No products in the cart.
MODULE 22: THE HOSPITAL ECOSYSTEM
Section 5.2: Anatomy of a Pre-Surgical Order Set
A Pharmacist’s Step-by-Step Verification Protocol for ensuring patient safety before, during, and after any invasive procedure.
SECTION 5.2
Anatomy of a Pre-Surgical Order Set
A Pharmacist’s Step-by-Step Verification Protocol.
Introduction: Your Role as the Final Clinical Gatekeeper
The pre-surgical order set is one of the most complex and high-stakes documents in hospital medicine. It is a symphony of coordinated commands that sets in motion the plan for a patient’s entire perioperative journey. It is also a minefield of potential medication errors. An incorrectly timed antibiotic, a missed anticoagulant hold, or a wrongly continued home medication can have devastating consequences. The “Why” of this masterclass is to empower you, the pharmacist, to deconstruct this complex document with the precision of a forensic investigator. You are not just a checker; you are the final clinical gatekeeper. Your systematic, protocol-driven verification is the last and most critical safety net that protects the patient from harm.
This section will provide you with a step-by-step protocol for dissecting any pre-procedural order set. We will break it down into four critical pillars: the foundational patient and procedure data, the clotting plan, the infection plan, and the home medication plan. For each pillar, we will provide a deep dive into the evidence, the common pitfalls, and your specific, actionable interventions. By the end of this masterclass, you will be able to approach any pre-surgical review with the confidence and competence of a seasoned perioperative pharmacy specialist.
5.2.1 The Foundation: Patient & Procedure Verification
Ensuring the bedrock of your review is solid.
The “Why”: Garbage In, Garbage Out
Before you can analyze the complexities of the medication plan, you must first verify the integrity of the basic data upon which that plan is built. If you perform a brilliant medication analysis based on an incorrect weight or an incomplete allergy list, your recommendations will be flawed and potentially dangerous. This is your first and most fundamental responsibility.
5.2.2 The Clotting Plan: VTE Prophylaxis Verification
Balancing the risk of clots vs. the risk of bleeding.
The “Why”: A High-Stakes Balancing Act
Surgery and immobility place patients at high risk for VTE (DVT/PE). The agents we use to prevent clots, however, increase the risk of surgical bleeding. Your role as the pharmacist is to act as the master regulator of this delicate balance, ensuring the patient receives the right prophylactic agent, at the right dose, and at the right time.
The Absolute Rule of Neuraxial Anesthesia
This is the highest-stakes scenario in VTE prophylaxis. A patient receiving an epidural or spinal anesthesia cannot receive pharmacologic VTE prophylaxis on a normal schedule due to the risk of a spinal hematoma. You are the final, non-negotiable safety check.
- Pre-Procedure: Ensure the last dose of prophylactic LMWH was given at least 12 hours prior to the neuraxial block (24 hours for treatment doses).
- Post-Procedure: Ensure the first dose of LMWH is not given until at least 4 hours after the epidural catheter has been removed.
5.2.3 The Infection Plan: Antimicrobial Prophylaxis Masterclass
Dose, Timing, and Selection for Surgical Site Infection (SSI) Prevention.
The “Why”: The Critical 60-Minute Window
The “Why” of antimicrobial prophylaxis is to prevent SSIs by ensuring bactericidal concentrations of an appropriate antibiotic are in the tissue *at the time of the first surgical incision*. The evidence is clear: the antibiotic must be administered within the 60 minutes prior to incision to be effective. Your role is to be the master of this critical timing, as well as the expert on drug selection and dosing.
Master Table: SSI Prophylaxis by Procedure Type
| Procedure Type | First-Line Recommended Agent & Dose | Alternative for Beta-Lactam Allergy |
|---|---|---|
| Cardiac / Orthopedic / Vascular | Cefazolin 2g IV (3g if ≥120 kg) |
Vancomycin OR Clindamycin |
| Colorectal Surgery | Cefoxitin OR Ceftriaxone + Metronidazole |
Clindamycin + (Gentamicin or Aztreonam) |
Mastering the Beta-Lactam Allergy Interview
A vague penicillin “allergy” often leads to the unnecessary use of broad-spectrum agents. You are the detective who must clarify the allergy. If the patient’s reaction was NOT hives, swelling, difficulty breathing, or anaphylaxis, it is generally safe to use a cephalosporin. Your intervention here prevents overuse of vancomycin.
