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Emergencies in Clinica Medicine. Edited by Kennedy H. J. Published by Blackwell Scientific Publications. Pp. 487; indexed; illustrated. Price £18.50.
BRITISH JOURNAL OF ANAESTHESIA
270 Lectures in Anaesthesiology, 1986/1. Edited by J. S. M. Zorab and R. M. Weller. Published by Blackwell Scientific Publications. Pp. 98; illustrated. Price £8.50.
A. P. Adams Emergencies in Clinical Medicine. Edited by H. J. Kennedy. Published by Blackwell Scientific Publications. Pp. 487; indexed; illustrated. Price £18.50. Clinicians continually require new information to adapt their practices to provide "state-of-the-art" patient management. A popular way to acquire this information, it seems, is the modest-sized volume of collected reviews, recent advances or updates. In the present work, Dr Kennedy has assembled a number of distinguished contributors who provide chapters on all the common medical emergencies likely to be found in a general hospital. The book is not targeted at beginners, but is designed to be "an aid to physicians who already have a knowledge of practical management of medical emergencies". The subjects covered are wide-ranging and include useful chapters on the epidemiology of medical emergencies and their presenting symptoms as well as on specific aetio-pathological entities. In the introduction Dr Kennedy indicates that the individual
W. G. Anderson Anaesthesiafor Ambulatory Surgery. Edited by B. V. Wetchler. Published (1985) by J. B. Lippencott Company, Philadelphia. Pp. 476; indexed; illustrated. A most welcome and timely addition to the anaesthetists bookshelf, this book sets a high standard. Ambulatory anaesthesia is not synonymous with outpatient anaesthesia, but the difference is, in the U.K., largely one of semantics, as they both have similar objectives. The principal difficulty in actively promoting ambulatory surgery is the reconciliation of the apparent paradox of the provision of acceptable facilities, the selection, preoperative investigation and equally safe treatment of patients with that available in hospitals, which cost so much more to equip and operate. This book is the product of the extensive experience and the enthusiasm of a number of authorities who critically analyse their experiences and present the solution clearly and most persuasively. Success is attained by the rigorous and unyielding application of high standards: costs can be reduced without compromising patient safety. The increasing popularity of this type of unit, often
Downloaded from http://bja.oxfordjournals.org/ at East Carolina University on June 29, 2015
This volume of the Lectures in Anaesthesiology series of two volumes or issues a year contains monographs on the following six topics: the pharmacology and toxicity of local anaesthetics; the effects of anaesthesia on uteroplacental blood flow; asthma and the anaesthetist; postoperative pain relief, the anaesthetic implications of porphyria; and the analgesic effects of intrathecal and extradural opioids. A brief historical note on the development of anaesthesia in the prone position for chest surgery is also included. As with previous volumes in this series, the major irritation to the reader is the lack of consistency of style. For instance, a chapter from a contributor from the U.S.A. will use American spelling, but the non-American authors tend to use English spelling. The chapters in themselves are informative and interesting. However, it really is quite annoying for authors repeatedly to mention that an important paper exists, only for the reader to find that the citation doesn't appear in the list of references. Some contributors give no references at all but, instead, offer a list of "further reading", which is sometimes very sparse indeed. Some reviewers of previous volumes in this series have suggested that the material is really only for anaesthetists in the developing countries. This is patently nonsense and all the material offered is generally very clearly presented and is to quite a high standard. I would strongly recommend most of it to the examination candidate; just to take a single example, the article on the pharmacology and toxicity of local anaesthetics in this volume is succinctly and concisely written by a master and can hardly be bettered by the chapters on the same subject which appear in the various standard textbooks on anaesthesia. However, some contributions can hardly be called "lectures", but have been considerably worked up into concise and sometimes complex monographs. This reviewer likes the series, for it deserves widespread success for its aims in the educational field. The editors obviously have a difficult job—so do all editors—but they must get their act together and do some firmer editing to prevent this series from just being a collection of highly individual disparate papers, albeit by highly respected experts, which are thrown together in sufficient numbers to make up an issue.
