conducting-preoperative-planning

# Conducting Preoperative Planning

Structures surgical planning with imaging review, risk stratification, and equipment/team requirements.

## Why This Skill Exists

Preoperative planning is the foundation of surgical safety. The Joint Commission's Universal Protocol requires a pre-procedure verification process, and ACS NSQIP data demonstrates that inadequate preoperative assessment correlates with higher 30-day morbidity and mortality. ASA guidelines mandate preoperative evaluation appropriate to the invasiveness of the procedure and patient comorbidity burden.

Structured preoperative planning reduces operating room cancellations (which cost institutions an estimated $1,500-$5,000 per case), prevents wrong-site surgery events, ensures appropriate blood products are available, and identifies patients who need preoperative medical optimization. This skill codifies the planning process to ensure nothing is missed between the surgical decision and the first incision.

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## Checkpoint A: Pre-Draft Intake (Mandatory)

1. What is the planned procedure and surgical approach? **Default: [VERIFY — obtain from surgeon]**
2. What is the patient's ASA physical status classification? **Default: ASA II**
3. Has the patient had prior surgeries in the same anatomic region? **Default: no**
4. What is the patient's current anticoagulation status? **Default: none**
5. Does the patient have allergies relevant to anesthetic agents, antibiotics, or latex? **Default: NKDA**
6. What imaging has been obtained and reviewed? **Default: [VERIFY]**
7. Is there a need for specialized equipment (e.g., robotic platform, intraoperative imaging, cell saver)? **Default: standard equipment**
8. What is the patient's BMI? (Relevant to positioning, airway management, and dosing.) **Default: [VERIFY]**

### Documents to Request

- Complete H&P (within 30 days per CMS requirements, updated within 24 hours of surgery)
- Relevant imaging studies with radiology reports
- Cardiology clearance (if indicated by RCRI score or active cardiac conditions)
- Pulmonary function tests (if thoracic surgery or significant pulmonary disease)
- Current medication list with last doses of anticoagulants
- Prior operative reports (for revision or re-operative cases)
- Laboratory results: CBC, BMP, coagulation studies, type and screen/crossmatch
- Anesthesia pre-assessment documentation

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## Step 1: Patient Risk Stratification

Apply standardized risk assessment tools:

| Tool | Application | Scoring |
|---|---|---|
| ASA Physical Status | Global fitness for anesthesia | I (healthy) to VI (brain dead) |
| Revised Cardiac Risk Index (RCRI) | Cardiac risk for non-cardiac surgery | 0-6 points; ≥3 = elevated risk |
| ACS NSQIP Surgical Risk Calculator | Procedure-specific morbidity/mortality | Percent risk for 17 outcomes |
| Caprini Score | VTE risk stratification | 0-2 low, 3-4 moderate, ≥5 high |
| STOP-BANG | Obstructive sleep apnea screening | ≥3 = high risk for OSA |

For each tool applied, record:
- Score and interpretation
- Whether the score triggers additional workup (e.g., RCRI ≥3 → consider cardiology consultation)
- Patient-specific modifying factors not captured by the tool

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## Step 2: Imaging Review and Anatomic Planning

Structure the imaging review as follows:

1. **Modality and date** — List each study reviewed (CT, MRI, ultrasound, plain film, angiography) with date obtained.
2. **Key anatomic findings** — Describe relevant anatomy that will affect the surgical approach (e.g., aberrant hepatic artery, renal vein anomaly, extent of tumor involvement).
3. **Measurements** — Record sizes of lesions, distances from critical structures, vessel diameters.
4. **Approach implications** — Document how imaging findings influence port placement, incision planning, or need for vascular control.
5. **Additional imaging needed** — Flag gaps (e.g., "CT angiography recommended to delineate mesenteric vascular anatomy prior to pancreaticoduodenectomy").

For complex cases, include annotated imaging screenshots or 3D reconstruction references.

