTE* ONCE THIS INFORMATION IS KNOWN THE PATIENT'S PHYSICAL

CONDITION CAN BE CATEGORIZED ACCORDING TO THE 3.
CLASSIFICATION OF PHYSICAL STATUS ADOPTED BY THE AMERICAN
SOCIETY OF ANESTHESIOLOGISTS (ASA PHYSICAL STATUS)- See
section Anesthesia
Laboratory Testing: BLOOD WORK, URINALYSIS, EKG AND CHEST XRAY
(CXR)
a. Complete Blood Count (Normal adult values):
i. WBC- 4,800-10,800/mm3
 NOTE* A WBC GREATER THAN 11, 000= LEUKOCYTOSIS Leukocytosis due
to:
a. AN ACUTE BACTERIAL INFECTION (Viral infection usually has normal
WBC's)
b. INTOXICATIONS (GOUT, HEAVY METAL POISONING, VACCINES)
c. HEMOLYSIS
d. HEMORRHAGE
e. MYELOPROLIFERATIVE DISORDERS
f. NORMAL VARIANT
g. STRESS
h. DEHYDRATION/ HEMOCONCENTRATION

NOTE* A WBC LESS THAN 4, 400= LEUKOPENIA Leukopenia can be due to:
a. SEVERE INFECTION OR SEPTICEMIA
b. HEPATITIS
c. DRUGS (SULFA, ANALGESICS, BUTAZOLIDIN, THORAZINE)
d. TRAUMA AND AIDS
e. MYELOPROLIFERATIVE DISORDERS (MOST COMMON)

ii. WBC differential: allows for identification of the proportions of each type of
WBC for a more specific diagnosis of a disease entity
Divided into 2 groups: Granulocytes (neutrophils, eosinophils, basophils) and
Nongranulocytes (lymphocytes, monocytes)

NON-GRANULOCYTES:
Lymphocytes (20-40%): involved in antibody production, function in cell-
mediated immunity, delayed hypersensitivity, graft rejection, defense against
intracellular organisms such as tubercle bacillus, brucella, and neoplasms. An
Increase can indicate VIRUSES (MOST COMMON), GERMAN MEASLES,
BRUCELLOSIS, CONGENITAL SYPHILIS, THYROTOXICOSIS, PERTUSSIS, AND
MONONUCLEOSIS. A decrease can indicate HODGKIN'S DISEASE, DRUGS. OR
IRRADIATION, AND IMMUNOLOGICAL DEFICIENCY DISORDERS.
Monocytes (4-8%): transform into macrophages which destroy/ingest
bacteria etc. An Increase can indicate RECOVERY FROM ACUTE INFECTIONS,
SUBACUTE BACTERIAL ENDOCARDITIS, MYCOTIC/RICKETTSIAL/PROTOZOAL &
VIRAL INFECTIONS, HEMATOLOGIC DISEASE, LEUKEMIA, AND HODGKIN'S
DISEASE.

GRANULOCYTES:
Neutrophils (45-65%): same as PMN's (either SEGS 40-60% or Bands 0-
5%). The first specific line of defense for the body, an increase being called a
SHIFT LEFT (of immature neutrophils, called bands) usually indicating an
acute bacterial infection. A decrease in neutrophils, NEUTROPENIA, may
indicate an OVERWHELMING BACTERIAL INFECTION, SEVERE FUNGAL OR
VIRAL INFECTION, BONE MARROW DEPRESSION, AUTOANTIBODIES, BONE
MARROW REPLACEMENT, HYPERSPLENISM, AND MATURATION DEFECTS
(VITAMIN DEFECTS)
An Increase in neutrophils, NEUTROPHILIA, can indicate: INFECTION
Neutropenia may be the earliest clue to marrow failure
(TYPHOID), TOXIC AGENTS, PHYSICAL OR EMOTIONAL STIMULI, TISSUE
NECROSIS, HEMORRHAGE, HEMOLYSIS, AND HEMOLYTIC DISORDERS, OR
RECENT STRAINED DEFECATION (VALSALVA MANEUVER).