5.2.4 The Home Medication Plan: The Critical “Continue, Hold, Modify” Orders
Navigating the most complex and error-prone aspect of perioperative care.
The “Why”: Preventing Pharmacological Chaos
Answering which drugs to continue, hold, or modify incorrectly can lead to hypertensive crises, dangerous hypoglycemia, or life-threatening bleeding. You are the ultimate expert and safety officer in this domain.
Deep Dive: Periprocedural Home Medication Management
I. Cardiovascular Medications
| Medication Class / Agent | Recommendation | Rationale & Your Critical Intervention |
|---|---|---|
| Beta-Blockers (Metoprolol, Atenolol, etc.) |
CONTINUE. Give the morning of surgery. | Rationale: Abrupt withdrawal causes rebound tachycardia/hypertension. This is a major quality metric. Your Intervention: This is a “never-miss” check. You must verify that the patient has received their morning dose. If held by mistake, you must alert the anesthesia/surgical team. |
| ACE Inhibitors / ARBs (Lisinopril, Losartan, etc.) |
HOLD on the morning of surgery. | Rationale: Can cause refractory hypotension during anesthesia induction. Your Intervention: Verify the morning dose was held. If given by mistake, this is critical information to relay to the anesthesia team. |
| Diuretics (Furosemide, HCTZ, etc.) |
HOLD on the morning of surgery. | Rationale: To prevent dehydration and electrolyte abnormalities (especially hypokalemia) in a patient who is NPO. |
II. Anticoagulant & Antiplatelet Medications
| Agent | Recommendation | Rationale & Your Critical Intervention |
|---|---|---|
| Warfarin | HOLD 5 days prior to surgery. | Rationale: Allows INR to normalize (<1.5) to minimize surgical bleeding. Your Intervention: Verify the hold and check the pre-op INR. If INR is still elevated, alert the team; the case may need to be postponed or reversal with Vitamin K may be needed. |
| DOACs (Apixaban, Rivaroxaban) |
HOLD 2-3 days prior (agent/renal function dependent). | Rationale: To allow drug clearance and minimize bleeding risk. Your Intervention: Your most critical role is **renal function assessment**. A patient with poor renal function needs a longer hold period. You must calculate the CrCl and verify the hold duration is appropriate. |
| Antiplatelets (Clopidogrel, Ticagrelor) |
HOLD 5-7 days prior to surgery. | Rationale: Allows for new, functional platelets to be produced. Your Intervention: For patients with recent drug-eluting stents (<1 year), stopping DAPT poses a high risk of stent thrombosis. You must flag this for a cardiology discussion to weigh the risks. |
III. Diabetic Medications
| Agent | Recommendation | Rationale & Your Critical Intervention |
|---|---|---|
| Oral Agents (Metformin, SGLT2i, etc.) |
HOLD on the morning of surgery. | Rationale: Risk of lactic acidosis with metformin if AKI develops; risk of euglycemic DKA with SGLT2 inhibitors due to surgical stress and NPO status. |
| Basal Insulin (Glargine, Detemir) |
MODIFY. Give 50-80% of the usual evening/morning dose. | Rationale: Provides basal coverage to prevent hyperglycemia/ketosis but reduces the dose to prevent hypoglycemia while NPO. |
| Prandial Insulin (Aspart, Lispro) |
HOLD morning of surgery. | Rationale: The patient is NPO. Giving mealtime insulin without food will cause severe hypoglycemia. This is a critical safety check. |
The Final Word: You Are the Perioperative Pharmacist
Verifying a pre-surgical order set is one of the highest-impact activities a hospital pharmacist performs. It is a systematic process of balancing the risk of clots vs. bleeding, infection vs. resistance, and therapeutic continuity vs. procedural complications. You are not just checking boxes; you are performing a comprehensive, patient-specific risk assessment.
Your detailed attention to the clotting plan, infection plan, and home medication plan is the invisible layer of safety that protects every patient who goes to the operating room. It is a profound professional responsibility and a cornerstone of your value to the healthcare team.
