Miller's Anesthesia, 6th Edition. Edited by Ronald D. Miller, M.D. Philadelphia, Elsevier, Churchill, Livingstone, 2005. Pages: 3,198. Price: $289.

Regarded by many as the most comprehensive text available focused on the theory and practice of anesthesia and allied areas, Miller's Anesthesia  is now in its sixth edition, which is testament to its popularity in the United States of America and abroad. The new edition builds on the strengths of previous editions with a number of enhancements, especially electronic ones, that are likely to be well received. In view of the text's staying power, Miller's Anesthesia  is likely to continue to enjoy its position as the standard by which competitors, both old and new, are judged.

As with previous editions, the text is organized into sections that reflect the theory and practice of modern anesthesia. The introduction is comprised of a single chapter chronicling the history of anesthesia from ancient times to modern (with brief biographies of major historical figures in the specialty), which serves as an excellent springboard for the rest of the text. The basic science section of the book, section II, covers basic pharmacology principles, individual drug classes, and physiology. It also includes chapters about drug delivery systems, complementary and alternative therapies, and statistics.

The remainder of the text is devoted to topics in clinical anesthesia and allied areas. Section III covers anesthesia management topics from preoperative preparation, monitoring, and anesthesia techniques (e.g. , airway management, regional anesthesia, transfusion medicine). Section IV is a large section focused on subspecialty management, including acute and chronic pain. Section V deals with adult and pediatric critical care, with additional chapters about nutrition, resuscitation, and brain death. The text's final segment, section VI, takes in a variety of topics, including operating room management, quality improvement, human simulation, medical information on the Internet, electrical safety, and ethical/legal aspects of anesthesia.

There are significant new chapters in the Sixth Edition. Some of these reflect the importance of new developments in medicine and society as they relate to anesthesia. Perhaps chief among these is the chapter about medical concerns associated with chemical and biologic warfare. Other new additions include chapters about implantable cardiac pulse generators, perioperative blindness, anesthesia for robotic surgery, and human performance in patient safety. It is worth noting that, by and large, the existing chapters from previous additions seem to have been updated with more recent information. In fact, some of these chapters are by new authors and have been completely revised.

The accompanying compact disc, an enhancement first introduced in the fifth edition, is primarily focused on technical aspects of the practice of anesthesia and was significantly expanded. New video segments include clips about patient positioning, code blue simulation, LMA-Fastrach™ (Laryngeal Mask Company Limited, San Diego, CA) tracheal intubation, thoracic epidural placement, ultrasound-guided nerve blocks, and needle cricothyrotomy. The video segments, although of variable quality, are a welcome means of teaching some of the technical nuances of anesthetic practice.

Perhaps the most innovative enhancement to the Sixth Edition is the “e-dition,” a Web site associated with the textbook that will apparently include weekly updates from experts in the field. Although it is not explicitly stated by the authors, presumably the underlying notion driving the creation of this Web site is that textbooks are often considered somewhat out-of-date by the time they are published because the writing, editing, and production process consumes so much time. A well-done Web site can address this heretofore unavoidable shortcoming of textbooks by providing contemporary updates on an ongoing basis. The publishers suggest that the Web site will allow search procedures and the download of figures into electronic presentation software. Most importantly, it will reportedly link bibliographies with electronic abstract sources. Assuming that the Web site's quality and currency are on a par with the hardbound edition, it is likely to be a popular enhancement to the textbook. Exactly how the Web site is accessed and whether there are fees involved is not explained in the preface.

With regard to format, there are a number of features that are appealing. The Sixth Edition includes a dual-color format, a comprehensive index, copious illustrations, and a key-point summary at the end of each chapter. There are also full color sections relating to regional anesthesia procedures and transesophageal echocardiography images.

Its comprehensive scope, although obviously a strength, is perhaps its main weakness, depending on the intended audience. The two-volume set is so big that it is not likely to be read cover to cover by residents in training. Rather, it is likely to be used as a source for detailed information when a specific question or topic arises. One could imagine that the chapters devoted to various subspecialties could be read as a “mini” textbook by residents rotating on those specialties (e.g. , neuroanesthesia, obstetric anesthesia). Alternatively, the section about scientific principles might well be read completely by residents in training as a review of physiology and pharmacology related to anesthesia.

When a textbook reaches its sixth edition, one can be sure that the authors, editors, and publishers are doing something right. As such, Miller's Anesthesia  will enjoy a preeminent place on the bookshelves of anesthesiologists for the foreseeable future.

University of Utah School of Medicine, Salt Lake City, Utah.