James C. Eisenach, M.D., Editor

Clinical Orthopedic Anesthesia. By John E. Tetzlaff. Stoneham, MA, Butterworth-Heinemann, 1996. Pages: 406. Price:$60

Clinical Orthopedic Anesthesia is a spiral bound, softcover text that could be carried in the pocket of a laboratory coat. The text consists of 22 chapters, with 17 solely authored by Dr. Tetzlaff and 5 co-authored by Tetzlaff and one of 4 contributing authors. The text is illustrated with black-and-white line drawings, and addresses the “subspecialty” of orthopedic anesthesia. It is intended to serve as a convenient reference for use in the operating room, particularly for trainees.

The organization of the book is logical, with the first three chapters addressing preoperative patient preparation, preparation for regional anesthesia, and orthopedic positioning considerations. The next five chapters discuss regional anesthesia and local anesthetics in moderate detail. Chapters 9–12 discuss specific surgical categories such as shoulder surgery and lower extremity joint replacement. The remaining 10 chapters cover miscellaneous topics, including deep venous thrombosis, fat embolism, postoperative pain control, and pneumatic tourniquet use.

Unfortunately, this work contains many dogmatic statements that limit the book's usefulness as a teaching tool or reference manual. For example, in the section addressing pulmonary disease, Tetzlaff argues that “if the patient is a heavy smoker, a carbon monoxide level (carboxyhemoglobin) should be obtained to predict falsely elevated oxygen saturation.” In some cases, this might be a useful piece of preoperative information, but in North Carolina, (at least) this approach would significantly increase the cost of preoperative testing, with no documented justification.

In the chapter “Preparation for Regional Anesthesia,” Tetzlaff makes the statement that “major body segment amputation is a procedure for which it is unrealistic to have the patient awake in the operating room.” This gives the impression that it is inappropriate to administer a regional anesthetic for an above-the-knee or below-the-knee amputation. The trainee would be better served by advice that regional anesthesia for amputation should be accompanied by appropriate levels of sedation and proper operating room decorum, including shielding the patient's line of sight. During his discussion of anesthetic techniques for lower extremity joint replacement, the author states that “the femoral sciatic leg block is a good anesthetic for total knee replacement, but is infrequently used because of its high total local anesthetic dose requirements, the time involved, and the amount of discomfort for the patient.” This is only partly true, because an obturator nerve block also must be performed to provide anesthesia for a total knee replacement, which, even in expert hands, can be difficult to perform successfully. In addition, no mention is made of the need for a lateral femoral cutaneous nerve block to provide anesthesia for the lateral aspect of the knee.

Further weaknesses are evident as omissions. No mention is made of the association between hyperbaric 5% lidocaine and cauda equina syndrome or transient radiculopathy. In the chapter on local anesthetics, toxic doses are expressed as milligrams, rather than milligrams per kilogram of body weight. This could lead the new trainee to assume that 500 mg lidocaine (with epinephrine) is a safe and appropriate dose in a 35-kg patient, and that exceeding this dose would be unsafe in a 130-kg patient.

On the positive side, the illustrations and line drawings are clear and well done. They serve as a simple, yet practical, anatomic guide to assist the trainee in performing multiple regional anesthetic procedures. The chapter on fat emboli is interesting and provides a great deal of information pertaining to both subclinical fat emboli and the full-blown fat embolism syndrome. In general, however, inaccuracies and unsubstantiated dogmatic statements occur throughout the book, This is a major drawback that precludes my recommendation of this text.

Robert C. Morell, MD; Assistant Professor, Department of Anesthesia, Bowman Gray School of Medicine, Winston-Salem, North Carolina 27157–1009.