Evidence-based Practice of Anesthesiology, 2nd Edition. Edited by Lee A. Fleisher, M.D. Philadelphia, Saunders Elsevier, 2009. Pages: 516. Price: $99.00.
We frequently think of medicine as having evolved to modern practice from the roots of ancient medicine, where physician skills and practices were passed down from mentor to student in an apprentice-style fashion. However, even dating back to this early era of physician practice, the art of medicine was already being directed by basic observations of patient outcomes, thus qualifying it as somewhat evidence based. Although a now common phrase, evidence-based medicine only emerged as a recognized component of medical education and clinical practice in the 1990s. With the widespread availability of medical literature through the technology of computers and databases, evidence-based medicine has evolved into a more concrete concept of the analysis and interpretation of published research as the basis of clinical practice, and has become the expectation and standard for practicing physicians. Even within the more narrowed focus of our specialty, the anesthesia literature has an abundance of information on most topics; we must know how to decide which articles offer valid information to impact our practice.
Anesthesiology itself still combines evidence-based practice with anecdotal learning, because much of our practice does involve technical skills and style that develop over time and are a direct consequence of our training. Evidence-based Practice of Anesthesiology , 2nd Edition, appreciates both aspects in its comprehensive review of current evidence supporting our clinical practice. There are topics with enough existing data to support accepted guidelines and recommendations. One example is, “Which Patient Should Have a Preoperative Cardiac Evaluation (Stress Test)?” Conversely, there are topics that are less clear-cut and void of formal practice guidelines, such as “What Works for Brain Protection?” The book is refreshing and enlightening because it reveals which of our practices are truly supported in the literature and which are not. For example, cricoid pressure has not been shown to reduce the incidence of aspiration despite that we routinely use it for that reason.
The organization and presentation of the book is similar to the first edition.1Every chapter is titled with a question, and the topics were selected carefully to address issues that we as anesthesiologists are frequently posed within daily practice. Chapters begin with a brief introduction, followed by therapeutic options, current evidence, and areas of uncertainty. The discussion is finalized with a summary of existing guidelines and/or recommendations by the author. The chapters are comprehensive but concise, and the recommendations are, in general, excellent summaries with valid suggestions.
There are several key changes present in this second edition. As expected, the necessary updates from changes in literature are present, e.g. , the elimination of rapacuronium and the mention of the potential role of sugammadex in the summary of the evidence-based approach to choice of muscle relaxant. Some chapters have been entirely eliminated, such as “Should Succinylcholine Be Used in Children?” Other chapters have been eliminated but their content placed within another chapter, e.g. , “Is There a Difference in Perioperative Morbidity and Mortality in Patients Undergoing Carotid Endarterectomy with Local versus General Anesthesia?” has been addressed in the chapter “What Are the Risk Factors for Perioperative Stroke?”
The book likewise has more than 20 new chapters, introducing many relevant debates in anesthesiology, such as “How Long Should You Wait after Percutaneous Coronary Intervention for Noncardiac Surgery?” The section having been transformed the most is Cardiovascular Anesthesia. The first edition has two chapters devoted to carotid endarterectomies, whereas the second edition appropriately focuses on more current topics in cardiac anesthesia: the evidence to support fast-tracking, and approaches to blood conservation in cardiac surgery. These changes improve the content of the first edition, making the second more current with respect to topics of controversy and debate in anesthesiology. Last, the second edition is an Expert Consult title and is conveniently accessible in its entirety on-line.
Resident trainees and the practicing clinicians alike will appreciate the concise but comprehensive nature of each chapter and the wide variety of topics covered by the text. The book explains the basis for many of our current practices and which of our practices are actually not supported by concrete evidence. It is an excellent learning tool for training clinicians and presents information in such a way that can aid the maturation from trainee to consultant in anesthesiology. Likewise, it is an outstanding text for practicing clinicians who wish to remain current over a broad span of topics, filtering through the vast body of available anesthesia literature and presenting the most relevant and valid contributions that should impact our specialty. The first edition of Evidence-based Practice of Anesthesiology was a landmark contribution, and the second edition maintains this standard.
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