What are the preoperative requirements and smartphrases for charting prior to surgery?

Preoperative Requirements and Charting Documentation

For standardized preoperative charting, document cardiovascular risk assessment, vital signs within 2 hours of surgery, functional capacity, relevant laboratory testing based on patient risk factors and surgery type, and a discussion of perioperative cardiovascular risks with the patient. 1

Essential Documentation Components

Cardiovascular Risk Assessment

• Document cardiovascular risk stratification for all patients undergoing high-risk surgery and for intermediate-risk patients with cardiac risk factors (coronary disease, structural heart disease, heart failure, cerebrovascular disease, diabetes, renal impairment). 1, 2
• Screen for active cardiac conditions requiring pre-surgery optimization: unstable coronary syndromes, decompensated heart failure, significant arrhythmias, or severe valvular disease. 1, 2
• Assess and document functional capacity in METs (metabolic equivalents) - patients with ≥4 METs or ability to climb ≥2 flights of stairs can generally proceed without further cardiac testing. 1, 3, 2

Vital Signs and Physical Examination

• Blood pressure and heart rate must be checked and documented within 2 hours preoperatively for all patients undergoing non-cardiac surgery. 1
• Perform and document cardiac physical examination findings preoperatively. 1

Patient Education Documentation

• Document a discussion with the patient about cardiovascular risks involved in the surgery - this is a quality indicator for preoperative care. 1
• Record preoperative counseling about surgical and anesthetic procedures to reduce anxiety. 4

Risk-Stratified Laboratory Testing

For Intermediate- and High-Risk Patients

• Full blood count (FBC) and renal function testing are required preoperatively for intermediate- and high-risk patients. 1
• Cardiac troponin levels should be checked preoperatively AND at 24 and 48 hours postoperatively for intermediate- and high-risk patients undergoing high-risk surgery. 1
• Electrolyte and creatinine testing for patients taking diuretics, ACE inhibitors, ARBs, NSAIDs, or digoxin, and those with hypertension, heart failure, chronic kidney disease, complicated diabetes, or liver disease. 3, 4

Selective Testing Based on Clinical Indications

• CBC only for patients with history of anemia, recent blood loss, liver disease, hematologic disorders, or when significant blood loss is anticipated. 3, 4
• Random glucose testing for patients at high risk of undiagnosed diabetes; A1C only if results would change perioperative management. 3
• Coagulation studies (PT, aPTT, platelet count) only for patients with bleeding history, liver disease, or taking anticoagulants - not routinely. 3
• Urinalysis only for urologic procedures or implantation of foreign material (prosthetic joints, heart valves). 3

Electrocardiography Requirements

ECG is indicated for:

• Patients with signs or symptoms of cardiovascular disease. 3, 4
• All patients undergoing vascular surgical procedures (even those without clinical risk factors). 1
• Patients with known coronary heart disease, peripheral arterial disease, or cerebrovascular disease undergoing intermediate-risk procedures. 1
• Patients undergoing high-risk surgery. 3
• Intermediate-risk surgery patients with additional risk factors (coronary disease, structural heart disease, heart failure, cerebrovascular disease, diabetes, renal impairment). 1, 2

ECG is NOT indicated for:

• Asymptomatic patients undergoing low-risk procedures. 1, 3

Imaging Requirements

Chest Radiography

• Not performed routinely for asymptomatic, healthy patients. 3, 4
• Indicated only for patients with new or unstable cardiopulmonary signs or symptoms. 3, 4

CT Scanning (for sinus surgery)

• Mandatory prior to sinus surgery to confirm disease extent and identify anatomical features predisposing to complications. 1
• Does not need to be repeated if previously performed (median interval studied: 782 days) unless interim surgical procedures occurred. 1

Preoperative Medication Management

Multimodal Analgesia Documentation

• Document preoperative administration of acetaminophen, NSAIDs, and gabapentinoids (if used) for opioid-sparing multimodal analgesia, with doses adjusted for age and renal function. 1
• Limit gabapentinoids to a single lowest preoperative dose to avoid sedative side effects, dizziness, and visual disturbances. 1

Anxiolysis Approach

• Avoid benzodiazepines and long-acting sedatives, especially in elderly patients - prioritize preoperative education over pharmacologic anxiolysis. 1

Antimicrobial Prophylaxis

• Intravenous antibiotics covering aerobic and anaerobic bacteria (cephalosporin plus metronidazole) administered within 60 minutes before incision for colorectal surgery. 1
• No benefit for repeated administration. 1

Institutional Requirements

Document institutional policies addressing:

• Fasting guidelines. 1
• Required investigations. 1
• Blood typing protocols. 1
• Thromboprophylaxis plans. 1
• Perioperative diabetes management. 1
• Allergy documentation. 1

Common Pitfalls to Avoid

• Do not order routine preoperative testing for all patients - testing should be based on clinical history, comorbidities, physical examination, and perioperative risk assessment, not performed indiscriminately. 3, 5
• Do not perform tests unless they will influence patient treatment - the goal is optimal patient care, not medical clearance. 1
• Avoid stopping aspirin/NSAIDs without considering individual bleeding risk versus thrombotic risk. 1
• Do not repeat imaging unnecessarily if prior studies are adequate and no interval procedures occurred. 1