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1
Sinclair, C. M. The report of the Manitoba Pediatriac [sic] Cardiac Surgery Inquest: An inquiry into twelve deaths at the Winnipeg Health Sciences Centre in 1994. [Winnipeg]: Provincial Court of Manitoba, 2000.
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2
Pepper, John. Cardioprotection During Cardiac Surgery. Oxford University Press, 2011. http://dx.doi.org/10.1093/med/9780199544769.003.0007.
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• Overall early mortality for cardiac surgery is low at 2–3% but in high risk patients it can be high as 10–15%• The demography of cardiac surgical patients is changing to older and sicker patients• Myocardial ischaemia-reperfusion injury and the systemic inflammatory response are closely related• Several pharmacological agents that have been demon-strated to confer cardioprotection in the experimental setting have been applied to the clinical setting of cardiac surgery. However, the transfer of these findings from the bench to the bedside has been largely disappointing• Potential cardioprotective strategies include pharma-cological agents such as adenosine, and mechanical interventional strategies such as acute normovolaemic haemodilution and remote ischaemic preconditioning.
3
Brown, Jeremiah R., and Chirag R. Parikh. Cardiovascular surgery and acute kidney injury. Edited by Norbert Lameire. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199592548.003.0245.
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Over the last decade, cardiac surgery-associated acute kidney injury (AKI) has been recognized as a frequent adverse event following cardiac surgery. In this clinical context and others, AKI has been strongly associated with increased morbidity, mortality, and length of hospitalization. These adverse events that accompany AKI have been shown to be directly proportional to the magnitude of the peak rise in serum creatinine and the duration of AKI making AKI a costly complication and a target for prevention in hospitalized patients around the world. This chapter discusses the subsequent healthcare costs, utilization, mortality, and morbidity that follow subtle changes in serum creatinine known as AKI in the perioperative setting of cardiac surgery.
4
Balik, Martin. Perioperative cardiac care of the high-risk non-cardiac patient. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199687039.003.0076.
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Non-cardiac surgery conveys a cardiac risk related to the status of the patient’s cardiovascular system. Cardiac-related risk of surgery can be assessed by integrating the risk and urgency of the procedure with cardiovascular risk factors, which include age, ischaemic heart disease, heart failure, stroke, diabetes mellitus, chronic obstructive pulmonary disease, and renal dysfunction. An individual assessment can include simple multivariate scoring systems, developed with the aim of evaluating cardiac risk prior to non-cardiac surgery. Patient assessment can be extended for indicated additional tests. The indications for further cardiac testing and treatments are the same as in the non-operative setting, but their timing is dependent on the urgency of surgery, and patient-specific and surgical risk factors. A delay in surgery, due to the use of both non-invasive and invasive preoperative testing, should be limited to those circumstances in which the results of such tests will clearly affect patient management. In high-risk patients, the result of the cardiac assessment helps to choose adequate perioperative monitoring and to indicate for an intensive care unit stay perioperatively. Chronic medications can be adjusted, according to the current knowledge on perioperative management. Drugs with the potential to reduce the incidence of post-operative cardiac events and mortality include beta-blockers, statins, and aspirin. Chronic platelet anti-aggregation and anticoagulation therapies have to be adapted by weighing the risk of bleeding against the risk of thrombotic complications.
5
Balik, Martin. Perioperative cardiac care of the high-risk non-cardiac patient. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199687039.003.0076_update_001.
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Non-cardiac surgery conveys a cardiac risk related to the status of the patient’s cardiovascular system. Cardiac-related risk of surgery can be assessed by integrating the risk and urgency of the procedure with cardiovascular risk factors, which include age, ischaemic heart disease, heart failure, stroke, diabetes mellitus, chronic obstructive pulmonary disease, and renal dysfunction. An individual assessment can include simple multivariate scoring systems, developed with the aim of evaluating cardiac risk prior to non-cardiac surgery. Patient assessment can be extended for indicated additional tests. The indications for further cardiac testing and treatments are the same as in the non-operative setting, but their timing is dependent on the urgency of surgery, and patient-specific and surgical risk factors. A delay in surgery, due to the use of both non-invasive and invasive preoperative testing, should be limited to those circumstances in which the results of such tests will clearly affect patient management. In high-risk patients, the result of the cardiac assessment helps to choose adequate perioperative monitoring and to indicate for an intensive care unit stay perioperatively. Chronic medications can be adjusted, according to the current knowledge on perioperative management. Drugs with the potential to reduce the incidence of post-operative cardiac events and mortality include beta-blockers, statins, and aspirin. Chronic platelet anti-aggregation and anticoagulation therapies have to be adapted by weighing the risk of bleeding against the risk of thrombotic complications.
