Well, I guess this wasn't that exciting of a case. So, literature is lacking on what to do. I did stumble across this VA study that happened to look at hcts and surgery. They looked at both ends of the spectrum, anemia, and polycythemia and 30 day mortality. Relative to the size of their retrospective cohort there really weren't that many patients with polycythemia, but as they point out, more than anyone else has published. And what did they find, when hct gets beyond 51 mortality starts to increase. They really don't explain causes of mortality.
Now, in the case I mentioned, how applicable is this? The JAMA study is pretty much all dudes, and its retrospective. Not great, but really not much out there to go on, except, "I've never had a problem polycythemia in the perioperative period, so it must be fine." But, to be fair, does taking action on it do anything? No one knows.
I guess I would favor heme evaluation for elective surgery if it can wait, although there may not be much to do for secondary polycythemia in a smoker, which many of these probably are. And I would consider active measures for surgery that can't wait based on likely blood loss, other comorbidities, (CAD, CVA, etc) and I would consider measures such as autologous blood donation for the phlebotomy benefit.
