Anesthesiology clinics of North America: Critical issues in critical care

Anesthesiology clinics of North America: Critical issues in critical care

637 BOOK REVIEWS particularly timely. Three eminent and experienced angioplasters with distinguished investigational careers have edited a concise a...

333KB Sizes 3 Downloads 141 Views

637

BOOK REVIEWS

particularly timely. Three eminent and experienced angioplasters with distinguished investigational careers have edited a concise and readable textbook sharing with the reader the experience of 13 contributors. Chapters range from the pathobiology of initial arterial injury to a discussion of the mechanisms involved in the late complication of restenosis. There are especially good chapters on the medical management of ischemic complications and the use of coronary artery bypass grafting for unsuccessful PTCA. Many patients with acute ischemic complications suffer Q wave myocardial infarction, suggesting that there is considerable room for improvement in the management of these patients. Undoubtedly, cardiothoracic anesthesiologists have the potential to substantially contribute to the development of more advanced management strategies in the future. There are several other interesting chapters covering newer interventional techniques including stenting, percutaneous cardiopulmonary support, and coronary sinus retroperfusion. The reader, however, wil1 find some of these chapters, such as the one on laser balloon angioplasty, to be dated because the approach has, for the most part, been abandoned owing to very high restenosis rates. Sticklers for tight editing wil1 be amused to find that in some cases “inadequate coronary blood flow cannot be restored” (although cardiothoracic anesthesiologists and surgeons caring for the percutaneous transluminal coronary angioplasty [PTCA] failure on an emergency basis might disagree). Overall, the text is focused and easy to read. Chapters are extensively referenced, which makes this text a worthwhile addition to the library of anyone who deals with the complications of PTCA on a regular basis. John R. Kramer, Jr, MD Cardiologist Cleveland Chnic Foundation Cleveland, OH

Anesthesiology Clinics of North America: Critical Issues in Critical Care. Guest Editors, Vladimir Kvetan, MD, FCCM, T. James Gallagher, MD, FCCM. Philadelphia, PA, Saunders, 1991 The Anesthesiology Clinics of North America have provided another monograph entitled, “Critical Issues in Critical Care.” Who should read this issue? The prominent guest editors are modest in their intent. Their purpose selects the audience by “touch(ing) on some topics of interest to anesthesia-based intensivists,” training and laboring in the multidisciplinary environment of the critical care units. The authors determined what topics to discuss in thorough fashion by conducting surveys among residents, fellows, and critical care practitioners to ferret out mundane areas of interest. As Dr Benumof writes in his forward, this monograph covers the care and support of every major organ function in 14 multiauthored, individual treatises, written by investigators from both sides of the Atlantic. The majority of authors are from the Albert Einstein College of Medicine, and the University of Florida College of Medicine in Gainesville. Other institutions represented include McGill University, University Hospita1 in Finland, and the University of Oslo, making for a truly international publication. The first chapter, “Modern Concepts in Monitoring and Manageis representative of the overall ment of Respiratory Failure,” quality of this monograph. It traces the path of the anesthesiologist’s existente in the intensive care unit (ICU) with a sophisticated yet lucid discussion of such modern concepts as dynamic hyperinflation, airway occlusion pressure, static and dynamic comphance of the respiratory system, and new tests for assessing respiratory