6
Balik, Martin. Perioperative cardiac care of the high-risk non-cardiac patient. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199687039.003.0076_update_002.
Full textAbstract:
Non-cardiac surgery conveys a cardiac risk related to the status of the patient’s cardiovascular system. Cardiac-related risk of surgery can be assessed by integrating the risk and urgency of the procedure with cardiovascular risk factors, which include age, ischaemic heart disease, heart failure, stroke, diabetes mellitus, chronic obstructive pulmonary disease, and renal dysfunction. An individual assessment can include simple multivariate scoring systems, developed with the aim of evaluating cardiac risk prior to non-cardiac surgery. Patient assessment can be extended for indicated additional tests. The indications for further cardiac testing and treatments are the same as in the non-operative setting, but their timing is dependent on the urgency of surgery, and patient-specific and surgical risk factors. A delay in surgery, due to the use of both non-invasive and invasive preoperative testing, should be limited to those circumstances in which the results of such tests will clearly affect patient management. In high-risk patients, the result of the cardiac assessment helps to choose adequate perioperative monitoring and to indicate for an intensive care unit stay perioperatively. Chronic medications can be adjusted, according to the current knowledge on perioperative management. Drugs with the potential to reduce the incidence of post-operative cardiac events and mortality include beta-blockers, statins, and aspirin. Chronic platelet anti-aggregation and anticoagulation therapies have to be adapted by weighing the risk of bleeding against the risk of thrombotic complications.
7
Taggart, David, and Yasir Abu-Omar. Heart surgery. Edited by Patrick Davey and David Sprigings. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199568741.003.0098.
Full textAbstract:
Cardiac surgery is still a relatively young specialty, having been developed only in the latter half of the twentieth century with the introduction of extracorporeal circulation or ‘cardiopulmonary bypass’ (CPB). This initiated the era of open heart surgery, initially allowing the repair of congenital heart defects, then valve replacements, coronary artery bypass grafting (CABG), and, finally, heart transplantation. Over the last two decades, improvements in medical, anaesthetic, and surgical management of patients, allied to refinements in extracorporeal perfusion technology, have resulted in a decreasing mortality and morbidity from heart surgery despite the advanced age and significant comorbidity of many patients. Today, heart surgery continues to improve the prognosis and quality of lives of patients around the world. Surgical techniques and technologies continue to evolve and recent years have witnessed the emergence of, amongst others, the use of long-lasting conduits for CABG procedures, beating-heart (‘off-pump’) surgery, the use of minimally invasive and robotic techniques, and long-term mechanical circulatory support.
8
AlJaroudi, Wael. Risk Assessment Before Noncardiac Surgery. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199392094.003.0014.
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Perioperative risk assessment is essential in screening patients before noncardiac surgery. Cardiovascular complications such as fatal and non-fatal myocardial infarction (MI), ventricular arrhythmia, pulmonary edema, and stroke are important in-hospital causes of morbidity and mortality intra and post-operatively. The optimal approach is to identify patients at increased risk so that appropriate testing and therapeutic interventions are undertaken a priori to minimize such risk. The initial preoperative evaluation includes identification of surgery-specific risk, patient exercise functional capacity and clinical risk profile. Patients with major predictors of events such as acute coronary syndromes, recent MI, unstable arrhythmia, and severe valvular disease warrant further management and optimization that often lead to delaying surgery. Those with three or more predictors (history of ischemic heart disease, compensated heart failure, diabetes, renal insufficiency, or history of cerebrovascular disease) undergoing high- risk surgery often require stress testing. Although data from randomized prospective trials are lacking, numerous studies have demonstrated the utility of myocardial perfusion imaging (MPI) for determination of perioperative cardiac risk. The goal of this chapter is to review the use of MPI for preoperative risk assessment and the recommendations from the current guidelines. The focus will be on short-term and long-term prognosis including special groups such as after coronary stenting and before vascular surgery, liver and renal transplantation.
9
AlJaroudi, Wael. Myocardial Perfusion Imaging Before and After Cardiac Revascularization. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199392094.003.0015.