NOTE* Usually with a shift left there is a characteristic relative fall in

lymphocytes with neutrophil leukocytosis and increase in young forms.
When the infection subsides and the fever drops, the total number of
leukocytes decreases

Eosinophils (1 -3%): contain histamine and transport alkaline

phosphatase, an increase indicating INTESTINAL PARASITES, ALLERGIC
REACTIONS, URTICARIAL SKIN ERUPTIONS, LEUKEMIA, GI DISTURBANCES OR
SCARLET FEVER. A decrease can indicate SEVERE INFECTIONS, CUSHING'S
SYNDROME, ELECTRIC SHOCK THERAPY, AFTER INJECTION WITH ACTH OR
EPINEPHRINE.
Basophils (0-1 %): contain heparin and transport alk phos and histamine,
an increase is associated with POLYCYTHEMIA,
LEUKEMIA, CHICKEN POX, SMALL POX. A decrease can be due to ACUTE
INFECTIONS AND ACTH OR CORTICOSTEROIDS

iii. PLATELET COUNT (150,000-400,000): Platelet disorders should be

suspected in patients exhibiting PETECHIAE in the skin or mucosa.
THROMBOCYTOPENIA: Decreased platelet count, is seen with
THROMBOCYTOPENIA PURPURA, APLASTIC ANEMIA, OR SEPTICEMIA.

NOTE* The most common cause of thrombocytopenia is chemotherapy

Decreased platelet count increases the risk for hemorrhage. If the platelet
count is less than 60,000 give platelets (1 unit will raise the count
5,000/cu mm. For any elective surgery the thrombocytopenic patient
should be postponed
• THROMBOCYTOSIS: Increased platelet count seen with splenectomy,
malignancy, and patient is prone to form clots with this condition
iv. RBC's: (Male, 4,700,000-6,100,000mm3) (Female, 4,200,000-
5,400,000/mm3)

An increase may be due to POLYCYTHEMIA, METASTATIC CARCINOMA

AFFECTING THE MARROW, THALASSEMIA, INCREASED ALTITUDE,
EXERCISE OR EMOTIONAL STRAIN
 v. RETICULOCYTE COUNT (.5-1.5% OF THE TOTAL RED COUNT):
• It is the best indicator to assess marrow activity
• Increases found with IRON DEFICIENCY AND MEGALOBLASTIC ANEMIA
(recent bleeding/hemorrhage is the #1 cause)
• Decreases found with MACROCYTIC AND APLASTIC ANEMIAS

vi. HEMATOCRIT (Males 43-53% Gm/dl) (Females 35-47% Gm/dl):

NOTE* THE HCT IS USUALLY 3 TIMES THE Hb

• That portion of the total blood volume occupied by red cells versus
plasma
• Increased with POLYCYTHEMIA, DEHYDRATION OR ADDISON'S DISEASE
• Decreased with anemias and hemorrhage

vii. HEMOGLOBIN (Males 12-17) (Females 11-16):

• Gives red cells their oxygen carrying capacity
• Increased with POLYCYTHEMIA, HEMOLYTIC ANEMIA, AND PORPHYRIAS
• Decreased with other anemias, HEMOGLOBINOPATHY and hemorrhage

viii. MCV=HCT/RBC: Reflects the size of the red cell

Decreased MCV Increased MCV

Iron deficiencies Pernicious anemia
Thalessemia (B12 and Folate deficiency)
Lead poisoning Liver disease
Sideroblastic anemia Hypothyroidism
Hypernatremia Leukemia

ix. MCH=Hb/RBC: Is an estimate of Hb in the average cell

x. MCHC=Hb/HCT: An estimate of Hb In an average cell

 Anemias: Anemia may result from inadequate production of RBC's due to
deficiency states of bone marrow failure or to excessive loss or
destruction of erythrocytes. Precise diagnosis is needed for
treatment with 4 basic tests used:
a. Hematocrit and hemoglobin
b. Reticulocyte count: low= marrow is the site of pathology
normal or high count= good RBC production but cellular destruction
peripherally
c. Peripheral smear (with bone marrow biopsy) to examine the shape and
color of the RBC.
d. Platelet count
Also can do COOMBS test (DIRECT): do when the HCT is falling, elevated
bilirubin, don't have obvious bleeding, and have hemolysis on the
peripheral smear
Macrocytic: either megaloblastic (B 12 or folic acid deficiency) or
chronic
liver disease (OH'ism), hypothyroidism
Normocytic: due to sudden loss of blood, hemolytic anemias, anemias
caused principally by impaired production, and anemia of chronic disease
(DM or RA)
Hypochromic -microcytic: seen with iron deficiency (most common cause),
thalassemia, and sideroblastosis
Normochromic-microcytic: seen with bone marrow suppression,
hemolysis, chronic infections, and inflammatory diseases

