Thoracic Surgery Preoperative Preparation: Comprehensive Checklist

Preoperative Optimization for Thoracic Surgery

Thoracic surgery (lung resection, esophagectomy, mediastinal tumor, pleural disease) demands meticulous preparation to minimize pulmonary complications—the leading cause of morbidity.

10-Point Preoperative Protocol

1. Comprehensive Assessment
   • History: Smoking (pack-years), COPD, CAD, prior thoracic RT/chemo, immunosuppression, functional status.
   • Exam: Focused cardiopulmonary; frailty screen (gait speed, grip strength).
   • Diagnostics: CXR, CT chest/abdomen, PFTs (spirometry, DLCO, lung volumes), CPET (if high risk), ECG, Echo (if indicated), CBC, BMP, coagulation, type/screen.
2. Risk Stratification
   • Predicted postoperative (ppo) FEV₁ and DLCO >40% = low risk; 30–40% = moderate; <30% = high (consider non-surgical alternatives).
   • STS/ESCVS risk models for mortality/morbidity.
3. Smoking Cessation
   • Mandatory ≥4 weeks preop (ideally 8+). Reduces pulmonary complications by 50%.
   • Offer varenicline, bupropion, NRT, counseling. Verify with cotinine if doubtful.
4. Pulmonary Optimization
   • Bronchodilator optimization (LAMA/LABA/ICS per GOLD).
   • Prehab: Inspiratory muscle training (IMT), aerobic conditioning, airway clearance techniques, incentive spirometry education—start 2–4 weeks preop.
   • Treat active infection; delay elective surgery if exacerbation.
5. Medication Management
   • Continue: Beta-blockers, statins, inhaled therapies, most cardiac meds.
   • Hold: Antiplatelets (per surgeon), anticoagulants (bridge per protocol), SGLT2i (3 days), MAOIs (2 wks).
   • Steroid stress dosing if on chronic steroids.
6. Nutritional Optimization
   • Screen (MUST, NRS-2002). If malnourished: oral supplements, consider delay for 7–14 days of aggressive nutrition.
   • Carbohydrate loading (clear CHO drink 2 hrs preop) per ERAS.
7. Anemia Management
   • Target Hb >13 g/dL (men), >12 g/dL (women). IV iron ± ESA if time permits (≥2–4 wks).
8. Skin Preparation
   • CHG shower night before and morning of surgery.
   • No shaving; clipping if needed in OR.
9. Psychosocial Support
   • Screen for anxiety/depression (PHQ-2, GAD-2).
   • Preop counseling, expectation setting, advance directives review.
10. Informed Consent & Logistics
    • Procedure-specific risks: air leak, bleeding, chylothorax, recurrent laryngeal nerve injury, atrial fibrillation, empyema.
    • NPO: Solids 8 hrs, clear liquids 2 hrs.
    • Preop antibiotics (cefazolin 2g IV ≤60 min incision), DVT prophylaxis (sequentials ± chemoprophylaxis per protocol).

Multidisciplinary Coordination

Thoracic surgeon, anesthesiologist, pulmonologist, nurse navigator, PT/OT, nutrition, social work, palliative care (if indicated). Tumor board for malignancies.

Systematic preparation reduces complications, shortens LOS, and improves long-term functional outcomes.