What are the necessary steps for a preoperative (pre-op) checklist to clear a patient for surgery?

From the Guidelines

A comprehensive preoperative checklist for surgical clearance should include a thorough medical history review, focusing on cardiovascular, pulmonary, renal, hepatic, and endocrine systems, as well as assessment of current medications, allergies, and previous surgical complications, as recommended by the most recent guidelines 1. The preoperative evaluation process should be tailored to the individual patient's needs and the nature of the surgical procedure.

• The patient's current medications, particularly anticoagulants like warfarin, DOACs, aspirin, and clopidogrel, should be assessed, and consideration given to discontinuing them 5-7 days before surgery if necessary.
• A physical examination should evaluate vital signs, cardiopulmonary status, and airway assessment.
• Laboratory tests typically include CBC, comprehensive metabolic panel, coagulation studies, and urinalysis.
• For patients over 40 or with cardiac risk factors, an ECG is recommended, as suggested by previous guidelines 1. Additional tests like chest X-rays, pulmonary function tests, or echocardiograms may be necessary based on patient history and surgical complexity.
• NPO status should be maintained for at least 8 hours before surgery, though clear liquids may be permitted up to 2 hours prior, as recommended by recent guidelines 1.
• Chronic medications for hypertension, cardiac conditions, or seizures should generally be continued through the morning of surgery with a small sip of water, while diabetic medications often require adjustment. This systematic approach helps identify risk factors that could complicate surgery and anesthesia, allowing for appropriate risk stratification and optimization before the procedure, and is supported by evidence from multiple studies 1.

From the FDA Drug Label

TREATMENT DURING DENTISTRY AND SURGERY The management of patients who undergo dental and surgical procedures requires close liaison between attending physicians, surgeons and dentists. PT/INR determination is recommended just prior to any dental or surgical procedure.

The necessary steps for a preoperative (pre-op) checklist to clear a patient for surgery include:

• PT/INR determination: just prior to any surgical procedure to ensure the patient's PT/INR is within the therapeutic range.
• Close liaison: between attending physicians, surgeons, and dentists to manage patients undergoing dental and surgical procedures. It is also recommended to consider adjusting the dosage of warfarin sodium tablets to maintain the PT/INR at the low end of the therapeutic range for patients undergoing minimal invasive procedures who must be anticoagulated prior to, during, or immediately following these procedures 2.

From the Research

Preoperative Checklist Steps

To clear a patient for surgery, the following steps should be taken as part of a preoperative checklist:

• A thorough preoperative evaluation to identify correctable medical abnormalities and understand the residual risk is mandatory for all patients undergoing any surgical procedure 3
• Routine preoperative evaluation will vary among patients, depending on age and general health 3
• Laboratory testing is a common component of preanesthesia evaluation and is designed to identify medical abnormalities that might otherwise remain undetected 4
• A history and physical examination, focusing on risk factors for cardiac and pulmonary complications and a determination of the patient's functional capacity, are essential to any preoperative evaluation 5
• Laboratory investigations should be ordered only when indicated by the patient's medical status, drug therapy, or the nature of the proposed procedure and not on a routine basis 5

Timing of Preoperative Testing

The timing of preoperative testing is also an important consideration:

• Blood testing might optimally be performed shortly before surgery, but it is often done earlier for practical reasons 4
• Risk of 30-day morbidity and mortality was not different with blood testing up to 2 months before surgery, suggesting that it is unnecessary to retest patients shortly before surgery 4
• Blood testing 2-3 months before surgery was associated with increased odds of outcome compared to patients whose most recent test was within 1 week 4

Preoperative Evaluation and Preparation

Preoperative evaluation and preparation involve:

• A thorough history taking and physical examination of all patients before surgery 6, 5
• Proper consultations with appropriate medical services should be obtained to improve the patient's health 5
• Preoperative preparation involves procedures that are implemented based on the nature of the expected operation as well as the findings of the diagnostic workup and the preoperative evaluation 5
• Preoperative care refers to the physical and psychosocial care that prepares a patient to undergo surgery safely, and can involve preoperative outpatient appointments and remote consultations 7