Note* Pernicious anemia, in which B, 2 is not absorbed when gastric mucosa is

unable to produce intrinsic factor, resulting in a liver depletion of B12 and
subsequently a disturbance of DNA. Diagnosis is via SCHILLING TEST. Pernicious
is part of an autoimmune complex

NOTE* Sickle-Cell Anemia is seen in 1:600 American blacks. Variants of sickle-

cell disease are types of hemolytic anemias caused by the substitution of
valine for glutamic acid in the B-globin chains of HbA, the normal adult
hemoglobin.
Three principle variants exist:
a. Homozygous state (SS) or true sickle-cell anemia b. Heterozygous state
(AS) or sickle-cell trait
c. Double heterozygous state (SC) consists of two abnormal hemoglobin
chains Patients with SS or SC hemoglobinopathies are usually aware of
their disorders because of previous crises, while the AS patient is usually
asymptomatic. Three major factors contribute to red blood cell sickling:
a. The Hgb-S concentration
b. The partial pressure of oxygen
c. The pH
b. Tests for Hemostasis:
i.. Platelet count: for quantification purposes
ii. Prothrombin time: measurement of extrinsic blood coagulation pathway
(normal 11-13 seconds)
PT will be long with deficiencies of prothrombin, Factor V, Factor Il, or Factor
X
• Affected by coumadin type anticoagulants

iii. Partial thromboplastin time: measurement of intrinsic blood coagulation

pathway (24-26 seconds is normal) and should be within 5 seconds of the
control (control is up to 45 seconds in some labs).
iv. Bleeding time (Lee-White): a standard in vivo assay that measures the
effectiveness of platelet plug formation. This test is performed in patients
who are suspected of having a qualitative platelet disorder, such as patients
having recently taken ASA or who have von Willebrand's disease

NOTE* The mechanism for blood clotting may be divided into 3 stages:
Stage 1: The production of plasma (extrinsic) or tissue (intrinsic)
thromboplastin to form prothrombin activator.
Stage 2: The conversion of fibrinogen to fibrin by the proteolytic action of
thrombin.
Stage 3: The conversion of fibrinogen to fibrin by the proteolytic action of
thrombin. Calcium is required for all stages.

NOTE* Coumadin prevents the conversion of vitamin K to its active form,

thereby impairing the formation of vitamin K-dependent clotting factors.
It is an anticoagulant indicated for the prophylaxis or treatment of
venous thrombosis, pulmonary embolism, atrial fibrillation with
embolization, and as a prophylaxis of embolism after myocardial
infarction.
Coumadin therapy should be monitored by monthly international
normalized ratio (INR) testing. The test represents a standardized or
corrected prothrombin time since results for prothrombin time may vary
by institution. The INR should be obtained preoperatively for any
patient on coumadin (Warfarin) and should range from 2 to 3.
The dosing of the coumadin should be adjusted preoperatively so that the
INR is maintained at the low end of of the therapeutic range. Holding the
dose of coumadin for 2-3 days prior to elective surgery will provide
protection against intraoperative bleeding without compromising
prophylaxis of the patient. If necessary, the coumadin effects on the INR
may be reversed by the administration of vitamin K1 or fresh frozen
plasma

c. Sequential Multiple Analyzer (SMA)

SMA 12 has the following tests: ALBUMIN, ALKALINE PHOSPHATASE,
BILIRUBIN, BLOOD UREA NITROGEN, CALCIUM, CHOLESTEROL, LACTATE
DEHYDROGENASE, SGOT, GLUCOSE, PHOSPHATE, TOTAL PROTEIN, AND URIC
ACID
SMA 16 adds the following four electrolytes: NA, K, CL, AND C02
1. Albumin (3.6-5.2 Gm/dl): A blood protein from the liver-a good indicator of
hepatic health
 Reduced levels are a problem and can result in EDEMA
 Increased levels can cause dehydration
 Reduction due to: LIVER DISEASE, MALIGNANCY, MALNUTRITION, KIDNEY
PATHOLOGY AND LARGE SKIN WOUNDS WITH SERUM LOSS SUCH AS
BURNS

ii. Alkaline Phosphatase (35-137 U/dl):

 Found in the liver, bone, placenta and lung as tissue-specific forms
Anything that stimulates osteoblastic activity increases the Alk
Phosphatase: METASTATIC BONE CANCER, GROWING CHILD, OSTEOGENIC
SARCOMA, PAGET'S DISEASE OF BONE, MONONUCLEOSIS, PREGNANCY,
GROWTH AFTER FRACTURE

NOTE* The most common cause of elevated liver alkaline phosphatase

is common duct obstruction, and the second most common cause is bed
rest in the hospitalized patient

iii. Bilirubin (less than 1.2 mg/dl):

 It is a pigment of bile from RBC breakdown in liver, spleen and marrow.
 Problems develop from abnormal production and decreased excretion
Total bilirubin divided into direct and indirect fractions (direct increased
due to direct hepatic obstruction- indirect due to liver disease.
Bilirubin increased with: CIRRHOSIS, ACUTE VIRAL HEPATITIS, CHF,
HEMOLYSIS AND SEPTICEMIA

iv. Blood Urea Nitrogen (5-25 mg/dl):

Is an end product of protein metabolism and produced only in the liver
and excreted by the kidney.
 BUN increased with: DIABETES AND PROTEIN BREAKDOWN, KIDNEY
PATHOLOGY, FEVER AND PROTEIN BREAKDOWN, CHF, RBC BREAKDOWN
AND STARVATION (dehydration is #1 cause)
 BUN decreased with: HYDRATION, LIVER PATHOLOGY AND DECREASED
PRODUCTION

v. Calcium (4.5-5.5 mg/dl):

Serum calcium increased with any disease of bony demineralization such
as: MULTIPLE MYELOMA, CANCER OF BONE, EXCESSIVE CALCIUM INTAKE,
HYPERPARATHYROIDISM AND HYPERVITAMINOSIS D.
Serum calcium decreased with: RENAL FAILURE (#1), POOR ABSORPTION,
MALNUTRITION, HYPOPARATHYROIDISM,
PSEUDOHYPOPARATHYROIDISM AND DIARRHEA
vi. Chlorides (98-110 meq/L):
 Usually lost from the urine or GI fluid which carry the chloride ion
 Chlorides decreased with: DEHYDRATION (#1), VOMITING, DIARRHEA,
ULCER AND FLUID LOSS, EDEMA, DIURESIS, GI OBSTRUCTION AND
INFECTION.
 Rare to have elevated chloride, if so, can indicate CYSTIC FIBROSIS

vii. Cholesterol (150-220 mg/dl):

 Produced from food and endogenous production (mostly in the liver)
 Used for membranes, STEROID hormones and bile acids.
 Increases: IDIOPATHIC, HYPOTHYROIDISM, DIABETES MELLITUS,
PANCREATITIS
 Decreases: MALABSORPTION, LIVER DAMAGE AND POOR PRODUCTION

viii. Creatinine (under 1.2 mg%):

 Produced from creatine in muscle tissue and excreted by the kidneys -Not
elevated in the blood until 50% of renal function obliterated
 Any major reduction in creatinine clearance of urine indicates kidney
impairment

ix. Glucose (70-110 mg/dl):

 The liver produces glucose from protein (gluconeogenesis).
 Blood glucose is filtered through the kidney glomeruli and reabsorbed in
the proximal tubule, and if renal threshold is exceeded glucose is spilled
into the urine.
 Elevated with: DIABETES MELLITUS, CUSHING'S SYNDROME,
ACROMEGALY, STRESS, BURNS, SHOCK, ACUTE PANCREATITIS, OBESITY,
ACTH ADMINISTRATION AND AGE
 Decreased with: INSULIN SHOCK, ISLET CELL TUMOR, NUTRITION,
GLUCAGON DEFICIENCY, ADDISON'S DISEASE AND HYPOTHYROIDISM
(Hypoglycemia may be precursor to DM)

x. Lactate Dehydrogenase (208-378U/L):