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## Step 3: Equipment, Instrumentation, and Team Requirements

Build the OR resource checklist:

- **Instrumentation trays**: List specific trays by name (e.g., major laparotomy set, vascular set, thoracotomy tray)
- **Energy devices**: Harmonic scalpel, LigaSure, argon beam coagulator, monopolar/bipolar
- **Specialized equipment**: Robotic system (which platform, arm count), C-arm fluoroscopy, intraoperative ultrasound, neuromonitoring, cell saver
- **Implants and prosthetics**: Mesh type and size, stents, vascular grafts — have alternates available
- **Blood products**: Type and screen vs. crossmatch; number of units to have available
- **Positioning aids**: Bean bag, Allen stirrups, shoulder roll, Mayfield head clamp
- **Team composition**: Surgeon, first assistant, scrub tech vs. scrub nurse, circulating nurse, anesthesia team, additional specialties on standby (e.g., vascular surgery, interventional radiology)

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## Step 4: Anticoagulation and Medication Management

Create a preoperative medication plan:

| Medication Class | Action | Timing |
|---|---|---|
| Warfarin | Hold | 5 days preop; check INR day before |
| DOACs (apixaban, rivarelbaan) | Hold | 48-72 hours depending on renal function |
| Aspirin | Continue or hold | Per AHA/ACC guidelines; hold 7 days for neurosurgery |
| Clopidogrel | Hold | 5-7 days preop |
| Metformin | Hold | Day of surgery; resume when tolerating diet |
| ACE inhibitors/ARBs | Hold | Morning of surgery (risk of intraoperative hypotension) |
| Beta-blockers | Continue | Do not abruptly discontinue |
| Insulin | Reduce dose | Half long-acting dose night before; hold short-acting day of |

Document bridging anticoagulation plan if indicated (e.g., LMWH bridge for mechanical valve patients).

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## Step 5: Preoperative Optimization Checklist

Before confirming the surgery date, verify:

- [ ] Hemoglobin A1c < 8% for elective cases (ACS and Endocrine Society guidance)
- [ ] Smoking cessation ≥4 weeks (reduces wound complications per Cochrane evidence)
- [ ] Nutritional status assessed; albumin ≥3.0 g/dL (ACS NSQIP predictor)
- [ ] Dental clearance obtained (if cardiac surgery or implant placement)
- [ ] MRSA screening completed (if institutional protocol requires)
- [ ] Bowel prep ordered (if colorectal surgery per ERAS guidelines)
- [ ] Preoperative surgical site marking completed by operating surgeon
- [ ] Consent form signed with correct procedure, laterality, and surgeon name

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## Checkpoint B: Post-Draft Alignment (Mandatory)

1. Are all risk scores calculated and documented with implications?
2. Has imaging been reviewed and anatomic concerns addressed in the surgical plan?
3. Is the anticoagulation management plan explicit with hold/resume dates?
4. Does the equipment list match the planned procedure and any contingencies?
5. Are all preoperative optimization criteria met or exceptions documented?

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## Quality Audit

- [ ] ASA classification assigned and documented
- [ ] RCRI score calculated for patients ≥45 years or with cardiac history
- [ ] ACS NSQIP risk calculator completed for major surgery
- [ ] Caprini VTE score calculated with prophylaxis plan
- [ ] All relevant imaging listed with dates and key findings summarized
- [ ] Equipment and instrumentation checklist generated
- [ ] Blood product plan documented (type and screen vs. crossmatch with units)
- [ ] Medication management plan documented with hold/resume dates
- [ ] Preoperative labs reviewed and within acceptable ranges
- [ ] H&P completed within 30 days and updated within 24 hours of surgery
- [ ] Surgical consent signed with correct laterality
- [ ] Operating surgeon has marked the surgical site
- [ ] Anesthesia pre-assessment completed

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## Guidelines

1. The H&P must be completed within 30 days of surgery per CMS CoP and updated within 24 hours — no exceptions for elective cases.
2. Never proceed with a planned case if the type and screen is expired; repeat if older than 72 hours per institutional blood bank policy.
3. For patients on anticoagulation, always document the indication for anticoagulation and the rationale for the hold/bridge decision.
4. Involve anesthesia early for patients with ASA ≥ III, anticipated difficult airway, or significant cardiac/pulmonary disease.
5. For re-operative cases, obtain and review all prior operative reports — adhesion density and altered anatomy significantly affect planning.
6. Document a contingency plan for the most likely intraoperative complication (e.g., "if unable to achieve laparoscopic access due to adhesions, will convert to midline laparotomy").
7. Ensure SCIP/CMS core measures compliance: appropriate antibiotic selection and timing, VTE prophylaxis plan, and normothermia maintenance plan.