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BOOK AND MULTIMEDIA REVIEWS

Tumescent Technique: Tumescent Anesthesia & Microcannular Liposuction

Any reader of this book might conclude that the professionals practicing anesthesiology are emulating the classic "Three Stooges," Larry, Moe and Curly—instead of the appropriately esteemed Barash, Stoelting, and Miller. Some readers may go one step further and find it to be a derogatory discourse that tarnishes our specialty by portraying the anesthesia profession in an extremely negative light. The basis of Klein’s arguments seems to be made up of old references, anecdotal reports, self-made statistics based on self-observation, and archaic cross-specialty citations.

In presenting challenges to the safety of modern anesthesia, Klein refers to poor clinical judgment, human error, and carelessness on the part of anesthesiologists. This casts an ominous and false shadow on the extraordinary progress we have made during the last two decades. For example, he asserts that the dangers of patient monitoring may outweigh the benefits and suggests that prudent and appropriate handling of a monitor alarms by anesthesiologists is more an exception than a rule. While alluding to our implied ineptitude, Klein strings together a variety of causes for anesthesia-related catastrophes. Further along in the book, using contorted reasoning, he remarks that there is a dose-response relationship between general anesthesia and pulmonary embolism. Based on his conclusion, a reader may believe that Virchow’s triad should be updated, perhaps supplanting stasis with general anesthesia. Klein tackles the issue of anesthesia-related mortality in a very curious and highly unorthodox fashion, implying that the risk may be as high as one (1) death for every one thousand (1000) general anesthetics. Perhaps unintentionally, some of Klein’s preposterous prose may serve to needlessly misinform and frighten. It distorts the realities of modern anesthesia care, where more patients than ever before receive exemplary care provided by intelligent, skilled, well-intentioned physician anesthesiologists using the latest technology.

Surgeons do not escape Klein’s criticism. He equates the personality traits of surgeons with minimally effective care. In addition, he states that systemic anesthesia tends to release surgeons from common-sense restraints—and the lack of knowledge about his suggested safe dose of lidocaine results in the use of more general anesthesia. I am certain that most surgeons would disagree with his reasoning and conclusions.

However, Dr. Klein’s book is not without merit. His discussions concerning the pharmacokinetics and pharmacodynamics of local anesthetics are very instructive. The sections that review the potentiation and inhibition of the cytochrome P450 system, and the effect on local anesthesia metabolism, are very complete. Every anesthesiologist would benefit from reviewing the list of medications that affect cytochrome P450 function and local anesthesia metabolism. In addition, he does an excellent job reviewing the procedural aspects of surgical liposuction and some of the nuances to consider, especially impressive considering the fact that he has not completed a residency in surgery.

Every office-based anesthesiologist recalls the very first time he/she provided anesthesia care for a tumescent liposuction patient. The routine inquiry about the dose of lidocaine the patient was anticipated to receive was probably answered with 35, 40, or 50 or more mg/kg. Thinking that this must be a mistake, and the dose was probably 5 mg per kg, a long discussion probably ensued with the surgeon or dermatologist. At this point, the surgeon or dermatologist probably evoked Dr. Klein’s name and rationale, the same way a discussion of home runs would, of course, involve Babe Ruth or Barry Bonds. Dr. Klein’s suggested maximum dose of lidocaine (50 mg/kg) and the exact way in which it must be administered—with epinephrine and into the subcutaneous fat—is based partly on personal observation, a strong dose of deductive reasoning, anecdotal reports, toxicity experienced by patients at higher doses, and to a lesser extent, basic scientific study. Nevertheless, Dr. Klein deserves much credit for bravely outlining his rationale for using such high doses of anesthesia, and explaining why it is safe in his opinion. His large-dose lidocaine anesthesia tumescent technique is becoming, or has become, a standard in the liposuction community. Therefore, despite his derisive and pejorative insinuations about our professional value and skill, familiarity with this book has some merit. Although he is unlikely to be invited to an anesthesia department lectern or to your home for dinner, Dr. Klein does has something interesting to say and many ambulatory and office-based anesthesiologists might therefore consider reading Tumescent Technique.

Medical Ethics; Volume 39 Number 3 (Summer 2001) of International Anesthesiology Clinics

Anesthesiologists are confronted with important, and at times gut-wrenching, ethical decisions in daily practice. Because most anesthesiologists have little ethics training, they struggle with determination of the most morally acceptable path. This issue of International Anesthesiology Clinics successfully fulfills the editor’s stated goals of providing ethical topics relevant to the practice of anesthesiology and information important to any physician. The contributing authors discuss their topics in an easily understood literary style, direct and to the point, omitting much of the often-confusing ethical lexicon used in many articles and texts in this discipline. In addition, several authors use clinical case examples to emphasize the ethical issue at hand. Each chapter is amply referenced.

The volume is divided into nine chapters covering a variety of topics. Belkin and Brandt review historical and social aspects of medical ethics, explaining why the field has developed as it has in recent years. Physicians are now confronting ethical issues from the perspective of "What can I do?" instead of "What should I do?" Ethical management must consider not only patient and physician autonomy but also how external forces such as managed care may change the available options.

Miller reviews ethical considerations of Phase I clinical cancer drug trials, i.e., those responsible for determining dose-toxicity information. He points out therapeutic misconceptions of the patients enrolled in these trials, their miniscule chance for therapeutic benefit as a result of participation, and the conflicts physician-investigators endure in this eye-opening discussion.

Hug eloquently addresses end-of-life issues in surgical patients. He logically defends his call for anesthesiologist involvement in decision making regarding surgical patients, discusses the concept of therapeutic surgical trials, and outlines his recommendations for withdrawal of life support when indicated.