 This is a glycolytic enzyme that functions in carbohydrate metabolism
which is found in the kidney, liver, heart, RBC's.
 Increased with any tissue damage, therefore it is NOT SPECIFIC

xi. Total Protein (6.4-8.3 g/dI):

 Contains albumin and globulins and rarely is total protein increased since
most disease states lower body reserves
 Increased with: DEHYDRATION caused by vomiting and diarrhea
 Albumin:Globulin Ratio= 1.5:1-2.5:1

xii. Phosphate (8-12 mg/dl):

 it is absorbed in the intestine, stored in bone, and excreted by the kidneys
 Elevated with: RENAL FAILURE, HYPOPARATHYROIDISM, INCREASE VIT D
 INTAKE, BONE DISEASE, FRACTURES, PAGET'S DISEASE OF BONE,
MULTIPLE MYELOMA
 Decreased with: HYPOVITAMINOSIS D, DIABETES, HYPERPARATHYROIDISM
(MOST COMMON IS POOR NUTRITION)

xiii. Potassium (3.5-5.1 mEq/l): Very important element in the pre-op

evaluation
 Decreased K produces muscle cramps and arrhythmias while increased K
produces arrhythmias and cardiac pathology
 increased with: USE OF MINERALCORTICOIDS, RENAL FAILURE, ACIDOSIS,
DIABETIC KETOACIDOSIS.
 Decreased with: ALKALOSIS, DIARRHEA, DIURETICS, INSULIN,
MALABSORPTION AND STARVATION (#1 cause is with excess IV's)
-Symptoms don't start until serum levels fall below 2.5 mEq/L -Cardiac
standstill can occur when levels exceed 7.5-8.0 mEq/L

xiv. SGOT (AST 1-45 IU/L):

 The enzyme used in glycolysis and energy production and found mostly in
the liver, heart, and also in the muscle, kidney, and pancreas.
 Sudden increase seen with MI, also with liver and lung pathology

NOTE* Elevated SCOT (AST) seen in pulmonary embolism postoperatively

 Elevated in: CARDIAC DAMAGE, LIVER DAMAGE, SKELETAL PATHOLOGY,

PANCREATIC PATHOLOGY.

The SGOT parallels the SGPT AL , whose normal values = 1-60 IU/L,
except the SGOT shows higher values with MI and the SGPT has
higher values with LIVER PATHOLOGY
xv. Uric Acid (2.8-8.0 mg/dl):
 Manufactured from purine metabolism
 The pH of urine must be close to 7.4, as uric acid is poorly soluble as the
pH decreases with crystals forming depositing in tissues across the cell
membrane. Therefore alkalinization of the urine increases uricosuric
activity.

NOTE* WHEN TREATING GOUT CHECK THE pH OF THE URINE

xvi. Serum Amylase: NOT USUALLY DONE PREOPERATIVELY

 Enzymes produced in the pancreas and used for the digestion of starch
 Elevation due to cellular destruction of amylase in the pancreas or poor
renal excretion, due to: PANCREATITIS, PERFORATED ULCER, PANCREATIC
DUCT OBSTRUCTION, AND RENAL FAILURE.
 Decreased due to CHRONIC PANCREATIC OBSTRUCTION.
xvi. Acetone: Detected by dipstick urine test- should be negative
 ketone body from fat metabolism
 Elevated with: STARVATION, STRESS, DIABETES, LOW CARBOHYDRATE
DIET

NOTE*AS KETONES INCREASE pH DECREASES

xvii. Acid phosphatase: NOT USUALLY DONE PREOPERATIVELY

 Found in the male prostate, the male urine, RBC's and platelets (female).
 High levels consistent with METASTATIC CARCINOMA OF THE PROSTATE
 Can also be elevated with MULTIPLE MYELOMA AND PAGET'S DISEASE OF
BONE