muscle function. These concepts are complemented by illustrations and recent references from prominent peer-review journals. Scholarship pleases when it challenges the mind’s dogma and checks it with new information. For instance, candidates studying for oral boards often memorize the usual weaning parameters of vita1 capacity, negative inspiratory pressure, and respiratory rate. The merits of inspiratory capacity, the maxima1 inspiratory pressure measured from functional residual capacity rather than residual volume, and the value of airway occlusion pressure in predicting weaning outcome in chronic ventilator-dependent patients are delineated. One has to know how to manipulate the modem ventilators to determine the mouth occlusion pressure in the first 0.1 second, intrinsic positive end-expiratory pressure, and static compliance; this is easily accomplished with the help of this article and our current ventilator technology. The concepts are clear, particularly in relation to chronic obstructive pulmonary disease and adult respiratory distress syndrome (ARDS). This chapter satisfies the aim of the editors to promote the discussion to the leve1 of interest for the anesthesia critical care fellow or his or her mentor. The second chapter, titled “Oxygenation and Blood Flow,” also realizes the same objectives in a concisely written six-page treatise covering the factors that govern tissue oxygen delivery in critically ill patients. While reading, the quality of the discussion leads one to half-expect to hear the final word on the optimal arterial oxygen partial pressure, the optimal hemoglobin, and the best cardiac output for our patients. This wil1 not be from these knowledgeable authors, they point out, because the data are lacking; instead, they do offer some guidelines from the latest studies concerning supranormal oxygen transport, oxygen debt in critically ill patients, and the conundrum of “pathologie supply dependency.” There is one obvious typing error: the partial pressure of arterial oxygen when cerebral vasodilation occurs is missing. There is good information in the following three chapters, ah focused on the multidisciplined aura of the ICU. “Vasodilating Drugs and Regional Circulation” looks at the pulmonary vasculature, the determinants of pulmonary vascular resistance, and pulmonary vasoactive agents useful in the persistent problem of pulmonary hypertension. Discussions on prostaglandins and intravenous fat emulsions are thorough. Some references are not as current as expected, nor is there any mention of nitric oxide, which is under clinical investigation. “Extracorporeal Methods in the Intensive Care Unit” addresses the use of hemodialysis, hemofiltration, continuous arteriovenous hemofiltration, and plasmapheresis in critically ill patients with renal failure, fluid overload, ARDS and sepsis. Diagrams would be helpful to convey the principles of diffusion and convection in hemodialysis. Certainly the use of illustrations makes “Metabolic Support in Severe Cardiopulmonary Insufficiency” one of the better chapters of this monograph. This treatise uniquely emphasizes the impact of malnutrition on cardiopulmonary function, ably supported by figures and references. The discussion of glucose-insulin-potassium (GIK) infusions is particularly informative. At this point, one might wonder how the chapters are organized. For instance, are the articles on “Critical Care of the Immunocompromised Patient, ” “Treatment of the Drug-Overdosed Patient in the Intensive Care Unit,” and “Gastrointestinal Crises in the Intensive Care Unit” subsumed in a medical-ICU classification, in contrast to the surgical-ICU practice in which many anesthesiabased intensivists tìnd themselves? There is no strict table of organization; the chapters stand by themselves with no evidente of overlap. Some might carp about the inclusion of these latter chapters, calling instead for such relevant topics as sedation and pain management in the ICU, or multiple organ failure syndrome. One cannot refute the scholarship of these latter three chapters

BOOK REVIEWS

638

and the presentation of information rarely found in critical care textbooks. The monograph falters in the chapters “Trauma Anesthesia and Critical Care,” “Care of the Patient with Brain Injury,” “High-Risk Cardiac Patient: Focus on Vascular Surgery,” and even “Hepatic and Cardiac Transplantation.” Is the critical care fellow managing these patients on the way to the operating room or the ICU? These discussions are directed towards the operating room, and though they are nicely reviewed, the same information can be found in current anesthesia textbooks. The editors are to be commended for the tinal chapters, “Ethics in the Intensive Care Unit,” and “The Intelligent Anesthesiologist’s Guide to the Language and Logie of Allocation.” The intensive care environment raises ethica1 dilemmas daily; the need for knowledge of ethica1 language and the processes of ethica1 decisions is obvious. Health care rationing, withholding of therapy, living wills, and the acquired immunodeficiency epidemie test our “discipline to deal with what is good and bad with mora1 duty and obligation.” For instance, the uniquely titled final chapter considers such terms as age rationing, tost containment, and quality-oflife measures. This is the language of allocation, charged with ethical, social, and economie judgments. Anesthesia-based ICU fellows need to be cognizant of the mora1 ambiguity of many of their decisions in the ICU environment; reflection on ethica1 theories and daily consideration roots them in practice. A daily discussion of ethica1 issues with the same fervor as reimbursement practices can only enhance our practice and raise om standing in the community, lay press, and politica1 arena. This monograph is recommended for its sustained scholarship and usefulness to fellows and practitioners in the critical care environment. It serves the fellow as a reference on some topics such as metabolic support and gastrointestinal crises; it serves the practitioner daily with its presentation of modern concepts in monitoring respiratory failure, oxygenation, and medical ethics. It deserves ready access in anesthesia and critical care unit libraries. Michael S. O’Connor, DO Department of Anesthesia Cleveland Clinic Cleveland, OH Thoracic Anesthesia (ed 2). Edited by Joel A. Kaplan, MD. New York, NY, Churchill-Livingstone, 1992,770 pp, $95.00. The first edition of Thoracic Anesrhesia, edited by Joel Kaplan, was published in 1983 and quickly became the standard textbook for the anesthetic management of patients undergoing noncardiac thoracic surgery. In the intervening nine years, many changes in the field have occurred requiring extensive revision, updating, and the addition of whole new chapters devoted to management of pain after thoracic surgery, nutritional care of the thoracic surgical patient, acquired immunodeficiency syndrome and hepatitis, and pulmonary transplantation. In the second edition, chapters have also been added addressing monitoring of oxygenation and ventilation during thora& surgery and a most interesting chapter dealing with the metabolic and hormonal function of the lung. As is the case with other textbooks edited by Dr. Kaplan, he has again been able to recruit acknowledged experts in each specific area of thoracic anesthesia to prepare their respective chapters. When viewing the textbook as a whole, one of its strengths is integrating the complex material from fields other than anesthesiology, such as pulmonary medicine, thoracic surgery and critical care medicine into a well-organized text. The book is divided into four parts and consists of 26 chapters. The major areas are (1) Preoperative Assessment and Management; (2) Respiratory Physiology and Pharmacology; (3) Specific Anesthetic Considerations; and (4) Postoperative Management.