Troug and Waisel discuss the issue of "Do-Not-Resuscitate" orders in the operating room, an ever-increasing occurrence in most hospitals. Through a clinical case example, they outline the management of this situation, providing options and appropriate steps for the perioperative team, including a prototype DNR order for the operating room.

Robinson and Mylott tackle cardiopulmonary resuscitation, offering a discussion of outcomes, hospital experience, and ethical and research implications. They suggest that CPR should be offered in light of "achievable goals to promote the patient’s well being" but not in all circumstances.

Other chapters provide practical guidelines for withdrawal of life-sustaining care, an interesting and provocative discussion of the ethics of cost containment in the hospital, the important topic of coercion and restraint in anesthetic delivery, and the issues involved in non-heartbeating organ donation. This last topic will likely provoke many questions in the minds of readers. Should the anesthesiologist become the responsible party for withdrawal of care in the operating room? If anesthesiologists withdraw care, should they avoid further participation? Would primary care physicians be more appropriate for this role?

It should be noted that the term "nonmalfeasance" is substituted in several locations of the text of this issue in place of the correct "nonmaleficence" (do no harm). This is likely a typographical error.

Anesthesiologists read many publications in the context of continuing medical education. Only few have an impact that might change practice patterns. The information in this succinct, well-written text is thought provoking and worth the reader’s time. It just might have such an effect.

Clinical Anesthesia Practice, 2nd Edition

In the preface the editors raise the question "why should this book be published?" and acknowledge that it is not encyclopedic. Nevertheless, in 10 sections ranging from "Safer Practice" through "Tools of the Trade" to "Transplantation" and divided into 76 chapters, considerable practical clinical material is presented. The four editors and the 28 authors are from the University of Florida, but the remaining 82 authors represent many institutions, including international contributions from Australia, Canada, Israel, and the United Kingdom.

The format employed is unique in that each chapter starts by listing a series of pertinent questions, ranging from 6 ("Critical Incident Management") to 94 ("Abdominal Surgery"). The questions range from "Why does [the abdominal wall] get tight?" to "What is a ‘snorkel’?" In many chapters, initial questions address "What. . .?" and later ones address the very important "Why. . .?" The questions are then answered, depending on their complexity, succinctly in a short paragraph or in an extensive discussion in a series of paragraphs as necessary.

The text is well supported with figures, diagrams, tables, and a 93-page index. Although the writing is uniformly good, there is considerable variation in the depth of coverage, which explains the nonencyclopedic comment in the preface. The 44 pages and 84 questions on "Post Anesthesia Recovery" provide a comprehensive review of the subject as does the six-page, six-question review of the "Critical Incident Management." In contrast the 12 pages and 6 questions on cardiology consultation appear terse. At the other extreme the 14 pages and 18 questions on the "Anesthesia Record" may provide more information than most desire. The failure to list postobstructive pulmonary edema (formerly called negative pressure pulmonary edema) as a cause of noncardiogenic pulmonary edema is a surprising omission in an anesthesia text (page 216). The inclusion of both defense and plaintiff lawyers’ perspective in the chapter on "Medicolegal Issues and Concerns," somewhat analogous to a Pro-Con debate on some newspaper editorial pages and/or society newsletters, provided a new perspective for this reviewer on this issue.

Who should consult this text? Although every clinical anesthesiologist would benefit from its availability, the question-and-answer format may make it especially helpful to candidates preparing for the Board examination, especially the oral portion.

Books and Multimedia Received

The Journal solicits reviews of new books and multimedia from its readers. If you wish to submit a review, before proceeding please send a letter of intent, identifying the book or multimedia in question, to Norig Ellison, MD, Department of Anesthesia, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104-4283. The Journal reserves the right of final decision on publication

Arthurs G: Anaesthesia, A Concise Handbook, Greenwich Medical Media, Dallas, TX, 2001.
ISBN 1-84110-080-3. 159 pages, $29.95. Available from JAMC Distribution, Lewisville, TX 75057.

Ashford R, Evans N (Eds): Surgical Critical Care, Greenwich Medical Media, Dallas, TX, 2001.
ISBN 1-84110-066-8. 247 pages, $35.00. Available from JAMC Distribution, Lewisville, TX 75057.

Erdmann A: Concise Anatomy for Anaesthesia, Greenwich Medical Media, Dallas, TX, 2001.
ISBN 1-84110-069-2. 141 pages, $39.95. Available from JAMC Distribution, Lewisville, TX 75057.

Galley HF (Ed): Critical Care Focus. 4: Endocrine Disturbance, BMJ Books, London, 2001.
ISBN 0-7279-1582-7. 68 pages, $24.95.

Galley HF (Ed): Critical Care Focus. 5: Antibiotic Resistance and Infection Control, BMJ Books, London, 2001.
ISBN 0-7279-1538-X. 54 pages, $24.95.

Galley HF (Ed): Critical Care Focus. 6: Cardiology in Critical Illness, BMJ Books, London, 2001.
ISBN 0-7279-1543-6. 60 pages, $24.95.

Galley HF (Ed): Critical Care Focus. 7: Nutritional Issues, BMJ Books, London, 2001.
ISBN 0-7279-1652-1. 70 pages, $24.95.

Morgan GE, Mikhail MS, Murray, MJ, Larson CP Jr (Eds): Clinical Anesthesiology, 3rd Ed., McGraw-Hill, New York, 2001.
ISBN 0-8385-1553-3. 1042 pages, $64.95.

Park G, Shelly M (Eds): Pharmacology of the Critically Ill, BMJ Books, London, 2001.
ISBN 0-7279-1221-6. 189 pages, $49.95.

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