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Coronary artery disease (CAD) remains the leading cause of morbidity and mortality worldwide. While the burden of the disease remains high, the rates of death attributable to CAD have declined by almost a third between 1998 and 2008. In patients with stable ischemic heart disease (SIHD), data supporting survival benefit from coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI) versus no revascularization are outdated with the recent advancement in medical therapy. Over the years, myocardial perfusion imaging (MPI) has played a significant role in detecting ischemic burden, risk stratifying patients and guiding physicians to the best treatment strategy. Contrary to data from other trials, the role of stress MPI has been downplayed in more contemporary randomized clinical trial that failed to show that ischemic burden identifies the ideal candidate for revascularization or carries incremental prognostic value. Hence, there is an equipoise on the role of MPI in the management of patients prior to revascularization. The role of stress MPI post-revascularization has also been evaluated in multiple studies, mostly done in the last decade or prior. The guidelines advocate against routine stress MPI in asymptomatic patients (unless 5 years or more post-CABG), but allows it in the presence or recurrence of symptoms. The current chapter will review the data on survival benefit from revascularization, complementary role of stress MPI in selecting the appropriate candidate for revascularization, prognostic value of ischemic versus atherosclerotic burden, role of MPI post revascularization, updated guidelines and proposed algorithms to guide the treating physicians.
10
Hert, Stefan De, and Patrick Wouters. Heart disease and anaesthesia. Edited by Philip M. Hopkins. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199642045.003.0083.
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Cardiovascular disease is a leading cause of mortality. Hypertension is one of the major risk factors for cardiovascular disease. Classically, hypertension is subdivided according to the aetiology into primary and secondary hypertension. Ischaemic heart disease constitutes a major concern for perioperative morbidity and mortality. Therefore important efforts are directed towards the identification of the patient at risk for perioperative cardiac complications and towards optimization of the cardiac status before intervention. Cardiac rhythm disturbances fall into two general classes: bradyarrhythmias and tachyarrhythmias. While single isolated extra or skipped heart beats are usually harmless, serious heart rhythm disturbances are caused by an underlying heart disease. Valvular heart disease refers to any disease process involving any valve of the heart. Valvular heart disease may be as a result of a stenosis or an insufficiency of the valve, or both. It is characterized by pressure or volume overload to the atria and the ventricles (or both). It is this overload that will be responsible for the symptomatology of the disease. As a result of significant advances in prenatal diagnosis, cardiac surgery, interventional cardiology, and perioperative medicine, about 90% of infants with congenital heart disease are currently expected to reach adulthood. Management of these patients requires insight into (1) the primary cardiac lesion, (2) the type of cardiac surgical or interventional procedure(s) performed, (3) the presence of residual defects or sequelae, (4) the current physical status (i.e. balanced vs unbalanced), (5) the effects of surgery or pregnancy on their pathophysiological condition, and (6) the presence of comorbidity.
11
Kreeger, Renee Nierman, and James P. Spaeth. Tetralogy of Fallot. Oxford University Press, 2013. http://dx.doi.org/10.1093/med/9780199764495.003.0032.
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Patients with congenital heart disease are frequently encountered by the pediatric anesthesiologist for non-cardiac surgery. Fortunately, the majority of these patients have already undergone definitive repair of their cardiac lesions and can often be managed using traditional anesthetic methods. However, given the known association of congenital heart disease with other congenital malformations and syndromes, there is a relatively high likelihood that a pediatric anesthesiologist will encounter a situation involving a child with an unrepaired lesion. With the reported increased mortality rate for patients with complex cardiac lesions undergoing non-cardiac procedures (see Chapter 30), an understanding of the pathophysiology and anatomy, as well as the potential effects of the anesthetic medications and techniques chosen, is paramount to their successful care.
12
Merry, Alan F., Simon J. Mitchell, and Jonathan G. Hardman. Hazards in anaesthetic practice: general considerations, injury, and drugs. Edited by Jonathan G. Hardman. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199642045.003.0044.
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The hazards of anaesthesia should be considered in the context of the hazard of surgery and of the pathology for which the surgery is being undertaken. Anaesthesia has become progressively safer since the successful demonstration of ether anaesthesia in Boston, Massachusetts, United States in 1846 and the first reported death under anaesthesia in 1847. The best estimation of the rate of anaesthesia-related mortality comes from the anaesthesia mortality review committees in Australia and New Zealand, where data have been collected under essentially consistent definitions since 1960, and reports are amalgamated under the auspices of the Australian and New Zealand College of Surgeons. An internationally accepted definition of anaesthetic mortality is overdue. Extending the time for inclusion of deaths from 24 h to 30 days or longer substantially increases estimated rates of mortality. Attribution of cause of death may be problematic. Even quite small degrees of myocardial injury in patients undergoing non-cardiac surgery increase the risk of subsequent mortality, and in older patients, 30-day all-cause mortality following inpatient surgery may be surprisingly high. Patients should be given a single estimate of the combined risk of surgery and anaesthesia, rather than placing undue emphasis on the risk from anaesthesia alone. Hazards may arise from equipment or from drugs either directly or through error. Error often underlies harmful events in anaesthesia and may be made more likely by fatigue or circadian factors, but violations are also important. Training in expert skills and knowledge, and in human factors, teamwork, and communication is key to improving safety.