authors were asked, not only to give practical guidance on management, but to discuss current limitations in knowledge, current controversies, and to give their reasons for following particular approaches to management. In their response to this injunction the individual authors have varied rather widely. For an established clinician to integrate to his practice a new development requires, ideally, information from new, well conducted original studies relevant to the question in hand. Such studies will appear in the literature as original articles and the practical value of a review is to place such new developments in context and to provide adequate bibliographies. Many of Dr Kennedy's authors have indeed taken this approach, and those of us who may have missed items in the original literature can readily pick up the references. However, some chapters are thoroughly unsatisfactory, consisting of an account of the clinical condition with references only to standard text books, an approach which provokes the view that it would be simpler to read the text book in the first place. Review articles frequently irritate the reader with recommendations that such and such a form of treatment " may be valuable", or this or that manoeuvre "has been tried". To a clinician seeking practical guidance, such observations are worse than useless and this volume sadly is not free from such frustrating enjoinders. However, not all chapters can so be criticized, as many give clear operational definitions of the clinical entities with clear recommendations for treatment often laid out graphically as decision trees or algorithms. A work such as this, seeking to bridge the gap between text books of medicine and the original literature, is likely to meet with most success with beginners in the subject who are avid for practical guidance. For more experienced clinicians the success of the work in reaching its audience may, in a curious way, be inversely proportional to the need, for surely as we extend our experience we tend to become more fixed in our clinical practices and find it easier to regard a fresh account as merely a catalogue of someone else's prejudices. To overcome such attitudes, a work such as this has to convince the reader that there is genuinely something new to be learned and this volume does so in some of its chapters. The book, at 487 pages, makes considerable demands on time and I cannot imagine wishing to read it all when the competing literature is so vast. Whether the demand on the pocket can be met will depend, as usual, on the size of the pocket.
BOOK REVIEWS
271
J. Thorbum Obstetric Anaesthesia and Analgesia, 3rd Edn. By D. D. Moir and J. Thorburn. Published by Balliere-Tindall. Pp. 390; indexed. Price £17.95. The first two editions of this book, published in 1976 and 1980, were considered essential reading for obstetric anaesthetists and those preparing for postgraduate examinations in anaesthesia. The present volume has been extensively revised, the sections on gastric acidity, failed or difficult intubation, extradural anaesthesia for Caesarean Section and the use of spinal anaesthesia having been rewritten. Dr Moir has been joined in authorship by his colleague, Dr Thorbum, and it is evident throughout that both are strong advocates for the greater use of regional anaesthesia. The first three chapters deal with the history of obstetric anaesthesia, the physiology of pregnancy and labour and the pharmacology of drugs used in labour. It is my view that the marked physiological changes occurring during childbirth and their influence on pharmacokinetics merited more detailed consideration. Nevertheless, these chapters contain a wealth of material, together with references to recent work, and the reader can easily pursue a particular topic. The inadequacies and dangers of the currently available drugs used for systemic analgesia are documented, yet one must remember that they still remain the mainstay of obstetric analgesic practice in the United Kingdom.
The section on general anaesthesia recommends one method for all situations. I would have liked to see a diagram or photograph showing the correct method of applying cricoid pressure. The doses of thiopentone sodium 3-3.5 mg kg"1 and etomidate 0.3 mg kg"1 are, in my opinion, too small to maintain unconsciousness in all patients during intubation and, indeed, may allow active movement if this procedure proves difficult. The question of hypo- and hyperventilation is considered in detail, and I would have liked a firm recommendation for end-tidal carbon dioxide monitoring in all patients. This would also help in ready recognition of inadvertent oesophageal intubation. The basic concepts relating to the management of general anaesthesia in obstetric patients are excellent. Dr Moir has done much to popularize extradural analgesia and to establish its safe practise in British obstetrics. It is evident from the section on regional anaesthesia that he recognizes the problems associated with its use in the non-teaching and smaller obstetric unit. The techniques, the institution of the block, its management and uses arc covered in detail. However, is the extradural space a mean or average 7 cm from the skin in the lumbar region? When dealing with extradural anaesthesia for Caesarean Section it is suggested that, if the blockade is inadequate after a substantial dose of bupivacaine, further spread might be obtained by additional lignocaine and this may be safer rhnn bupivacaine. This could be dangerous, as the toxic effects of local anaesthetics are additive and the reviewer feels that this advice in no way diminishes the risk of overdosage reactions. Spinal anaesthesia, which is becoming more popular, is well described. However, manufactured introducers for 25-s.w.g. spinal needles are readily available, so there is no need to make-do with the "make-shift" needle suggested. Infiltration of the skin and interspinous ligaments is not considered an essential part of the author's technique, yet if a second attempt (not uncommon) has to be made, the patient's co-operation may be lost because of the pain from a lack of analgesia. The management of maternal and