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2012年1月2日月曜日

(麻) 2011年のCirculationに掲載されたACCF/AHA CABG guideline

読まれた方はとっくに読まれたのでしょうが、Podcast「OpenAnesthesia.org」の「Article of the Month - January 2012 - Martin London」で取り上げられていたので目を通して見ました。

ちょっと前ですが、
2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery : A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
で読めます。無料で。

2.1.1. Anesthetic Considerations: Recommendationsを見ますと
Class I
1. Anesthetic management directed toward early postoperative extubation and accelerated recovery of low- to medium-risk patients undergoing uncomplicated CABG is recommended. (Level of Evidence: B)
2. Multidisciplinary efforts are indicated to ensure an optimal level of analgesia and patient comfort throughout the perioperative period. (Level of Evidence: B)
3. Efforts are recommended to improve interdisciplinary communication and patient safety in the perioperative environment (eg, formalized checklist-guided multidisciplinary communication). (Level of Evidence: B)
4. A fellowship-trained cardiac anesthesiologist (or experienced board-certified practitioner) credentialed in the use of perioperative TEE is recommended to provide or supervise anesthetic care of patients who are considered to be at high risk. (Level of Evidence: C)

Class IIa
1. Volatile anesthetic-based regimens can be useful in facilitating early extubation and reducing patient recall. (Level of Evidence: A)
Class IIb
1. The effectiveness of high thoracic epidural anesthesia/ analgesia for routine analgesic use is uncertain. (Level of Evidence: B)

Class III: HARM
1. Cyclooxygenase-2 inhibitors are not recommended for pain relief in the postoperative period after CABG. (Level of Evidence: B)
2. Routine use of early extubation strategies in facilities with limited backup for airway emergencies or advanced respiratory support is potentially harmful. (Level of Evidence: C)

術中のTEEについては

2.1.7. Intraoperative TEE: Recommendations
Class I
1. Intraoperative TEE should be performed for evaluation of acute, persistent, and life-threatening hemodynamic disturbances that have not responded to treatment. (Level of Evidence: B)
2. Intraoperative TEE should be performed in patients undergoing concomitant valvular surgery. (Level of Evidence: B)
Class IIa
1. Intraoperative TEE is reasonable for monitoring of hemodynamic status, ventricular function, regional wall motion, and valvular function in patients undergoing CABG. (Level of Evidence: B)

と…まぁ無難なところで大して面白くないのですが。ほかにもPACやモニタリング、合併症がある場合などについても言及されているので、勉強になるかもしれません。こういうguidelineを読むと、guidelineの根拠となる原著論文を読まずにいると具合悪くなってしまいます。参考文献が295個もあって新年早々眩暈が…。

***
セネカの「人生の短さについて」(岩波文庫、1980年)にこう書いてありました。

生きることは生涯をかけて学ぶべきことである。そして、おそらくそれ以上に不思議に思われるであろうが、生涯をかけて学ぶべきことは死ぬことである。(p22)

よく死ぬためによく生きる。このことが今年、少しでも身に沁みますよう。

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