Even though the textbook has been expanded to cover these new areas, it stil1 maintains a strong emphasis on understanding the physiology of the open chest patient with one-Iung ventilation. The section dealing with preoperative evaluation of the patient covers basic evaluation of pulmonary function tests and arterial bloed gases. radiology of the chest, and preparation of the patient with chronic pulmonary disease. Understanding the chest x-ray is basic to the practice of thoracic anesthesia and remains one of the outstanding chapters in this textbook. This chapter has been modified to provide more extensive coverage of magnetic resonance imaging. The chapter by Alexander Gotta is an outstanding review of AIDS. addressing its impact on the practice of anesthesiology. The Respiratory Physiology and Pharmacology section begins with a chapter on metabolic and hormonal functions of the hing. The lung was once viewed as an organ involved solely with gas exchange and only in recent years has it become regarded as an active metabolic organ that plays an important role in maintaining cardiovascular stability. In this chapter, Dr. Roger Johns brings the clinical anesthesiologist up to date on the most recent basic science discoveries, such as endothelium-derived relaxing factor and a detailed discussion of the eicosanoids and ends with an excellent discussion of the metabolism of xenobiotics and a suggested pathology of acute lung injury. There are separate chapters dealing with respiratory physiology during anesthesia, and physiology of the lateral decubitus position in the open chest and one-lung ventilation. The chapter on one-lung ventilation is written by the world’s expert in this area, Jonathan Benumof, and is presented in a logical, straightforward understandable fashion. The chapter on bronchodilators and bronchoactive drugs brings the practicing clinician up to date regarding some of the controversies with theophylline and newer bronchodilating agents. A new chapter by Kevin Tremper on the monitoring of oxygenation and ventilation is particularly appropriate because of the special considerations for pulse oximetry and capnometry in the patient undergoing one-lung ventilation. The sections on mediastinoscopy and thoracoscopy have been expanded in the chapter “Anesthesia for Thoracic Diagnostic Procedures.” The chapter “Anesthesia for Esophageal and Mediastinal Surgery“ is an excellent review, particularly for those cases that are infrequently done, such as thymectomy for myasthenic syndrome and management of patients with mediastinal masses that can result in life-threatening complications if there is an error in anesthetic management. The book is updated to cover anesthetic management for therapeutic procedures such as laser resection of trachea1 tumors, as well as the anesthetic management of the patient for bronchopulmonary lavage. Patients requiring this procedure can be suffering from alveolar proteinosis, inhalation of radioactive dust. cystic fibrosis, bronchiectasis, and asthmatic bronchitis. A discussion of management of the complex problems of trachea1 resection also is extensively covered in this textbook. A chapter on thoracic trauma is too brief in its discussion of these challenging cases. The chapter on anesthesia for pediatrie and neonatal thoracic surgery contains two tables that take up more than 12 large pages and lists more than 70 thoracic and cardiac abnormalities. A brief description of the syndrome is given. and anesthetic and perioperative considerations are also provided in tabular form. This provides a most valuable reference for the clinician faced with the diverse group of pediatrie pulmonary and cardiac problems that are sporadically seen in this clinical setting. The chapter on pulmonary transplantation is a valuable addition to the literature. The chapter devoted to pain management following thoracic surgery is comprehensive both in theory and specific management. In the chapters “Etiology and Treatment of Respiratory Failure.” and “Techniques of Ventilation and Oxygenation,“ the expansion of the discussion on pressure support ventilation and