Anesthesiology Clinics

With the promise to be a “cutting edge” book, the editors and authors of this edition of Anesthesiology Clinics have set a high standard for themselves. Of the 10 chapters, 8 could be said to have successfully met this standard. One chapter did not, and a “bonus chapter” was not reviewed because it is unrelated to the principal theme of the monograph. Fiadjoe and Stricker briefly, but thoroughly, describe the plethora of pediatric airway devices available to practitioners. The management of pediatric patients with difficult airways is usually performed under general inhalational anesthesia, but occasionally, one encounters a patient whose airway is so significantly compromised that spontaneous ventilation under volatile anesthesia may not be safe. What options for sedation do the authors suggest in this situation? Propofol? Ketamine? Dexmedetomidine? Unfortunately, they do not tackle this important question. A variety of airway adjuncts are discussed in detail, and these reviewers wholeheartedly agree with the authors when they recommend familiarity with fiberoptic techniques and only 2 other airway devices rather than attempting to be the “jack of all trades and master of none.” They also rightly stress that expertise in the use of a particular airway device should be gained first in patients with normal airways. Ultrasound-guided pediatric regional anesthesia is certainly a “cutting edge” topic. The chapter is very comprehensive but has some obvious limitations. There is no mention of the very useful supraclavicular approach to the brachial plexus. There were relatively few clinical pearls that highlight the technical differences between adult and pediatric regional anesthesia. However, we acknowledge that this type of information is probably best taught “hands on” rather than through the written word. Despite the chapter title, a significant amount of attention is given to pure nerve stimulator techniques for reasons that are unclear to these reviewers. In addition, the authors do not state whether they believe that nerve stimulation should be used in conjunction with ultrasound guidance. Does combining the 2 techniques lead to increased efficacy and/or safety, or is it merely a waste of time? The authors leave this important question unanswered. With the exception of a very brief passing mention in the section on sciatic nerve blocks, also left unaddressed are the indications, ease of placement (relative to adults), utility, and success of maintenance of catheters for prolonged administration of local anesthetic. Finally, no information is provided on the expected duration of analgesia at the suggested doses of the frequently used local anesthetics. The chapter on treatment of traumatic brain injury does an excellent job covering the spectrum from basic science to clinical management. The inclusion of a small section on the effects of anesthetics on the developing brain is puzzling. It is not relevant to the topic at hand and is the topic of an entire chapter later in the book. We would have appreciated a more complete discussion of the pros and cons of rapid sequence induction (RSI). RSI for the head-injured patient is anesthetic dogma but is neither supported nor refuted by the peer-reviewed literature. Given the need to critically maintain stable hemodynamics avoiding both hypotension and hypertension, would a modified RSI with mask ventilation be a better approach? What is the appropriate role for cricoid pressure, given the similar lack of supporting evidence? These controversial questions demand more attention. Kraemer and Rose offer a comprehensive review of the current state of pharmacologic management of acute pain in children. Many readers will be surprised by their inclusion of acetaminophen as a nonsteroidal antiinflammatory drug, but they offer evidence of its central cyclooxygenase inhibition. Less common agents such as ketamine, methadone, and dexmedetomidine are discussed along with the usual opioid and non-opioid analgesic compounds. McCann and Soriano tackle what must certainly be the most contentious current topic in pediatric anesthesia, namely the effects of anesthetics on the immature brain. Even the nonpediatric anesthesiologist is aware of this controversy from both medical journals and the local newspaper. The chapter provides an excellent review of the current (and very concerning) animal data, and the fact that there are very limited human data. As current as this chapter is, in such a rapidly developing field any review will shortly be out of date, so it is important to stay abreast by reading the recent publications on this topic in the peer-reviewed journals. Patients with Fontan circulation are surviving in greater numbers and presenting for all types of noncardiac (including obstetric) procedures in later life. This chapter provides a good discussion of the limitations of Fontan physiology and the formulation of a sound perioperative plan from preoperative assessment through postoperative pain management. The authors stress the need for multidisciplinary care for these challenging patients when they present for elective noncardiac surgery at institutions with appropriate infrastructure to handle potential complications. The authors also provide some guidance for unique and physiologically complex scenarios such as laparoscopic surgery and one-lung ventilation that particularly stress the Fontan patient. Diaz and Jones discuss the incredible growth industry of pediatric sedation for the child with congenital heart disease. Although this is nominally a chapter on sedating children with congenital heart disease, there is in fact very little specific information provided on sedation for children with congenital heart disease. However, as a general review of pediatric sedation, the chapter is good. These reviewers believe that the suggested low-dose infusion rate of 50 μg/kg/min for propofol will not provide successful sedation for most children, and readers would have been better served with a discussion of the increased dosing requirements for propofol sedation in children. The chapter on anesthesia and hemoglobinopathies by Firth is the only disappointing chapter. In the opinion of these reviewers, the chapter does not measure up to the “cutting edge” standard that the editors established for this edition in the Anesthesiology Clinics series. There are fully 13 references that are 30+ years old. This chapter is almost exclusively a review of sickle cell disease, but there is sadly little that is new in the management of this serious condition. Only 1 page is devoted to the thalassemias, and 1 page to “other.” All books, particularly multiauthored books, are at risk for undetected errors, but we believe someone should have picked up the reference to the Fe37+ form of iron. The last chapter by Verma, Eisses, and Richards on blood conservation is also on a current cutting edge topic. Although this is a good discussion, the section on the specifics of blood conservation during and after cardiopulmonary bypass was very disappointing. In addition, the chapter suffers somewhat from a lack of an in-depth discussion on the immunomodulatory effects of blood transfusion, which is clearly a cutting edge issue and a reason to minimize transfusions. The authors do not explore the potential role of antifibrinolytic drugs in noncardiac surgery with large-volume transfusion requirements such as spinal instrumentation and craniofacial reconstruction. Of the 9 chapters, 6 were written by colleagues of the editors from the Children's Hospital of Philadelphia, 2 others were written by authors from Boston, and 1 by authors from Seattle. We fully understand the practical constraints that might have encouraged the editors to enlist an overwhelming percentage of authors from their home institution. Pediatric anesthesiologists will be quite aware of this coastal-centric bias, but hopefully, nonpediatric anesthesiologist readers will appreciate that “cutting edge” pediatric anesthesia also occurs between the coasts and at a wider spectrum of institutions than the editors might lead a casual reader to believe. Overall, the editors have identified an appropriate variety of topics that will be of interest to pediatric and even nonpediatric anesthesiologists. Although we have identified some minor shortcomings, the book made for enjoyable reading, and we found ourselves learning new things about topics with which we were already familiar. Taking the time to read this relatively slim book is time well spent. Victor C. Baum, MD Duncan G. de Souza, MD, FRCPC Departments of Anesthesiology and Pediatrics University of Virginia Health System Charlottesville, Virginia [email protected]