James C. Eisenach, M.D., Editor.
Geroanesthesia. Principles for Management of the Elderly Patient. By Stanley Muravchick. St. Louis, Mosby-Year Book, Inc., 1997. Pages: 306. Price:$64.95.
Geroanesthesia is an ambitious, thought-provoking “how-I-rationalize-what-I-do” treatise discussing a physiology-based approach to the perioperative treatment of the elderly patient and not a “how-to-do-it” manual or a standard textbook chapter expanded into full text. Its uniqueness is reflected in the quirkiness of its title, which is defined in the Preface. For this monograph to be truly appreciated, it first should be recognized for what it is not because it focuses on a select audience for a serious intellectual purpose. It is not a reference book to select the night before the administration of an anesthetic to a geriatric patient. It is not a book to be read without a strong basic knowledge of normal physiology or anesthesiology. It is not a book to be read in preparation for the written or oral certifying examinations. Finally, it is not a book to be read casually. But it is a book that could serve as the sole background reading for a consensus development conference convened to define the subspecialty of geroanesthesia. Each chapter is really a serious essay by the same author who has written extensively in the field of geriatric anesthesia. To fully appreciate this book, the reader should forget speed reading, ignore its Index, and set aside some time. Each chapter is meant to be perused, each conclusion challenged, and each revelation savored. If the standard textbook chapter is viewed as a cup of instant coffee to be drunk on the run, this book is a pot brewed for the evening from the best beans freshly ground.
Chapters 1 and 2 provide overviews of aging, preoperative evaluation, and perioperative management. Chapters 3–8 are organized as follows: physiologic overview of an organ system, specific discussion of how aging affects physiologic function within this system, anesthetic implications, and a case history. All the illustrations are original with the author, and they contributed significantly to my understanding of the author's line of reasoning. The physiologic interpretations in the chapters devoted to the central nervous system, the peripheral and autonomic nervous system, body composition and metabolism, the cardiovascular system, and the respiratory system inspired many “I-didn't-realize-that” and “that's-an-interesting-way-to-present-this” thoughts. But the combination of renal and blood functions in the final chapter seemed awkward and contrived. A separate chapter on blood functions including an extensive discussion of oxygen delivery and transfusion criteria in the elderly population would have been welcome. The bibliography for each chapter averages more than 200 references.
The real strength of each chapter is the physiologic overview and how aging affects function. In the Preface, the author states that “… for perhaps the first time, we now have an adequate understanding of general concepts of human aging and sufficient data regarding organ function and functional reserve in older adults to attempt a comprehensive and detailed overview of the implications of aging with regard to the perioperative management of the elderly patient. That is the purpose of this book.” I think he has demonstrated that we are not there yet because each chapter consistently becomes less satisfying when anesthetic implications and perioperative management are discussed. The brief clinical histories provided as clinical correlations at the end of each chapter do not really work and could easily have been deleted.
The risk of challenging readers is to invite criticism. I would like to suggest just a few. First, the American Society of Anesthesiologists' physical status is vigorously defended as “… influenced neither by the patient age nor by the type of surgery …,” yet the effect of aging discussed in each chapter could be classified at least as significant as mild systemic disease. Second, the statement is made that “… the importance of avoiding arterial hypotension intraoperatively in elderly patients with pre-existing hypertension and cerebrovascular disease would seem to be self-evident …”[to avoid a perioperative stroke] despite no definition of hypotension, an acknowledgment of the success of deliberate hypotensive techniques, and the nonacknowledgment that most perioperative strokes are embolic or hemorrhagic in origin. Third, although the body composition and metabolism portion of Chapter 5 is enlightening, the ensuing pharmacokinetic discussion tries too hard to associate mathematical with physiologic compartments. I would also recommend skipping the pharmacokinetic discussions on pages 166–174-the only really significant blemishes in 306 pages.
In summary, Geroanesthesia is like a movie that succeeds in the eyes of the critics but does poorly at the box office. The serious in-control-of-his/her-time anesthesiologist will find this introspective effort worth the price and the time commitment. The harried trying-to-catch-up anesthesiologist will be annoyed that the author expects the reader to read whole sections of “why” rather than just one paragraph of “how” to answer a specific clinical question. Sadly there are more of the latter than the former.
Raymond C. Roy, M.D., Ph.D.
Professor and Chair; Department of Anesthesiology; University of Virginia Health Sciences Center; P.O. Box 10010; Charlottesville, Virginia 22906–0010