5.1 Preoperative Preparation, Fasting & WHO Surgical Checklist

Preoperative Preparation, Fasting & WHO Surgical Checklist

Core Clinical Principle: Perioperative patient safety hinges on meticulous preparation before the patient enters the operating theater. Preoperative nursing is not a passive administrative checklist; it is an active clinical risk-mitigation process that identifies physiological vulnerabilities, manages pharmacological interactions, upholds statutory consent principles, and guarantees surgical team verification through standardized safety checklists.

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1. Preoperative Nursing Assessment & Baseline Physiological Profiling

The fundamental goal of the preoperative nursing assessment is to establish a comprehensive baseline of the patient's physiological, psychological, and cognitive status. In Irish acute hospitals, this evaluation begins during the pre-admission assessment clinic (PAAC) or upon acute hospital admission and culminates in the final ward-based pre-theater check.

Baseline Physiological Recordings (INEWS v2)

Every surgical candidate must have a complete set of baseline vital signs recorded using the Irish National Early Warning System (INEWS v2). Establishing an accurate baseline is clinically vital because postoperative deviations can only be interpreted correctly when compared against the patient's habitual parameters:

• Respiratory Rate & Oxygen Saturation: Identifies underlying restrictive or obstructive pulmonary disease. For instance, a postoperative SpO2 of 91% on room air may indicate acute atelectasis in a previously healthy patient, whereas in a patient with severe chronic obstructive pulmonary disease (COPD) with a pre-op baseline of 90–92% on room air, it represents their baseline target range.
• Blood Pressure & Heart Rate: Chronic untreated or poorly controlled hypertension (systolic BP ≥ 160 mmHg or diastolic BP ≥ 100 mmHg) significantly increases the risk of intraoperative myocardial ischaemia, dysrhythmias, and cerebrovascular events. Conversely, baseline bradycardia in athletes must be distinguished from pharmacological or pathological conduction blocks.
• Conscious Level & Neurological Status: Documenting baseline cognitive function is essential, particularly in older adults, to enable prompt recognition of postoperative delirium, stroke, or residual anaesthetic narcosis.

Co-Morbidity Identification & Risk Stratification

A rigorous review of organ systems identifies pre-existing conditions that influence anaesthetic management and surgical recovery:

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|                   PREOPERATIVE ORGAN SYSTEM STRATIFICATION                  |
+-------------------+---------------------------------------------------------+
| Cardiovascular    | - Ischaemic heart disease, heart failure, arrhythmias   |
|                   | - Implanted pacemakers or ICDs (magnet / cautery plan)   |
|                   | - Functional exercise tolerance (climbing 2 flights)    |
+-------------------+---------------------------------------------------------+
| Respiratory       | - Asthma, COPD, active chest infection (wheeze, sputum) |
|                   | - Obstructive Sleep Apnoea (OSA) via STOP-BANG score    |
|                   | - Requirement for nocturnal CPAP in hospital            |
+-------------------+---------------------------------------------------------+
| Endocrine         | - Type 1 vs Type 2 Diabetes Mellitus; baseline HbA1c    |
|                   | - Target perioperative glucose range: 5.0–10.0 mmol/L    |
|                   | - Thyroid disorders and adrenal insufficiency           |
+-------------------+---------------------------------------------------------+
| Renal & Hepatic   | - Baseline urea, creatinine, and estimated GFR          |
|                   | - Coagulopathy, fluid retention, impaired drug clearance |
+-------------------+---------------------------------------------------------+

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2. Fasting Guidelines in Ireland: The 2-6 Rule

Preoperative fasting is essential to reduce gastric residual volume and acidity, thereby minimizing the risk of regurgitation and pulmonary aspiration of gastric contents—a catastrophic complication known as Mendelson's syndrome (chemical pneumonitis leading to severe acute respiratory distress syndrome). However, prolonged starvation is equally detrimental, inducing hypovolaemia, dehydration, electrolyte imbalances, metabolic ketoacidosis, insulin resistance, and heightened patient distress.

Irish acute hospitals operate under standardized evidence-based fasting guidelines, widely recognized as the 2-6 Rule:

[!WARNING] Clinical Trap: The "Milk in Tea" Pitfall Adding even a single splash of bovine milk or plant-based creamer to tea or black coffee immediately transforms a "clear fluid" into a solid protein/fat emulsion. Once milk is added, the required fasting window jumps from 2 hours to 6 hours. If a patient consumed tea with milk 3 hours prior to elective surgery, their surgery must be delayed to avoid fatal aspiration.

Chewing Gum, Sweets, and Medications

• Chewing Gum & Hard Boiled Sweets: Chewing gum stimulates gastric acid secretion and swallowing saliva, which increases gastric volume. Under standard Irish hospital protocols, chewing gum is prohibited for 2 hours prior to anaesthesia. If swallowed, it is treated as a solid ingestion.
• Morning Oral Medications: Prescribed, essential medications approved by the anaesthetist may be swallowed with a minimal sip of water (up to 30 mL) up to 1 hour prior to surgery.

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3. Preoperative Medication Reconciliation & Management

Medication reconciliation is a collaborative nursing and medical responsibility. Preoperative omission or inadvertent administration of regular medications can lead to surgical cancellation, uncontrolled intraoperative bleeding, or severe haemodynamic instability.

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4. Informed Consent, Capacity & Legal Principles in Ireland

Informed consent is an ethical, professional, and statutory mandate in Irish healthcare. The legal framework governing consent and capacity in Ireland is defined by common law, the Nurses and Midwives Act 2011, and the Assisted Decision-Making (Capacity) Act 2015 (fully commenced in 2023).

