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Assistant Professor, Department of Anesthesiology, The University of Texas Medical Branch, Galveston, TX
G. D. Shorten, ed.
Philadelphia: Lippincott Williams & Wilkins, 2003. ISSN 0020-5907. 107 pp., $246 (annual subscription for 4 issues).
Inflammation plays an important role in the pathophysiological processes associated with surgery and critical illness. Immunomodulation and the Inflammatory Response is a collection of six chapters that addresses several topics related to inflammation that are of interest to anesthesiologists and critical care practitioners. The goal of this collection, as stated by the editor, is to address "bench to bedside" issues that are relevant to anesthesiologists.
The first chapter examines the effect of local anesthetics on the inflammatory response. The authors provide a brief overview of the pathophysiologic processes associated with inflammation including mechanisms of vasodilation, increased vascular permeability, and neutrophil recruitment. A limited discussion of inflammatory mediators such as autocoids, eicosanoids and cytokines is also presented. Although limited in scope, this overview provides a foundation for discussing the effects of local anesthetics on the inflammatory response. The remainder of the chapter examines the current literature on local anesthetics and their effects on inflammatory processes. The potential cellular and molecular mechanisms by which local anesthetics inhibit inflammation are also discussed and include membrane stabilization and altered intracellular signaling. In the end, the authors point out that local anesthetics have limited antiinflammatory applications in the clinical setting. The primary benefit appears to be to decrease inflammation at sites of local anesthetic infiltration.
A review of the effects of volatile and intravenous anesthetics on neutrophil function is provided in the second chapter. Neutrophils are key mediators of the acute inflammatory response and are known to participate in organ injury in cases of severe local or systemic inflammation. The authors provide a brief review of neutrophil functions. This is followed by a synopsis of the literature pertaining to the effects of volatile and intravenous anesthetics on neutrophils. Most of these studies were performed using isolated human neutrophils that were cultured with fixed concentrations of anesthetic agents. The authors point out the significant limitations of this approach, particularly the lack of relevance to the clinical setting. Nevertheless, current knowledge of the effects of systemic anesthetics on a variety of neutrophil functions is reviewed.
The most comprehensive chapter in this volume addresses the implications of anesthesia for infection and wound healing. Infection is one of the most common complications during the perioperative period and contributes significantly to duration of hospital stay, cost of care, and outcome. Likewise, the adequacy of surgical wound healing has a major impact on the final outcome of any surgical procedure. The authors provide a detailed list of risk factors associated with perioperative infections, ranging from local factors such as impaired tissue perfusion to systemic considerations such as the presence of diabetes mellitus. The stress response to surgery and anesthesia also has an impact on the host response to infection. The authors provide an overview of the surgery-induced stress response and cover important topics such as neuroendocrine mediators and cytokines. Little is known about the clinical effects of anesthetics on antimicrobial immunity. Nevertheless, the authors provide a list of possible effects of different anesthetic agents on immune function. It is stated that general anesthetic agents have little effect on the stress response and may actually inhibit immune function. However, little evidence is provided to support this contention. A more detailed discussion of the effects of regional anesthesia on the stress response is provided.
Sepsis is a leading cause of death in critically ill patients. The third chapter provides an overview of clinical issues associated with sepsis ranging from consensus conference definitions to pathophysiologic mechanisms. Brief discussion of hemodynamic alterations, respiratory failure, renal dysfunction, and coagulopathy are presented, as is a discussion of clinical management. Another important consideration for anesthesiologists that care for patients with existing infections is the use of techniques that will minimize the spread of infection to other patients. Anesthesiologists must protect themselves by practicing universal precautions, and other patients, by practicing hand washing and isolation of contaminated equipment. The authors conclude their discussion of perioperative infection by addressing the issue of epidural abscess, which is a relatively unusual, but devastating, complication. A good overview of the epidemiology, diagnosis, and management of epidural abscess is provided.