NOTE*: SERUM PROFILE

LIVER- BILIRUBIN, CHOLESTEROL, SGOT, SGPT, ALKALINE PHOSPHATASE,
ALBUMIN
KIDNEY- CHLORIDE, CREATININE, BUN, PHOSPHOROUS, PROTEIN, TOTAL
PROTEIN, LDH, Na, K, C1, Co 2
CARDIAC- LDH, CPK, SGOT, ELECTROLYTES, BUN
ARTHRITIC- LATEX FIX, ESR, VDRL, ANA, ASO TITER, URIC ACID, LE PREP
(RARELY DONE- ANA MORE ACCURATE)
4. URINE ANALYSIS:
a. A multitest dipstick is used on the urine to get rough readings on glucose,
acetone, bile, urobilinogen, protein and blood. The urine is then centrifuged
and the solid matter goes to the bottom and is then examined
microscopically for red/white/epithelial cells, crystals and casts.
b. Also checked is the color, clarity, pH and specific gravity
c. The specific gravity range is 1.020-1.032. (when concentrated in the AM)
A measure of the kidney's ability to concentrate and the SG is elevated by
extra glucose (diabetes) and protein due to increased concentration in the
fluid.
d. All glucose in the urine is competely reabsorbed by the proximal tubules,
therefore the appearance of glucose in the urine when the blood glucose
levels is below 180 (250 IN SOME TEXTS) may signify proximal tubule
damage.
e. Small amounts of protein are found in the urine (albumin and globulins),
however, large amounts in excess of 4gms daily indicate glomerular disease
(mostly albumin)
f. Ketone bodies accumulate due to altered lipid metabolism, most frequently
as a consequence of diabetes mellitus or low carbohydrate diet
g. OCCULT hematuria occurs from: EXCERCISE (#1), CYSTITIS,
HEMORRHAGE, MENSTRUATION, GLOMERULONEPHRITIS, HYPERTENSION,
POLYCYSTIC DISEASE AND RENAL THROMBOSIS
i. Microscopic hematuria seen with acute infection, sickle cell anemia,
excercise, menses and SBE.
h. GROSS hematuria associated with stones, tumors, TB, and acute
glomerulonephritis.
i. Normal urine is slightly acidic, pH usually below 5.3, is-altered by diet or
medications
i. An alkaline urine in the presence of metabolic acidosis suggests Renal
Tubular Acidosis.

NOTE* An alkaline urine is most commonly seen in a proteus UTI

j. Normal findings in the urinary sediment includes up to : 1 RBC, 5 WBC'S,

AND AN OCCASIONAL CAST.
k. Abnormal findings in the sediment include: RBC'S, WBC CASTS, YEAST,
CRYSTALS OR EPITHELIAL CELLS.
l. Casts are protein conglomerations in the shape of the renal tubule.
Two types of casts:
i. CELLULAR- RBC, WBC, EPITHELIAL CELLS, OR ANY COMBINATION IN A
PROTEIN MATRIX

NOTE* With WBC casts, the cells become emulsified in the protein matrix and
may be found in pyelonephritis, acute glomerulonephritis, or SLE.
The cells in RBC cell casts are emulsified in protein matrix and are indicative of
glomerulitis.
Casts containing fat droplets are called fatty casts and are associated with
nephrotic syndrome

ii. PROTEIN- are composed entirely of protein

m. Crystals in the urine may indicate stones or certain metabolic diseases
n. Bile present indicates hepatic obstruction or constipation
o. Urobilinogen can be present due to HEPATITIS
p. Catecholamines: elevation in the urine is indicative of pheochromocytoma
or extramedullary chromaffin tumors, malignant hypertension, progressive
ms. dystrophy, myasthenia gravis, and drugs. (this is not usually done
preoperatively)

5. Pregnancy testing:
Should be performed on all women within childbearing years

6. Chest x-ray:
This compliments the H & P as a starting point for the diagnosis and
evaluation of suspected pulmonary disorders. Abnormalities seen on the x-
ray are: CHF, pulmonary masses, pleural effusions, pneumonia. Remember
that the chest x-ray alone is not a good indicator for operative risk

7. Electrocardiogram:
Recommended that all patients over the age of 40 have this test done,
however, a poor predictor of ischemic heart disease and perioperative
cardiac morbidity and mortality. Electrocardiography is a graphic
representation of the electrical currents associated with the contraction of
the heart muscle. The basic function of the electrocardiographic monitor is to
amplify the small voltage formed by the depolarization of the heart so that it
can be presented on the screen for visual monitoring or so that a graphic
record can be made.
a. Conduction mechanism of the heart
i. Sinoatrial node (SA): The electrical impulse is formed in the SA node, which
is the physiologic pacemaker of the heart, located at the junction of the right
atrium and superior vena cava
ii. Atrioventricular node (AV): After the SA node the impulse speeds to the AV
node, at the junction of the atria and ventricles

iii. Bundle of His: After the AV node fires, the impulse travels to the bundle of
His, then the right and left bundle branches, Purkinje's fibers, and the
ventricles
b. The normal electrocardiogram:
i. P wave: Indicates the results of the electrical activity during atrial
depolarization that initiates atrial contractions
 P-R interval: Represents the time it takes the impulse to spread from the
SA node to the ventricles (normal time 0.12-0.20 sec)

