Peripheral Nerve Blocks: Principles and Practice.  Admir Hadzic and Jerry D. Vloka. New York, McGraw-Hill, 2004. ISBN: 0-07-140918-1. Pages: 364. Price: $99.99.

Is a picture worth a thousand words? If you consider this maxim to hold true for regional anesthesia reference books, then the 364 pages of Peripheral Nerve Blocks  will offer you more information than the entire text of any encyclopedia. Nearly every page is filled with full-color illustrations and photographs to supplement the superb textual material. However, do not confuse this new volume with a generic anatomy atlas: it offers an enormous amount of detailed didactic information of value to all practitioners of regional anesthesia, regardless of experience level.

The text is divided into 25 chapters, the first seven of which cover topics related to regional anesthesia. The remaining chapters are devoted to specific nerve blocks. In the initial chapters, readers will find the second distinguishing characteristic of this volume: thorough preparation for placing peripheral nerve blocks. Another applicable title for this text would be “Regional Anesthesia: From A to Z.” In addition to expected chapters on anatomy and local anesthetic pharmacology, readers will find nearly 80 pages devoted to such often-overlooked topics as training in peripheral nerve blocks, choosing block needles, catheters, and nerve stimulators, patient monitoring, and neurologic complications of peripheral nerve blocks. For practitioners with limited regional anesthesia experience, these chapters offer essential information such as how to set up a regional anesthesia “cart” and “block room.” In a methodical fashion, the authors take readers literally step-by-step through the process of preparing to place peripheral nerve blocks. The multitude of pictures not only enliven what could otherwise be less-than-stimulating material but also demystify this critical preparation for practitioners unaccustomed to regional techniques.

The last of these introductory chapters, “Keys to Success with Peripheral Nerve Blocks,” offers additional information for practitioners with minimal regional experience, including information regarding patient selection and education, premedication choices and dosages, and intraoperative and postoperative patient management. In addition, an especially informative table (Table 7.2) lists various common surgical procedures and suggested regional techniques for each, along with specific potential benefits and drawbacks. Inexperienced practitioners will find this information invaluable, as few providers pick up a reference book to discover which surgeries are applicable to a specific block (as most texts are laid out) but rather are preparing for a specific surgical procedure and are therefore interested in the applicable regional techniques.

Subsequent chapters each encompass a specific regional block in a coherent order, beginning with the cervical plexus and upper extremity, then thoracic and lumbar paravertebral blocks, and finally lower extremity techniques. Each chapter begins with a section, “Block at a Glance,” that gives important basic information such as indications, landmarks, nerve stimulation endpoints, and recommended local anesthetic volume. Next, relevant anatomy is reviewed with an emphasis on both superficial landmarks and underlying structures. A plethora of full-color diagrams and photographs supplement the thorough textual descriptions. Single-injection techniques are reviewed first. Not a single detail of block placement is overlooked, with patient positioning, specific needle gauge and length, maneuvers to accentuate landmarks, local anesthetic skin infiltration, hand positioning, choice of local anesthetic, and perioperative management all thoroughly discussed.

Included in each chapter readers will find the text’s third distinguishing characteristic: extensive descriptions of redirection cues. Although most reference materials describe where to place the block needle and the desired endpoint before local anesthetic injection, few provide suggestions to practitioners on what to do when the desired endpoint (e.g. , “twitch”) is not reached after the first pass. These redirection cues are provided for nearly every possible undesired obtained response. Performing an interscalene block and finding trapezius muscle twitches? No problem: the authors provide an interpretation (e.g. , accessory nerve stimulation), the specific problem (e.g. , needle too posterior), and corrective action (e.g. , withdraw needle and reinsert anteriorly). These extensive discussions and tables provided for every block remove much of the ambiguity surrounding peripheral nerve block placement, and will enable a high degree of success for even the least experienced practitioners.

After the review of single-injection techniques in each chapter, the authors repeat this thorough description for continuous nerve blocks (i.e. , continuous catheters) when applicable. Suggestions for managing the postoperative local anesthetic infusion are also provided. As techniques for perineural catheter placement have evolved relatively rapidly in the past decade, even experienced regionalists will find this information beneficial. Finally, each chapter concludes with a table of potential complications and methods to avoid them, followed by a suggested reading list of peer-reviewed/invited journal articles and additional reference texts.

Additional positive qualities that deserve mention are the superb writing style of the authors and thorough index provided by the publisher. Limitations of this volume are few and pale in comparison to its relative strengths. As with any reference written exclusively by a few authors, personal bias is unavoidable throughout the text. For example, the authors present an interscalene block technique in which the needle is inserted more distal than in the commonly described procedure performed at the level of the cricoid cartilage, although no data are presented to support a benefit over the traditional approach. There are a few inconsistencies or errors throughout the text as well. For example, the authors describe using percutaneous stimulation for brachial plexus location with a current of 4–5 mA in the chapter on axillary blocks and describe the same procedure with a current of 0.4–0.5 mA on the next page. However, these oversights are exceedingly rare, and that they are mentioned at all is a testament to how few limitations this reviewer found of the text in general. So, whether you already have a small library devoted to regional anesthesia or desire a single volume to fulfill your reference needs, this new tome will most probably serve you well for years to come.

University of Florida, Gainesville, Florida.