The remainder of this chapter discusses the issue of surgical wound healing. An overview of the phases of wound healing and risk factors for poor wound healing are presented. The primary message aimed at anesthesiologists is the recognition and management of perioperative factors that predispose patients to impaired wound healing and wound infection. Among the factors discussed are hypothermia, blood transfusion, and tissue oxygen tension during surgeries that have a high rate of postoperative infection. Colorectal surgery is most commonly discussed. A few highly lauded studies are referenced, yet few confirmatory studies are available in some areas. Nevertheless, the authors raise several important issues that anesthesiologists should be aware of in order to maximize postoperative wound healing and minimize perioperative wound infections.
The fourth chapter provides a discussion of apoptosis in the critically ill patient. A brief overview of the cell biology of apoptosis and the potential contribution of apoptosis to organ dysfunction is provided. Most studies on apoptosis and the development of organ failure have been performed in experimental models. Evidence for a role of apoptosis in the clinical setting is lacking. However, a relatively strong case is made for the role of apoptosis in the development of myopathy in critically ill patients. The chapter concludes with a discussion of therapeutic interventions that may decrease apoptosis in the ICU setting. Among the approaches discussed include the use of caspase inhibitors and overexpression of the anti-apoptotic protein bcl-2. All of these approaches are experimental and the authors point out the incomplete level of knowledge in this area.
The fifth chapter provides a discussion of cytosolic phospholipase A2 knockout mice and their use in the study of a variety of pathophysiologic processes ranging from acute brain injury to acid aspiration. The authors provide a thorough overview of phospholipase A2 function and an abundance of data to indicate that cytosolic phospholipase A2 is an important factor in the pathophysiology of numerous disease processes. It remains to be determined whether blockade of cytosolic phospholipase A2 will provide therapeutic benefit in the clinical setting.
The final chapter discusses inhaled nitric oxide in the treatment of acute respiratory distress syndrome. A clinically relevant discussion of the pharmacology of inhaled NO in the lung is provided. Specifically, the mechanisms by which NO improves oxygenation and decreases pulmonary hypertension during ARDS are discussed. The authors also provide a discussion of the effect of inhaled NO on the inflammatory processes associated with ARDS. The chapter concludes by discussing mechanisms of NO delivery and monitoring in critically ill patients.
Overall, this monograph provides some clinically useful information in the areas of infection control, wound healing and the use of NO in the treatment of ARDS. Much of the information provided does not have direct clinical relevance but provides a strong basis for understanding issues that may prove to be clinically important in the future. Therefore, this volume meets the goal of discussing "bench to bedside" issues that are generally related to inflammation and immunomodulation. Basic science and clinical investigators with interests in inflammation, infection, wound healing, and nitric oxide are likely to find this publication to be informative and useful.
Professor and Chair, Department of Anesthesiology, University of Arizona School of Medicine, Tuscon, AZ
J. T. B. Moyle
London: BMJ Books, 2002. ISBN 0-7279-1740-4, 182 pp., $32.95.
This text on pulse oximetry starts off rather slow but improves as the reader gets further along. This history chapter is so sketchy that it is almost useless—it does not even mention the name of the inventor of the pulse oximeter. The chapters describing how the pulse oximeter works are generally adequate, but in some areas they are incomplete. The sections on clinical applications are more useful, and the best chapter of all is the one on high altitude. The second half of the book digresses into related areas such as clinical causes of hypoxemia. These are useful reviews, but the reader is not drawn to a text called Pulse Oximetry to learn about the differential diagnosis of hypoxemia. In summary, this is a useful text containing some excellent references, but it suffers from a lack of completeness in some areas and a tendency to digress in others.
Examples of the weak and strong chapters include:
Chapter 1: In an attempt to maintain brevity, the author has unfortunately "thrown out the baby with the bathwater" in this chapter. How can a chapter on "history" fail to mention either Mathes or Aoyagi? The inventor of pulse oximetry, Takuo Aoyagi, is named only in the table. Carl Mathes is not mentioned at all. There is relatively too much emphasis on the Hewlett Packard Ear Oximeter, which was merely a transitional phase prior to pulse oximetry.
Chapter 7: This is really an excellent chapter. Table 7.1 is particularly useful. The analysis of saturation values during airline flights was especially interesting.
Chapter 11: The chapter on dishemoglobins is fairly complete, but does not appear to mention fetal hemoglobin. This is an important point, because fetal hemoglobin does NOT affect the accuracy of conventional pulse oximeters, while it can affect the accuracy of some CO-oximeters.
Department of Anesthesia, University of Chicago, Chicago, IL
M. S. Bogetz, Guest Editor
Philadelphia: W.B. Saunders, 2002. ISBN 0889-8537. 268 pp, $210 (annual subscription for 4 issues).
The popularity of the laryngeal mask airway (LMA) has renewed our interest in upper airway anatomy, physiology, and the LMA’s role in management of the difficult airway. The guest editor is one of the pioneers of LMA use in the United States and has had extensive experience in the management of the difficult airway. The primary mission of the book is to highlight airway problems and the use of supraglottic airway devices for their management.
The first two chapters discuss the anatomy and physiology of the upper airway in adults and children. Chapter 3 reviews congenital and noncongenital diseases that adversely affect the upper airway. This chapter contains many excellent references, including 70 not cited in the chapter. Chapter 4 is devoted to obstructive sleep apnea with valuable information for every anesthesiologist about this condition. Obstructive sleep apnea interferes with airway management in several ways, often adding risk and difficulty to anesthesia.
The chapter "Approaches to Managing the Upper Airway" considers evaluation of the airway, recognition of the difficulty airway, the difficult airway algorithm suggested by the American Society of Anesthesiologists, and a brief review of the different techniques applied for tracheal intubation. The writing is clear and the points are well made; however, the contents of the chapter are not reflected in its title.
The chapter on "Facemask, Nasal, and Oral Airway Devices" is long, with many fine details. Shaving a patient’s beard to solve the problem of difficult mask ventilation is neither a common practice nor a valuable suggestion, especially now that alternative ventilatory devices such as the laryngeal mask exist. Fragmentation within the chapter has resulted in repetitions that decrease the impact of the subject. This reviewer cannot think of any situation in which a nasal airway has to be stiffened by placing in a cold-water bath before insertion.
The role of the LMA in management of difficult mask ventilation and difficult intubation is presented well in Chapter 7. Various methods of applying the LMA for the management of difficult facemask ventilation and intubation are highlighted. The main shortcoming of this chapter is the omission of key references. The Web page address of a company is not a substitute for peer review references.
The chapter on the ProSeal Laryngeal Mask Airway is concise and up-to-date. Of the 15 references, in press during the writing, most are now published. The several advantages of this device over other LMAs or laryngeal tubes are discussed in detail. The authors emphasize that one needs to know the device well before embarking on its use. With 51 references, 2 figures, and 10 informative tables, this chapter is one of the best sources for information on the LMA-ProSeal. Fortunately, the description of the Esophageal-Tracheal Cobmitube in the next chapter is quite clear, not confusing as is typical of many other articles on the subject. In 14 pages with 5 figures, the Combitube is described simply and clearly. The 60 references are up to date. The chapter on "Special Devices and Techniques" is a historical presentation of many intubating techniques, endotracheal tube guides and exchangers, fiberoptic rigid laryngoscopes, and supraglottic ventilatory devices. The writing is clear, but the content does not seem suitable for the goals of this volume.
The penultimate chapter, "Fiberoptic Airway Management," offers many good and technically useful clues for successful fiberoptic intubation. However, the use of the term "channel" for the "insertion cord" caused some confusion. Conditions such as edema of the pharynx and tongue, upper airway infections, hematoma, and infiltrating masses are considered as relative indications to fiberoptic intubation, because they may add to the difficulty of the techniques. However, this reviewer believes these conditions actually present some of the best indications for fiberoptic intubation, because most other techniques are more difficult, less successful, or more invasive.
