What should be included in a pre-operative (pre-op) checklist?

Pre-Operative Checklist

A comprehensive pre-operative checklist should include patient identification and medical history review, focused physical examination with airway assessment, risk-stratified laboratory testing based on clinical indications rather than routine protocols, medication reconciliation, allergy screening, and surgical safety verification—with testing decisions guided by patient comorbidities, surgical risk level, and potential to change perioperative management.

Patient Identification and Medical Record Review

• Verify patient identity, correct surgical procedure, correct surgical site, and obtain informed consent 1
• Review previous medical records for history of airway difficulty with previous anesthetics, cardiovascular problems, and congenital or acquired medical conditions 1
• Document current medications with careful review for inappropriate dosing, potential drug interactions, and medications requiring perioperative adjustment 1, 2
• Beta-blockers should NOT be routinely withdrawn prior to major surgery, though they may impair the heart's ability to respond to reflex adrenergic stimuli during general anesthesia 2
• Establish whether patient has a cardiac rhythm management device (pacemaker/ICD), define device type, determine pacemaker dependency, and assess device function 1

Focused History and Risk Assessment

Cardiovascular Assessment

• Obtain ECG for patients with signs/symptoms of cardiovascular disease, those undergoing high-risk surgery, and those undergoing intermediate-risk surgery with additional risk factors (coronary disease, heart failure, cerebrovascular disease, diabetes, renal impairment) 3
• Patients undergoing low-risk surgery do not require ECG 3
• Assess functional capacity—patients with good functional capacity (≥4 METs or ability to climb ≥2 flights of stairs) can generally proceed without further cardiac testing 3
• Screen for metabolic syndrome features as there is strong association with cardiac morbidity 1

Pulmonary Assessment

• Screen for obstructive sleep apnea (OSA) by asking about snoring, apneic episodes, frequent arousals during sleep, morning headaches, and daytime somnolence 1
• Measure baseline oxygen saturation and assess for symptoms of sleep-disordered breathing 1
• Consider overnight saturation measurement or formal sleep study if severe OSA suspected 1
• Chest radiography is NOT performed routinely for asymptomatic patients but is indicated for those with new or unstable cardiopulmonary signs/symptoms 3

Allergy and Anaphylaxis Risk

• Obtain thorough allergy history including previous anaphylactic reactions, latex allergy (ask specifically about reactions to balloons, condoms, latex gloves), and drug allergies 1
• High-risk groups for latex allergy include patients with atopy, children with spina bifida or multiple surgeries, healthcare workers, and those with fruit allergies (banana, chestnut, avocado) 1
• If latex allergy suspected, refer for testing before surgery (latex-specific IgE blood test or skin prick testing) and implement latex-free precautions 1
• Document chlorhexidine allergy as it is more common than povidone-iodine allergy 1

Comorbidity Screening

• Screen for smoking, alcohol usage, hypertension, diabetes, anemia, and conduct nutritional assessment 1
• In countries with high HIV/AIDS prevalence, perform preoperative HIV testing 1
• Conduct delirium screening in elderly patients 1
• For patients with sickle cell disease, involve lead haematologist early and schedule patient first on operating list 1

Physical Examination

Airway Assessment

• Evaluate airway, nasopharyngeal characteristics, neck circumference, tonsil size, and tongue volume 1
• Assess for musculoskeletal abnormalities (osteoarthritis, kyphoscoliosis, fixed flexion deformities) 1
• Examine skin condition, pressure areas, and dentition 1

Obesity-Specific Assessment

• Ensure suitably sized theatre gowns and equipment are available 1
• Consider asking male patients with beards to shave/trim facial hair pre-operatively to facilitate mask ventilation 1
• Plan for additional personnel and extra time for positioning 1

Laboratory Testing (Risk-Stratified, NOT Routine)

Complete Blood Count

• Obtain CBC for patients with diseases increasing anemia risk (liver disease, hematologic disorders), history of anemia, or when significant perioperative blood loss anticipated 3
• Pre-operative anaemia occurs in approximately 40% of hip fracture patients 1
• Consider pre-operative transfusion if Hb <9 g/dL, or Hb <10 g/dL with history of ischaemic heart disease 1
• If Hb 10-12 g/dL, crossmatch two units of blood 1