13
U, Alt E., Klein H, and Griffin Jerry C, eds. The Implantable cardioverter/defibrillator. Berlin: Springer-Verlag, 1992.
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14
Alt, E., and H. Klein. Implantable Cardioverter/Difibrillator. Springer, 1992.
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15
van Lier, Felix, and Robert Jan Stolker. Preoperative assessment and optimization. Edited by Jonathan G. Hardman. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199642045.003.0040.
Full textAbstract:
Perioperative cardiovascular complications (including myocardial ischaemia and myocardial infarction) are the predominant cause of morbidity and mortality in patients undergoing non-cardiac surgery. The pathophysiology of perioperative myocardial infarction is complex. Prolonged myocardial ischaemia due to the stress of surgery in the presence of a haemodynamically significant coronary lesion, leading to subendocardial ischaemia, and acute coronary artery occlusion after plaque rupture and thrombus formation contribute equally to these devastating events. Perioperative management aims at optimizing the patient’s condition by identification and modification of underlying cardiac risk factors and diseases. The first part of this chapter covers current knowledge on preoperative risk assessment. Current risk indices, the value of additional testing, and new preoperative cardiac risk makers are investigated. During recent decades there has been a shift from the assessment and treatment of the underlying culprit coronary lesion towards a systemic medical therapy aiming at prevention of myocardial oxygen supply–demand mismatch and coronary plaque stabilization. In the second part of this chapter, risk-reduction strategies are discussed, including β-blocker therapy, statins, and aspirins. A central theme in this chapter will focus on long-term cardiovascular risk reduction. Patients who undergo non-cardiac (vascular) surgery are particularly prone to long-term adverse cardiac outcomes. The goal of perioperative cardiovascular risk identification and modification should not be limited to the perioperative period, but should extend well into the postoperative period.
16
Hunt, Beverley J. Haemostatic agents in critical illness. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0052.
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Antifibrinolytics can prevent excessive bleeding during surgery and are also used to reduce established bleeding. By blocking the effects of plasmin, they prevent premature clot breakdown and enhance clot stability. The CRASH-2 trial showed that use of tranexamic acid in those with or at high risk of traumatic haemorrhage reduced mortality by 9%. Importantly for a drug that affects haemostasis, there appears to be no increased risk of either arterial or venous thromboembolism. Aprotinin while an excellent agent in reducing bleeding disproves previous assumption that reducing bleeding improves outcome, for the BART study demonstrated an increased mortality compared with tranexamic acid and EACA. It is still used occasionally in very high risk cardiac surgery patients. DDAVP (desmopressin) stimulates platelet function and is of use in patients with uraemia, although needs to be given with an antifibrinolytics, because it does also stimulate fibrinolytic activity. Off-license use of rVIIa is waning, clinical trials have as yet failed to show major benefit. Moreover, there is a high rate of arterial thrombosis after using rVIIA.
17
Clarkin, Andrew J., and Nigel R. Webster. Pre-surgical optimization of the high-risk patient. Edited by Neil Soni and Jonathan G. Hardman. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199642045.003.0088.
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There is a small group of patients undergoing surgery who comprise the majority of perioperative deaths. Morbidity and mortality resulting from tissue hypoxia in the perioperative period can be predicted and prevented by identification of the at-risk group and targeted interventions. Management of these patients requires an understanding of oxygen delivery, the use of cardiac output monitoring to guide fluid and inotrope administration to attain a predefined goal of supranormal oxygen delivery, and the attainment of physiological goals. There are both patient outcome and economic benefits to this management strategy which support the individualized goal-directed therapy approach to managing high-risk patients.
18
Mythen, Monty, and Michael P. W. Grocott. Peri-operative optimization of the high risk surgical patient. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0361.
