Standard Preoperative Orders for Adult Surgical Patients
Adult surgical patients should receive a standardized preoperative order set that includes: patient education, medical optimization with specific attention to smoking/alcohol cessation, fasting guidelines (clear fluids until 2 hours, solids until 6 hours before surgery), carbohydrate loading, antibiotic prophylaxis within 60 minutes of incision, VTE prophylaxis, glucose control targeting <180 mg/dL, and avoidance of routine sedative premedication. 1, 2
Preoperative Patient Education and Counseling
Provide comprehensive preoperative education in oral, written, or pictorial format to both patient and caregiver 1. This reduces anxiety, pain, nausea/vomiting, and improves satisfaction 1. Education must cover:
- Expected surgical and anesthetic care plan
- Patient's role in recovery
- Discharge planning and emergency contacts
- Transport arrangements (critical in resource-limited settings)
Medical Optimization
Screening Requirements
Screen all patients for 1:
- Smoking and alcohol use
- Hypertension and diabetes
- Anemia and nutritional status
- Delirium risk (especially elderly)
- In high HIV prevalence areas: HIV testing
Specific Interventions
Smoking and Alcohol Cessation: Stop 4-6 weeks before elective surgery 3, 2. The AATS recommends minimum 4 weeks cessation 3. This significantly reduces postoperative morbidity.
Nutritional Optimization: Patients with hypoalbuminemia (<2.5 g/mL) should have surgery postponed for 7-10 days of enteral nutrition if safely delayable 4, 3. Consider protein supplementation and oral nutritional supplements.
Glucose Control: Target preoperative glucose <200 mg/dL. Institute continuous insulin infusion if glucose >200 mg/dL preoperatively 4. Maintain glucose <180 mg/dL during surgery and for 24 hours postoperatively 4, 3.
Infection Treatment: Treat all distant extrathoracic infections before surgery if procedure can be safely delayed 4.
Preoperative Fasting Guidelines
Clear fluids allowed until 2 hours before induction; solids until 6 hours before induction 2, 1, 2. After full meals (meat, fatty/fried foods), 8+ hours may be required 1. This is Level II evidence with strong recommendation 2.
Carbohydrate Loading: Administer 400 mL of 12.5% carbohydrate drink (50g CHO, osmolality <300 mOsm/kg) 2 hours before surgery 2, 1. This reduces:
- Preoperative thirst, hunger, anxiety
- Postoperative insulin resistance
- Nitrogen/protein losses
- Hospital length of stay
For diabetic patients, carbohydrate loading can be given with diabetic medication 2.
Infection Prevention Protocol
MRSA/MSSA Screening and Decolonization
Obtain nasal swabs or PCR testing on all surgical patients 4, 3. This is Class I, Level A evidence.
For MRSA/MSSA positive patients:
- Mupirocin 2% nasal ointment: 1 application each naris twice daily for 5 days 3
- Chlorhexidine gluconate (CHG) 4% shower/bath daily for 5 days before surgery 3
- If unable to shower: 2% CHG wipes from neck to ankles (including arms) 3
All patients (regardless of screening):
- CHG 4% shower/bath evening before surgery 4, 3
- In preoperative holding: nasal antisepsis with 5% povidone-iodine 3
- Wipe with CHG 2% wipes from neck to ankles before surgery 3
Antibiotic Prophylaxis
Weight-based cephalosporin (cefazolin 2g IV) within 60 minutes of incision 4, 3, 1, 5. This is Class I, Level A evidence.
Redosing: Every 3-4 hours for prolonged procedures 3:
Duration: Maximum 24-48 hours postoperatively 4, 1. Do NOT continue beyond 48 hours 4.
MRSA-positive patients: Add vancomycin 15 mg/kg IV (infused over 60-120 minutes, completed before incision) to cephalosporin 4, 3. Do NOT use vancomycin as sole prophylactic agent 4.
Beta-lactam allergy: Clindamycin 900 mg IV + gentamicin 5 mg/kg/day 5
Venous Thromboembolism Prophylaxis
All patients require combination prophylaxis 1, 2:
- Well-fitted compression stockings
- Intermittent pneumatic compression devices
- Low molecular weight heparin (LMWH) or unfractionated heparin
Extended prophylaxis for 28 days in colorectal cancer patients 2
Preoperative Medication Management
Avoid Routine Sedative Premedication
Do NOT routinely administer long- or short-acting sedatives 2, 1, 2. This is high-level evidence with strong recommendation. Sedatives delay immediate postoperative recovery, impair mobility, and increase delirium risk.
If necessary for severe anxiety: short-acting IV agents (fentanyl + small incremental midazolam or propofol) titrated carefully by anesthesiologist 2.
Special Medication Considerations
GLP-1 Receptor Agonists: Specific withholding protocols required (see specialized guidelines) 6
SGLT2 Inhibitors: Omit the day before and day of procedure to prevent ketoacidosis 6. Ensure adequate hydration and avoid prolonged fasting. Consider glucose-containing IV fluids if prolonged fasting unavoidable.
For patients on very low-energy/liver reduction diets: Stop SGLT2 inhibitors at diet commencement 6
Bowel Preparation
Do NOT routinely use mechanical bowel preparation for colonic or gynecologic surgery 1, 2. This is high-level evidence. Mechanical bowel prep causes:
- Preoperative dehydration
- Electrolyte abnormalities
- Patient dissatisfaction
- Interrupted sleep
- Increased anxiety
Exception: May consider for low rectal surgery or planned ostomy creation.
Additional Preoperative Orders
Hair Removal
Clip hair only if necessary, according to guidelines 3. Change bed linen and patient gown after clipping.
Skin Preparation
Use alcohol-containing chlorhexidine product (ChloraPrep) per manufacturer instructions 3. Allow minimum 3 minutes drying time 3.
PONV Prophylaxis
Assess PONV risk. High-risk patients (≥2 risk factors) require 2-3 antiemetics using multimodal approach 1, 2.
Surgical Safety Checklist
Mandatory use of WHO 19-item checklist with three pause points 1. This is high-level evidence with strong recommendation and significantly reduces perioperative morbidity/mortality.
Common Pitfalls to Avoid
- Do NOT use bone wax on sternal edges (Class III recommendation for cardiac surgery) 4
- Do NOT routinely place nasogastric tubes or remove before anesthesia reversal if placed 2
- Do NOT use vancomycin as sole antibiotic prophylaxis 4
- Do NOT continue prophylactic antibiotics beyond 24-48 hours 4, 1
- Do NOT enforce midnight NPO - this is outdated and harmful 2
Documentation Requirements
Ensure preoperative orders include:
- Consent obtained and reviewed
- Allergy documentation
- ASA physical status classification
- Laboratory/ECG/imaging results reviewed
- Medication reconciliation completed
- Discharge planning initiated
- Emergency contact information verified