The last chapter, "Traumatic Complications of Intubation and Other Airway Management Procedures," is written by two head-and-neck surgeons who present the common acute and chronic airway complications that result from intubation, tracheostomy, jet ventilation, the laryngeal mask airway, and the Combitube in very clear terms. Overlapping and repetition of subjects is unavoidable with multiauthored books, but they can be kept to a minimum. Some subjects in this volume are presented in more than two chapters, and such repetition could easily have been avoided. A few spelling errors reflect negatively on the publisher and the editors. Although complete avoidance of such errors may be impossible, the frequency of such errors certainly can be minimized.
The deficiencies noted are minor and do not affect the mission of the book. The information presented in this issue is of clinical value and includes many take-home messages. This reviewer recommends this book to anesthesiologists, nurse anesthetists, and residents alike. Airway management of an unconscious patient is a critical responsibility. Studying this and similar books will help us to avoid some of the most dangerous complications caused by poor airway management.
Department of Anesthesiology, Duke University Medical Center, Durham, NC
W. Camann, M.C.M. Pian-Smith, eds.
Philadelphia: Lippincott Williams & Wilkins, 2002. ISBN 0020-5907. 156 pp, $225.00 (annual subscription for 4 issues).
The fall issue of the International Clinics in Anesthesiology is dedicated to topics relevant to the practice of obstetric anesthesia. The editors of this issue, Dr. Camann and Pian-Smith, both from Harvard Medical School, have done a fine job of choosing topics that are both informative and controversial.
The issue starts with a historical review of anesthesia-related maternal mortality and sets the stage for the subsequent chapters that highlight the progressive nature of the specialty of obstetric anesthesia. Although there has been a significant decline in anesthesia-related maternal mortality over the past few decades, deaths still occur and thus efforts to reach a rate of zero are still required.
A good review, both historical and current, on the effects of epidural analgesia on the progress and outcome of labor and delivery sets the stage for the lively debate that has been ongoing between anesthesiologists, obstetricians, and other maternal care providers. In this chapter, recent studies are highlighted, noting the flaws in their methodology and proposing mechanism for some of the observations made. The chapter concludes with an eloquent plea to move on from these debates and concentrates on more fundamental issues such as the physiology of the labor process itself and the impact of certain individual patient variations on it.
The next chapter on combined spinal-epidural (CSE) analgesia for labor and delivery attempts to provide a thorough review of the technique and its complications (both potential and real), indications, and the agents used to provide labor analgesia. This technique has not been without controversy. The authors adequately cover the controversial points, although some aspects may be somewhat influenced by their personal perspective. An excellent review on the neonatal effects of labor and analgesia follows and both opens some controversial issues and puts closure on others. This serves as a very thought provoking and educational manuscript.
The next section is somewhat inappropriately titled "Neurologic Complications of Labor Analgesia and Anesthesia," as most of the injuries described have little evidence of anesthesia involvement. Nevertheless, there is a fine description of the anatomy and physiology of many of the obstetric nerve palsies seen in the postpartum period. An update on postdural puncture headache adds little new knowledge, largely due to the paucity of research in this area. The authors note that for most of the treatments described, no mechanism of action is known. It is curious that a condition described 100 years ago can continue to be an arena surrounded by such mystery!
A very brief description of some options for nonpharmacologic methods for labor analgesia is presented next. Although the editors might be criticized for allotting such a small amount of space for this topic, this reviewer applauds inclusion of this topic. Expansion of this section to allow for some discussion on the merits and controversy of unmedicated childbirth may have been an enlightening read for some clinicians.
In contrast to the brevity of the previous section, a detailed review of the current state of or really lack of knowledge on preeclampsia follows. A wealth of information on the etiology, pathogenesis, and treatment of the symptom complex encompassing preeclampsia is synthesized. However, the section on the anesthetic management of this condition is brief and lacks clear instruction and direction.
The final chapter in this issue is dedicated to the discussion of the drug abusing parturient. The author effectively describes the effects of many of the common street drugs and their anesthetic implications. Unfortunately, a significant portion of the drug abusing population is not addressed in this review. These are parturients, abusing both prescribed and illegally obtained narcotics, who represent a rapidly enlarging patient population, often with significant anesthetic management challenges.
In summary, for a practicing obstetric anesthesiologist, this issue of the International Anesthesiology Clinics provides an entertaining review of some of the current topics in the field of obstetric anesthesia. While this issue is informative, it is not instructive and it is not recommended as an educational tool for teaching those new to the field. Rather, this issue is well referenced with a good index and therefore could serve as a starting point for more research into these topics. Noteworthy, but maybe not significant, is the lack of an international contribution to this issue. All authors come from American centers, with the majority located in the northeast corner of the country! Therefore, unlike the series title would suggest, a primarily American perspective on these issues is presented.
Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC
C. B. Mueller
Ontario, Canada: B.C. Decker, Inc., 2002. ISBN 1-55009-222-7. 494 pp., $47.00
Evarts Graham was a remarkable man with remarkable accomplishments. Early in his career he investigated the effects of inhaled anesthetics on infection and immunity, and he also performed extensive investigations regarding the hepatoxicity of chloroform. He defined the proper management of thoracic empyema during the days before antibiotics. He developed the radiographic tracer and then performed the first cholecystograms in animals and humans. He performed the first one-stage pneumonectomy for lung cancer. Despite smoking for nearly his entire life, his research with Ernest Wynder led the way to general acceptance of cigarette smoking as the etiology of squamous cell carcinoma of the lung.
Evarts Graham served as the highly successful chairman of Surgery at Washington University. Twenty of his trainees and protégés subsequently became surgery department chairmen. He hired surgical subspecialty heads who became leaders in their areas (e.g., Henry Schwartz, the longtime editor of the Journal of Neurosurgery).
Graham was active on the national scene. He helped create the American Board of Surgery. He was the founding editor of the Journal of Thoracic Surgery (now the Journal of Thoracic and Cardiovascular Surgery). He created the Joint Commission on the Accreditation of Hospitals (now the Joint Commission on the Accreditation of Health Care Organizations). He, with Harvey Cushing and W. S. Halsted, was one of the three most celebrated surgeons during the formative years of the first half of the 20th century.
Graham had a long scientific interest in anesthesia and in having anesthesiology be recognized as the practice of medicine. His stature was such that on October 16, 1946, he was invited to deliver one of four addresses commemorating the centennial of W. T. G. Morton’s administration of ether to E. Gilbert Abbott. The other speakers were Henry K. Beecher of the Massachusetts General Hospital, Raymond Fosdick, President of the Rockefeller Foundation, and Karl Compton, President of the Massachusetts Institute of Technology. Despite controversy surrounding his 1946 address (see E. A. Graham: Ether and Humbug. JAMA 1947:133:97–100), which would erroneously suggest that he did not support the fledgling specialty of anesthesiology, Graham led the search for anesthesiologists at the Barnes Hospital. He worked tirelessly to identify an Anesthesiologist-in-Chief after securing a Mallinckrodt endowment to support the new chief’s salary.
Barber Mueller presents a fascinating portrait of Graham in this biography. The great man had his faults, and they have not been overlooked. Nevertheless, reading this biography was intensely humbling. It describes a time, not so long ago, when giants walked the earth. I recommend this volume to all with interest in the history of surgery.
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.
Newman MF (ed): Perioperative Organ Protection, a Society of Cardiovascular Anesthesiologist’s Monograph, Lippincott Williams & Wilkins, Phila, 2003.
ISBN 0-781-74917-4. 154 pages, $68.00.
Osborn IP (ed): Anesthesia Outside The Operating Room, Vol 41, No. 2 of Intl Anesth Clin, Lippincott Williams & Wilkins, Phila, 2003.
ISSN 0020-5907. 111 pages, $246.00 annual subscription for four issues.
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