+-----------------------------------------------------------------------------+
|                   THE NURSING ROLE IN SURGICAL CONSENT                      |
+-----------------------------------------------------------------------------+
|                             OPERATING SURGEON                               |
| - Explains procedure, expected benefits, serious and common risks,          |
|   treatment alternatives, and consequences of non-treatment.                |
| - Formally takes and signs the legal consent document with the patient.     |
| - NON-DELEGABLE DUTY: Cannot be delegated to nursing staff.                 |
+-----------------------------------------------------------------------------+
                                      |
                                      v
+-----------------------------------------------------------------------------+
|                             REGISTERED NURSE                                |
| - Verifies consent form is signed, dated, and matches surgical booking.    |
| - Confirms patient understands the procedure and is acting voluntarily.     |
| - Witnesses patient signature (verifying identity and lack of duress).      |
| - PATIENT ADVOCATE: If patient expresses doubt or lack of understanding,    |
|   the nurse HALTS pre-op medication/transfer and alerts the surgical team.  |
+-----------------------------------------------------------------------------+

The Assisted Decision-Making (Capacity) Act 2015

The 2015 Act establishes critical statutory rules that every nurse practicing in Ireland must uphold:

1. Presumption of Capacity: Every adult is presumed to have decision-making capacity unless all practicable steps to assist them have been taken without success.
2. Functional Test of Capacity: Capacity is time-specific and decision-specific. A patient has capacity for a specific surgical decision if they can:
   • Understand the information relevant to the decision;
   • Retain that information long enough to make the decision;
   • Weigh or use that information as part of the process of making the decision; and
   • Communicate their decision (verbally, via sign language, assistive technology, or gesture).
3. Unwise Decisions: A patient with capacity has the legal right to make an "unwise" or unconventional decision (including refusing life-saving surgery), provided they understand the consequences.
4. Role of the Nurse: The Registered General Nurse never obtains surgical consent. If a patient scheduled for surgery tells the nurse, "I don't really understand why the doctor is taking out my bowel," or expresses ambivalence, the nurse must not attempt to explain the surgical technique or persuade the patient. The nurse must withhold sedative pre-medications, pause transfer to theater, and immediately contact the operating surgical team to return to the bedside, address the patient's concerns, and establish valid consent.

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5. The WHO Surgical Safety Checklist (Irish National Surgical Checklist)

The WHO Surgical Safety Checklist is mandated in Irish public hospitals through the HSE National Policy and Procedure for Safe Surgery (2022) - a document RCSI places on its minimum background reading list, directing candidates specifically to pages 9-12. (It is not an NCEC National Clinical Guideline; NCEC National Clinical Guideline No. 10 covers the management of constipation in adult patients receiving palliative care.) It structures perioperative safety communication into three distinct, non-negotiable phases:

[ PATIENT ADMISSION ]
         |
         v
+-----------------------------------------------------------------------------+
| PHASE 1: SIGN IN (Before Induction of Anaesthesia - Anaesthetic Room)        |
| - Patient confirms identity, site, procedure, and consent                   |
| - Site marked with indelible marker by operating team                       |
| - Anaesthetic machine & medication safety check completed                   |
| - Pulse oximeter on patient and functioning                                 |
| - Check: Known allergies? Difficult airway/aspiration risk?                 |
| - Blood loss risk assessed (> 500 mL in adults / > 7 mL/kg in children)?    |
| - Adequate IV access and fluids/blood products available?                   |
+-----------------------------------------------------------------------------+
         |
         v
+-----------------------------------------------------------------------------+
| PHASE 2: TIME OUT (Before Skin Incision - Operating Theater)                |
| - Entire team verbally pauses ("Sterile Cockpit" rule)                      |
| - All team members introduce themselves by name and role                     |
| - Confirm patient name, exact procedure, and correct surgical site/side     |
| - Anticipated critical events reviewed:                                     |
|     * Surgeon: operative steps, operative duration, anticipated blood loss   |
|     * Anaesthetist: specific anaesthetic concerns, resuscitation plan        |
|     * Nursing Team: sterility indicators, equipment availability, implants  |
| - Prophylactic antibiotics confirmed (administered within preceding 60 min)|
| - Essential diagnostic imaging displayed correctly                          |
+-----------------------------------------------------------------------------+
         |
         v
+-----------------------------------------------------------------------------+
| PHASE 3: SIGN OUT (Before Leaving the Operating Theater)                    |
| - Nurse verbally confirms: name of the procedure recorded                   |
| - Instrument, sponge, and needle counts confirmed correct                   |
| - Specimen labelling verified aloud (patient name, MRN, anatomical source)  |
| - Any equipment problems or malfunctions addressed                          |
| - Surgeon, anaesthetist, and nurse review key concerns for PACU recovery    |
+-----------------------------------------------------------------------------+
         |
         v
[ PACU TRANSFER ]

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6. Perioperative Venous Thromboembolism (VTE) Thromboprophylaxis

Hospital-acquired venous thromboembolism is a major cause of preventable perioperative morbidity and mortality. Surgery activates all three components of Virchow's Triad:

• Venous Stasis: Immobility on the operating table, muscle relaxants paralyzing the calf muscle pump, and venous pooling.
• Endothelial Injury: Direct surgical vessel transection, traction, retraction, and intraoperative positioning.
• Hypercoagulability: Surgical tissue trauma releasing tissue factor, activating systemic inflammatory and coagulation cascades.

Mechanical vs. Pharmacological Prophylaxis

Irish national clinical guidelines mandate an individualized VTE risk assessment upon admission, utilizing combined mechanical and pharmacological modalities: