Are you evaluating a patient prior to surgery?



Systolic blood pressure

mm Hg

Diastolic blood pressure

mm Hg

Unintended weight loss over the past 6 months

Serum osmolality

mosm per kg H2O

Serum albumin

Serum creatinine

Upper limit of reference range for serum creatinine

Serum bilirubin

Upper limit of reference range for serum bilirubin

Serum ammonia

Hematocrit (enter from 0 to 100)


Recent acute blood loss



FIO2 (enter from 21 to 100)


Urinary output

mL per hour

White blood cell count

Does the patient have?

• severe pancreatitis?

• gangrenous bowel?

• peritonitis?

• bowel perforation?

• severe gastrointestinal bleeding?

• late state vascular disease involving the aorta?

• respiratory failure requiring mechanical ventilation for > 48 hours?

• a positive blood culture with a pathogenic organism or a septic focus?

• major trauma affecting multiple organs or systems?

• major trauma with penetration into 2 or more body cavities?

• spiking fever >= 38.8°C for 48 hours?

Is the patient scheduled for?

• extensive ablative surgery for malignant disease?

• prolonged surgery (more than 8 hours)?

Select an appropriate answer for each question

Chronic lung disease

NYHA classification heart failure


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