Normal EKG Tracing

i. QRS complex: Is due to the depolarization of the ventricles, which triggers

their contraction. It indicates the time it takes for ventricular depolarization
(normal time 0.06-0.10 sec)
ii. T wave: Occurs at the end of ventricular systole
b. The recording paper has horizontal and vertical lines:
i. Horizontal lines: Indicate voltage and are 1 mm apart (1 mm represents 1
mV)
ii. Vertical lines: Indicate time and are separated by an interval of 0.04 sec.
The heavy vertical lines represent 0.2 sec intervals, and the five large
squares represent 1 sec
iii. Heart rate per minute: Is determined by counting the number of QRS
complexes that occur in 3 seconds (15 large squares) and multiplying by 20
c. EKG (ECG) leads:
i. Standard lead (I, II, Ill): Are bipolar indirect leads, that record the difference
between two points on the body, in electrical events formed by the cardiac
action. The electrodes are attached to the left arm, right arm, and left leg.
The right leg is used for a ground. The terminals are placed as follows:
• Lead l: right arm, left arm
• Lead II: right arm, left leg
• Lead III: left arm, left leg
ii. Unipolar extrmity leads: Indicate the electrical potentials at one point. The
electrodes of the three limbs are attached together to form one electrode,
called the central terminal lead. The differences of the electrical potentials
are recorded between the central terminal and each of the three extremities
• Lead aVr: is positioned at the right arm
• Lead aVL: is positioned at the left arm
• Lead aVf: is positioned at the left foot
iii. Precordial leads: Are unipolar leads that indicate the variation of electrical
potentials at a given cardiac anatomic site. The central terminal lead is used,
and the exploring electrode is positioned in the chest and in six different
locations, V1 to V6

Summary of Perioperative Laboratory Testing

1. Blood studies:
a. CBC: Hgb, Hct, RBC, WBC, platelets, red cell indices (MCV MCH etc.), WBC
differential (segs, lymphs, bands, etc.)
b. Serum electrolytes: Sodium, potassium, chloride, calcium, magnesium
c. Liver studies:
i. Hepatocellular enzymes: SGOT/ALT
ii. Studies of obstruction: Alkaline phosphatase, glutamyltransferase (GGT),
and 5' Nucleotidase
iii. Evaluation of jaundice: Bilirubin (conjugated or unconjugated)
iv. Other liver studies: Albumin, prothrombin time (PT)
d. Renal studies: Blood Urea Nitrogen, creatinine, serum electrolytes
(mediated by kidney), creatine
e. Cardiac enzymes: Lactic dehydrogenase (LDH), SCOT (AST), creatine
phosphokinase (CPK)
f. Clotting: Partial thromboplastin, prothrombin, bleeding time, INR
2. Urinalysis:
a. Dipstick: Protein, blood, glucose, ketones, pH
b. Microscopic exam: RBC's, WBC's, cellular casts, bacteria, crystals

3. Pulmonary function tests:

a. Static lung volumes: Total lung capacity, functional residual capacity,
residual volume, vital capacity
b. Dynamic volume measurement: Forced vital capacity (FVC), forced vital
capacity in 1 second (FEV1), and FEV1 /FVC

4. Arterial blood gas: Oxygenation, carbon dioxide, 02 saturation, pH

5. Chest x-rays: Cardiac size, calcifications, lung masses, pleural effusions,
infiltrates, interstitial patterns

6. EKG:
a. Rate
b. Rhythm
c. Intracardiac conduction times (PR interval, QRS interval, QT interval)
d. Chamber enlargement (hypertrophy of myocardium)
e. Myocardial infarction patterns (pathologic Q waves)
f. ST segments of ischemia