What is the comprehensive checklist for operating theater (OT) preparation for a non-emergency surgical procedure in an adult patient with pre-existing medical conditions, allergies, and current medications?

Operating Theater Preparation Checklist for Non-Emergency Surgery in Adults with Comorbidities

For adult patients with pre-existing medical conditions, allergies, and current medications undergoing non-emergency surgery, the operating theater must be prepared with specific attention to anaphylaxis preparedness, equipment for difficult airway management, appropriate monitoring devices, and documented verification of patient-specific risk factors before the patient enters the OR.

Pre-Procedure Team Brief and Equipment Verification

WHO Surgical Checklist Adaptation

• Complete a pre-operative team brief before the patient enters the OR, specifically addressing patient comorbidities, obesity status (if applicable), allergy history, and availability of specialized equipment 1
• Verify that all team members know each other's names and roles to improve communication and safety 2
• Allow extra time for positioning and anesthesia induction if the patient has obesity or complex medical conditions 1
• Ensure appropriate seniority of both anesthetist and surgeon based on patient risk stratification 1

Anaphylaxis Treatment Pack Preparation

• Assemble an immediately accessible anaphylaxis treatment kit containing: laminated treatment algorithm emphasizing IV epinephrine and fluids, prefilled syringes of dilute epinephrine (100 mcg/mL if available), alternative vasopressor infusion protocols (vasopressin, norepinephrine, metaraminol, phenylephrine), and tryptase sampling tubes with timing instructions 1
• Position this kit in a standardized, known location in every OR 1
• Ensure all team members are familiar with epinephrine dilution methods, particularly for 20 mcg bolus dosing in Grade II reactions 1

Patient-Specific Allergy and Medication Documentation

Allergy Verification Protocol

• Document all known drug allergies with specific reaction descriptions, not just "allergic" notation 1
• For patients with documented penicillin allergy and renal impairment requiring prophylactic antibiotics, prepare ciprofloxacin 400 mg IV every 12 hours plus metronidazole 500 mg IV every 8 hours as the primary regimen 3
• For latex-sensitive patients, schedule as first case of the day and remove all latex products from the OR; ideally use a designated latex-safe operative suite 1
• If the patient has a history of previous uninvestigated perioperative allergic reaction, flag this as a high-risk case and avoid all suspected agents 1

Current Medication Review

• List all prescription medications, over-the-counter drugs, herbal preparations, and supplements with dosages 1
• Identify patients on beta-blockers, as these may complicate anaphylaxis resuscitation requiring alternative vasopressors 1
• For elderly patients (>75 years), calculate age-adjusted and renal function-adjusted doses for all anesthetic agents (30-50% reduction from standard adult dosing) and document these before induction 4

Airway Management Equipment

Standard and Difficult Airway Preparation

• Verify availability of bag-mask ventilation equipment; if male patient has a beard, request pre-operative shaving or trimming to facilitate effective mask seal 1
• Prepare difficult airway cart with video laryngoscopy, supraglottic airways, and emergency cricothyrotomy equipment for obese patients or those with predicted difficult airways 1
• Have extra-long spinal or epidural needles available if regional anesthesia is planned for obese patients 1

Monitoring and Positioning Equipment

Specialized Monitoring for High-Risk Patients

• For elderly patients (>75 years) or those with significant comorbidities, ensure depth of anesthesia monitoring (BIS or entropy) is available and functional to prevent relative overdose and facilitate faster emergence 4
• Verify standard ASA monitoring (ECG, pulse oximetry, blood pressure, capnography, temperature) is operational 1

Positioning and Pressure Injury Prevention

• Prepare comprehensive padding for all probable sites of nerve injury and pressure necrosis, with particular attention to heels, elbows, and bony prominences in elderly or obese patients 4
• Plan for reassessment of positioning every 30 minutes during prolonged procedures 4
• Ensure availability of appropriately sized operating tables, beds, and trolleys for obese patients 1

Fluid and Medication Preparation

Fluid Management Setup

• Prepare crystalloid fluids for immediate administration; plan for 20 mL/kg boluses repeated as needed if anaphylaxis occurs 1
• For high-risk patients undergoing major surgery, prepare for "restrictive" fluid therapy that replaces losses without causing overload 4

Antibiotic Prophylaxis Preparation

• For penicillin-allergic patients with normal renal function, prepare standard alternative prophylaxis 1
• For penicillin-allergic patients with renal impairment (CrCl 26-50 mL/min), prepare ciprofloxacin 400 mg IV plus metronidazole 500 mg IV, with doses adjusted for creatinine clearance 3
• For dialysis patients, plan to administer antibiotics immediately after dialysis completion 3

Corticosteroid and Antihistamine Availability

• Have IV corticosteroids available but recognize these are given after adequate resuscitation, not as priority treatment for anaphylaxis 1
• Stock locally recommended IV antihistamine (e.g., chlorphenamine where available), understanding it may be given after resuscitation but does not change outcome 1

Post-Procedure Planning Documentation

Recovery and Monitoring Plans

• For elderly patients (>75 years) undergoing major/emergency surgery, prepare the end-of-surgery checklist including: core temperature measurement, hemoglobin concentration, age-adjusted analgesic doses, postoperative fluid plan, and determination of appropriate recovery location 4
• Plan minimum 6-hour monitored observation for any patient who experiences suspected anaphylaxis 1
• For patients with predicted perioperative mortality >10%, arrange level 2 or 3 critical care admission in advance 4

Tryptase Sampling Protocol

• Prepare labeled tubes for mast cell tryptase sampling at specific time points: 1 hour after reaction onset, 2-4 hours after onset, and baseline sample at least 24 hours post-reaction 1
• Post sampling instructions in the anaphylaxis treatment pack 1

Regional Anesthesia Considerations

• Where possible, prefer regional anesthesia to general anesthesia, though maintain a complete airway management plan regardless 1
• Counsel patients about higher failure rates of regional techniques in obese patients 1
• Calculate local anesthetic doses using lean body weight for obese patients 1
• Leave at least 5 cm of epidural catheter in the epidural space to reduce migration risk 1

Critical Pitfalls to Avoid

• Never use standard adult anesthetic dosing in elderly patients; this causes relative overdose leading to myocardial depression and delayed recovery 4
• Do not assume premedication with antihistamines or corticosteroids prevents anaphylaxis; these have no proven benefit for IgE-mediated reactions 1
• Do not delay emergency surgery for allergy investigation, but document all suspected allergens and avoid them if possible 1
• Do not combine aminoglycosides with NSAIDs or other nephrotoxic agents in patients with renal impairment 3
• Do not neglect to verify patient identity, correct procedure, and correct surgical site during the team brief 2