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Flow-based cardiovascular variables, such as cardiac output and oxygen delivery predict peri-operative outcome better than alternative, predominantly pressure-based measures. Targeting flow-based goals, using fluid boluses with or without additional blood or vasoactive agents in patients undergoing major surgery has been shown to improve outcome in some studies. However, the literature is limited due to a large number of small single-centre studies, and heterogeneity of interventions and outcomes evaluated. Early studies used pulmonary artery catheters to monitor blood flow, but newer studies have used less invasive techniques, such as oesophageal Doppler monitoring or pulse contour analysis. Meta-analysis of the current evidence base suggests that this approach is unlikely to cause harm and may not reduce mortality, but reduces complications and duration of hospital stay. Goal-directed therapy is considered an important element of enhanced recovery packages that have been shown to improve outcome after several types of major elective surgery.
19
Grossman, Jonah, Tanzila Shams, and Cathy Sila. Neurological Complications of Infective Endocarditis. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199937837.003.0167.
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Infective endocarditis is the fourth leading cause of life-threatening infections, accounting for 40,000 annual U.S. hospital admissions. Due to decline in rheumatic heart disease, a shift in causative organisms from viridans streptococci to S. aureus, Group D Streptococcus, and multidrug-resistant species has been observed. The spectrum of neurological complications ranges widely from cerebrovascular pathologies-including septic embolization, mycotic aneurysms, and intracerebral hemorrhages-to seizures, meningitis, cerebritis, and abscess. Transthoracic echocardiogram remains the standard for initial investigation whereas CT scans, MRI with DWI sequence, and cerebral angiograms are useful for exploring neurological complications. Antibiotic regimens, tailored to culprit organisms, should be initiated early after obtaining blood cultures and continued for 4 to 6 weeks. Antithrombotic treatment may pose increased risk for intracerebral hemorrhage, even in the absence of mycotic aneurysms (MA). Unruptured MA must be treated according to risk of rupture and overall health of the patient. MAs either at risk or previously ruptured should be secured by neurosurgical or endovascular means. Early cardiac surgery is a viable option for prevention of septic embolization for high-risk cardiac diseases such as perivalvular abscess and infection with resistant organisms, but may increase mortality rates for those with decompensated heart failure.
20
Grisoli, Dominique, and Didier Raoult. Prevention and treatment of endocarditis. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0161.
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Initially always lethal, the prognosis of infective endocarditis (IE) has been revolutionized by antibacterial therapy and valve surgery. Nevertheless, it remains one of the deadliest infectious diseases, with ≥30% of patients dying within a year of diagnosis. Its incidence has also remained stable at 25–50 cases per million per year, and results predominantly from a combination of bacteraemia and a predisposing cardiac condition, including endocardial lesions and/or intracardiac foreign material. While antibiotic prophylaxis is recommended by various learned societies to cover healthcare procedures with the potential of causing bacteraemia in at-risk patients, there is no evidence to support this strategy. Even though the benefits are hypothetical, national guidelines should still be followed to avoid medico-legal issues. General preventive measures, such as education of clinicians and at-risk patients appear to be more crucial. Invasive procedures, especially intravenous catheterization, should be kept to the minimum possible. The severity of IE mandates a multidisciplinary and standardized approach to treatment, with involvement of dedicated surgeons within specialist centres. Standardized antibiotic protocols have produced dramatic reductions in hospital and 1-year mortality in reference centres. Most deaths now result from complications that constitute definite surgical indications, so optimization of surgical management and avoidance of delay will clearly improve prognosis. This disease has now entered an ‘early surgery’ era, with a more aggressive surgical approach showing promising results. Conditions such as septic shock, sudden death, and vancomycin-resistant staphylococcal endocarditis still constitute therapeutic and research challenges, and justify an important role for specialist centres.
21
Williams, Erin S. Pulmonary Hypertension. Edited by Erin S. Williams, Olutoyin A. Olutoye, Catherine P. Seipel, and Titilopemi A. O. Aina. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780190678333.003.0029.
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Pulmonary hypertension is one of the most challenging medical conditions for even the most experienced anesthesiologist to manage. The very dynamic nature of pulmonary vascular disease lends itself to potential catastrophic changes that can increase the perioperative morbidity and mortality. Given the potential for significant hemodynamic, oxygenation, and ventilation changes during perioperative care it is imperative that the pediatric anesthesiologist not only perform a history and physical exam in this high-risk patient population but also carefully evaluate the most recent cardiac studies such as echocardiograms and catheterizations. The anesthesiologist must ensure that the patient is not overdue for cardiology exams and studies. Finally, the pediatric anesthesiologist must also communicate with the surgeon and cardiologist regarding the risk and benefit of the procedure; along with the severity of the patient’s pulmonary hypertension, in order to formulate and ultimately execute an anesthetic plan that decreases the possibility for perioperative complications.