infant complications of labour are discussed, together with sections on paracervical and pudendal block anaesthesia. The section on pre-eclampsia underlines the need for intensive management. In correcting acidosis in the newborn, a 4.2 % solution of sodium bicarbonate is less irritant than the recommended 8.4%. The book also contains a chapter on the management of pregnancy and labour by an obstetrician (M. R. Whittle), so the reader is given a good overall view of the problems likely to present in the delivery room. This book is well produced, written in a clear distinctive style and every chapter has an extensive up-to-date bibliography. It is strongly biased towards regional anaesthesia and only time will tell if this will reduce maternal mortality associated with anaesthesia. Like previous editions, it is essential reading for all associated with obstetric analgesic and anaesthetic practice. J. Moore Guidelines in Clinical Anaesthesia. By P. Hurton and G. Cooper. Published by Blackwell Scientific Publications. Pp. 403; indexed; illustrated. The time honoured advice of the physician who does not understand his role in prcoperative assessment is "avoid hypotension, hypoxia and hypercarbia". This book goes one step further. In the section on cerebrovascular disease, it states "The patient should be maintained normotensive by application of the techniques described in Chapter 1". Would that
Downloaded from http://bja.oxfordjournals.org/ at East Carolina University on June 29, 2015
apparently freestanding in the U.S.A., depends on strict attention to detail in its planning, the careful selection of staff and their continuous education. The importance of the design and integrated function is comprehensively discussed in the first pan of the book, this is perhaps less relevant in the U.K., where the majority of out patient surgical facilities arc integrated with hospitals, but the principles of care presented so clearly are very relevant. Obviously, this is a book aimed at the American anaesthetist, but it is not parochial, and the U.K. literature is referred to when appropriate. One distinct difference is that the ambulatory unit is responsible for the provision of after care, and patients are followed up by telephone and postcard. In the U.K., community services provide the convalescent care. Suitable anaesthetic techniques are considered in great detail with appropriate and comprehensive references. The emphasis is always on patient care and safety. The references are worthy of comment: their presentation is, in my experience, unique. At the end of each chapter, the references are placed in alphabetical order, and numbered in that order. References in the text are given the appropriate number. This produces a neat and economical solution to a minor but irritating problem and should be widely copied. The editor is to be congratulated in producing such a book, the contributors' enthusiasm is evident, but the evidence relating to ambulatory anaesthesia is carefully and critically examined. Clear and sensible guidance is given, some "real life" situations are presented in the form of question and answer; the issues are not fudged. Copies of leaflets successfully used in large units, which cover all relevant aspects of care and which are given to ambulatory surgical patients, are usefully included. The volume is well produced, with clear illustrations. Although quite expensive, it is a bargain; no comparable book exists. It should be compulsory reading for anyone involved in outpatient anaesthesia, and is interesting and informative to those who are not.
270 Lectures in Anaesthesiology, 1986/1. Edited by J. S. M. Zorab and R. M. Weller. Published by Blackwell Scientific Publications. Pp. 98; illustrated. Price £8.50.
A. P. Adams Emergencies in Clinical Medicine. Edited by H. J. Kennedy. Published by Blackwell Scientific Publications. Pp. 487; indexed; illustrated. Price £18.50. Clinicians continually require new information to adapt their practices to provide "state-of-the-art" patient management. A popular way to acquire this information, it seems, is the modest-sized volume of collected reviews, recent advances or updates. In the present work, Dr Kennedy has assembled a number of distinguished contributors who provide chapters on all the common medical emergencies likely to be found in a general hospital. The book is not targeted at beginners, but is designed to be "an aid to physicians who already have a knowledge of practical management of medical emergencies". The subjects covered are wide-ranging and include useful chapters on the epidemiology of medical emergencies and their presenting symptoms as well as on specific aetio-pathological entities. In the introduction Dr Kennedy indicates that the individual
W. G. Anderson Anaesthesiafor Ambulatory Surgery. Edited by B. V. Wetchler. Published (1985) by J. B. Lippencott Company, Philadelphia. Pp. 476; indexed; illustrated. A most welcome and timely addition to the anaesthetists bookshelf, this book sets a high standard. Ambulatory anaesthesia is not synonymous with outpatient anaesthesia, but the difference is, in the U.K., largely one of semantics, as they both have similar objectives. The principal difficulty in actively promoting ambulatory surgery is the reconciliation of the apparent paradox of the provision of acceptable facilities, the selection, preoperative investigation and equally safe treatment of patients with that available in hospitals, which cost so much more to equip and operate. This book is the product of the extensive experience and the enthusiasm of a number of authorities who critically analyse their experiences and present the solution clearly and most persuasively. Success is attained by the rigorous and unyielding application of high standards: costs can be reduced without compromising patient safety. The increasing popularity of this type of unit, often
Downloaded from http://bja.oxfordjournals.org/ at East Carolina University on June 29, 2015
This volume of the Lectures in Anaesthesiology series of two volumes or issues a year contains monographs on the following six topics: the pharmacology and toxicity of local anaesthetics; the effects of anaesthesia on uteroplacental blood flow; asthma and the anaesthetist; postoperative pain relief, the anaesthetic implications of porphyria; and the analgesic effects of intrathecal and extradural opioids. A brief historical note on the development of anaesthesia in the prone position for chest surgery is also included. As with previous volumes in this series, the major irritation to the reader is the lack of consistency of style. For instance, a chapter from a contributor from the U.S.A. will use American spelling, but the non-American authors tend to use English spelling. The chapters in themselves are informative and interesting. However, it really is quite annoying for authors repeatedly to mention that an important paper exists, only for the reader to find that the citation doesn't appear in the list of references. Some contributors give no references at all but, instead, offer a list of "further reading", which is sometimes very sparse indeed. Some reviewers of previous volumes in this series have suggested that the material is really only for anaesthetists in the developing countries. This is patently nonsense and all the material offered is generally very clearly presented and is to quite a high standard. I would strongly recommend most of it to the examination candidate; just to take a single example, the article on the pharmacology and toxicity of local anaesthetics in this volume is succinctly and concisely written by a master and can hardly be bettered by the chapters on the same subject which appear in the various standard textbooks on anaesthesia. However, some contributions can hardly be called "lectures", but have been considerably worked up into concise and sometimes complex monographs. This reviewer likes the series, for it deserves widespread success for its aims in the educational field. The editors obviously have a difficult job—so do all editors—but they must get their act together and do some firmer editing to prevent this series from just being a collection of highly individual disparate papers, albeit by highly respected experts, which are thrown together in sufficient numbers to make up an issue.
authors were asked, not only to give practical guidance on management, but to discuss current limitations in knowledge, current controversies, and to give their reasons for following particular approaches to management. In their response to this injunction the individual authors have varied rather widely. For an established clinician to integrate to his practice a new development requires, ideally, information from new, well conducted original studies relevant to the question in hand. Such studies will appear in the literature as original articles and the practical value of a review is to place such new developments in context and to provide adequate bibliographies. Many of Dr Kennedy's authors have indeed taken this approach, and those of us who may have missed items in the original literature can readily pick up the references. However, some chapters are thoroughly unsatisfactory, consisting of an account of the clinical condition with references only to standard text books, an approach which provokes the view that it would be simpler to read the text book in the first place. Review articles frequently irritate the reader with recommendations that such and such a form of treatment " may be valuable", or this or that manoeuvre "has been tried". To a clinician seeking practical guidance, such observations are worse than useless and this volume sadly is not free from such frustrating enjoinders. However, not all chapters can so be criticized, as many give clear operational definitions of the clinical entities with clear recommendations for treatment often laid out graphically as decision trees or algorithms. A work such as this, seeking to bridge the gap between text books of medicine and the original literature, is likely to meet with most success with beginners in the subject who are avid for practical guidance. For more experienced clinicians the success of the work in reaching its audience may, in a curious way, be inversely proportional to the need, for surely as we extend our experience we tend to become more fixed in our clinical practices and find it easier to regard a fresh account as merely a catalogue of someone else's prejudices. To overcome such attitudes, a work such as this has to convince the reader that there is genuinely something new to be learned and this volume does so in some of its chapters. The book, at 487 pages, makes considerable demands on time and I cannot imagine wishing to read it all when the competing literature is so vast. Whether the demand on the pocket can be met will depend, as usual, on the size of the pocket.
BOOK REVIEWS
271
J. Thorbum Obstetric Anaesthesia and Analgesia, 3rd Edn. By D. D. Moir and J. Thorburn. Published by Balliere-Tindall. Pp. 390; indexed. Price £17.95. The first two editions of this book, published in 1976 and 1980, were considered essential reading for obstetric anaesthetists and those preparing for postgraduate examinations in anaesthesia. The present volume has been extensively revised, the sections on gastric acidity, failed or difficult intubation, extradural anaesthesia for Caesarean Section and the use of spinal anaesthesia having been rewritten. Dr Moir has been joined in authorship by his colleague, Dr Thorbum, and it is evident throughout that both are strong advocates for the greater use of regional anaesthesia. The first three chapters deal with the history of obstetric anaesthesia, the physiology of pregnancy and labour and the pharmacology of drugs used in labour. It is my view that the marked physiological changes occurring during childbirth and their influence on pharmacokinetics merited more detailed consideration. Nevertheless, these chapters contain a wealth of material, together with references to recent work, and the reader can easily pursue a particular topic. The inadequacies and dangers of the currently available drugs used for systemic analgesia are documented, yet one must remember that they still remain the mainstay of obstetric analgesic practice in the United Kingdom.