Electrolytes and Renal Function

• Perform electrolyte and creatinine testing for patients with chronic disease (hypertension, heart failure, chronic kidney disease, diabetes, liver disease) and those taking medications predisposing to electrolyte abnormalities (diuretics, ACE inhibitors, ARBs, NSAIDs, digoxin) 3
• Required for all patients with known renal conditions and those undergoing neurosurgery or cardiovascular surgery 3

Glucose Testing

• Perform random glucose testing for patients at high risk of undiagnosed diabetes 3
• In patients with diagnosed diabetes, A1C testing only if results would change perioperative management 3
• Universal screening not justified as incidence of occult diabetes in presurgical population is low (0.5%) 3

Coagulation Studies

• Reserve coagulation testing (PT, aPTT, platelet count) for patients with history of bleeding, medical conditions predisposing to coagulopathy (liver disease), or those taking anticoagulants 3
• Platelet count 50-80 × 10⁹/L is relative contraindication to neuraxial anaesthesia 1
• Platelet count <50 × 10⁹/L normally requires pre-operative platelet transfusion 1

Urinalysis

• Urinalysis is NOT routine but is indicated for patients undergoing urologic procedures or implantation of foreign material (prosthetic joint, heart valve) 3

Medication Management

• Review current medication list for inappropriate dosing, potential interactions, and perioperative continuation/discontinuation decisions 1
• Polypharmacy increases likelihood of adverse drug reactions—20% of people aged >70 take more than five medications 1
• Do NOT abruptly discontinue beta-blockers in patients with coronary artery disease—severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias have been reported 2
• When discontinuing chronically administered beta-blockers, reduce dosage gradually over 1-2 weeks 2

Preoperative Fasting and Optimization

• Allow oral intake of clear fluids up to 2 hours and light meal up to 6 hours before induction 1
• After full meal (including meat, fatty/fried foods), 8 or more hours may be required 1
• Administer complex carbohydrate drink (400 mL with 50 g CHO) 2 hours before surgery for elective patients 1
• Avoid routine use of premedication; consider short-acting anxiolytic only in patients with severe anxiety 1

Surgical Safety Checklist and Team Communication

• Implement WHO surgical safety checklist with all 19 items and three pause points 1
• Conduct pre-operative team brief to ensure appropriate equipment available, including suitable operating tables, beds, and trolleys for obese patients 1
• Alert surgical team, nursing, and anaesthetic support teams if latex allergy diagnosed—place "Latex allergy" notice on doors and use only latex-free products 1
• Document allergy status in case notes and on patient's wrist bracelet 1

Antimicrobial and Thromboprophylaxis

• Administer first-generation cephalosporin within 1 hour of incision; antibiotic prophylaxis NOT recommended in postoperative period 1
• Assess all patients for postoperative nausea/vomiting (PONV) risk; high-risk patients should receive 2-3 antiemetics 1
• Use combination of compression stockings and/or intermittent pneumatic compression with LMWH or unfractionated heparin for VTE prophylaxis, continued in hospital 1

Special Population Considerations

High-Risk Patients Requiring Specialized Centers

• Patients with prior Fontan procedure, severe pulmonary arterial hypertension, cyanotic congenital heart disease, complex CHD with residua, or malignant arrhythmias should be managed at specialized centers unless absolute emergency 1
• Consultation with congenital heart disease experts recommended for all CHD patients undergoing noncardiac surgery 1

Pediatric Considerations

• For children <16 years with sickle cell disease, transcranial Doppler results should be available from within previous 12 months 1
• Children undergoing multiple surgical procedures (spina bifida) or surgery at very young age are at increased risk for latex allergy 1

Postoperative Planning

• Plan postoperative care location based on pre-existing comorbidities, surgical procedure invasiveness, and need for parenteral opioids—obesity alone is NOT indication for high-dependency care 1
• Establish discharge plans preoperatively and provide patient/family education in oral, written, and/or pictorial format 1
• Ensure clear emergency contact details and transport plans, particularly important in settings with long travel distances 1

Documentation Requirements

• Document sickle cell disease diagnosis clearly in patient record so relevant teams aware at all stages 1
• Record cardiac rhythm management device information and perioperative management plan 1
• Document allergy status, particularly latex and drug allergies, in multiple locations 1