The section on general anaesthesia recommends one method for all situations. I would have liked to see a diagram or photograph showing the correct method of applying cricoid pressure. The doses of thiopentone sodium 3-3.5 mg kg"1 and etomidate 0.3 mg kg"1 are, in my opinion, too small to maintain unconsciousness in all patients during intubation and, indeed, may allow active movement if this procedure proves difficult. The question of hypo- and hyperventilation is considered in detail, and I would have liked a firm recommendation for end-tidal carbon dioxide monitoring in all patients. This would also help in ready recognition of inadvertent oesophageal intubation. The basic concepts relating to the management of general anaesthesia in obstetric patients are excellent. Dr Moir has done much to popularize extradural analgesia and to establish its safe practise in British obstetrics. It is evident from the section on regional anaesthesia that he recognizes the problems associated with its use in the non-teaching and smaller obstetric unit. The techniques, the institution of the block, its management and uses arc covered in detail. However, is the extradural space a mean or average 7 cm from the skin in the lumbar region? When dealing with extradural anaesthesia for Caesarean Section it is suggested that, if the blockade is inadequate after a substantial dose of bupivacaine, further spread might be obtained by additional lignocaine and this may be safer rhnn bupivacaine. This could be dangerous, as the toxic effects of local anaesthetics are additive and the reviewer feels that this advice in no way diminishes the risk of overdosage reactions. Spinal anaesthesia, which is becoming more popular, is well described. However, manufactured introducers for 25-s.w.g. spinal needles are readily available, so there is no need to make-do with the "make-shift" needle suggested. Infiltration of the skin and interspinous ligaments is not considered an essential part of the author's technique, yet if a second attempt (not uncommon) has to be made, the patient's co-operation may be lost because of the pain from a lack of analgesia. The management of maternal and infant complications of labour are discussed, together with sections on paracervical and pudendal block anaesthesia. The section on pre-eclampsia underlines the need for intensive management. In correcting acidosis in the newborn, a 4.2 % solution of sodium bicarbonate is less irritant than the recommended 8.4%. The book also contains a chapter on the management of pregnancy and labour by an obstetrician (M. R. Whittle), so the reader is given a good overall view of the problems likely to present in the delivery room. This book is well produced, written in a clear distinctive style and every chapter has an extensive up-to-date bibliography. It is strongly biased towards regional anaesthesia and only time will tell if this will reduce maternal mortality associated with anaesthesia. Like previous editions, it is essential reading for all associated with obstetric analgesic and anaesthetic practice. J. Moore Guidelines in Clinical Anaesthesia. By P. Hurton and G. Cooper. Published by Blackwell Scientific Publications. Pp. 403; indexed; illustrated. The time honoured advice of the physician who does not understand his role in prcoperative assessment is "avoid hypotension, hypoxia and hypercarbia". This book goes one step further. In the section on cerebrovascular disease, it states "The patient should be maintained normotensive by application of the techniques described in Chapter 1". Would that
Downloaded from http://bja.oxfordjournals.org/ at East Carolina University on June 29, 2015
apparently freestanding in the U.S.A., depends on strict attention to detail in its planning, the careful selection of staff and their continuous education. The importance of the design and integrated function is comprehensively discussed in the first pan of the book, this is perhaps less relevant in the U.K., where the majority of out patient surgical facilities arc integrated with hospitals, but the principles of care presented so clearly are very relevant. Obviously, this is a book aimed at the American anaesthetist, but it is not parochial, and the U.K. literature is referred to when appropriate. One distinct difference is that the ambulatory unit is responsible for the provision of after care, and patients are followed up by telephone and postcard. In the U.K., community services provide the convalescent care. Suitable anaesthetic techniques are considered in great detail with appropriate and comprehensive references. The emphasis is always on patient care and safety. The references are worthy of comment: their presentation is, in my experience, unique. At the end of each chapter, the references are placed in alphabetical order, and numbered in that order. References in the text are given the appropriate number. This produces a neat and economical solution to a minor but irritating problem and should be widely copied. The editor is to be congratulated in producing such a book, the contributors' enthusiasm is evident, but the evidence relating to ambulatory anaesthesia is carefully and critically examined. Clear and sensible guidance is given, some "real life" situations are presented in the form of question and answer; the issues are not fudged. Copies of leaflets successfully used in large units, which cover all relevant aspects of care and which are given to ambulatory surgical patients, are usefully included. The volume is well produced, with clear illustrations. Although quite expensive, it is a bargain; no comparable book exists. It should be compulsory reading for anyone involved in outpatient anaesthesia, and is interesting and informative to those who are not.