James C. Eisenach, M.D., Editor.
Introduction to Anesthesia, Ninth Edition. By Dripps, Eckenhoff, Vandam. Edited by David E. Longnecker and Frank L. Murphy. Philadelphia, W.B. Saunders, 1996. Pages: 528. Price:$47.50.
I became familiar with the fourth edition of this text during my residency in anesthesiology and purchased the fifth edition shortly after completing my residency. Both texts were easy to read, reasonable in price, and contained a wealth of information for the novice or newly educated anesthesia care provider, although my fifth edition has markedly fewer underlined passages than does the fourth, and it is less worn. The ninth edition retains the above qualities of the preceding issues. The text has undergone a degree of evolution over the years, especially in the addition of new chapters, as our knowledge base and emphasis change. Previous editions used a number of authors from institutions outside of Philadelphia, Pennsylvania, compared with the ninth edition, wherein only 4 of 43 authors are from outside of Philadelphia. This is a mere observation and does not appear to affect the quality of this textbook. These 43 authors have contributed 38 chapters divided into 7 sections. These sections will be discussed individually.
Section I is a brief overview of the evolution of the specialty and the progress that has been made. In Section II, there are five chapters dealing with preoperative evaluation, premedication, monitoring, blood gas interpretation, and the anesthesia machine. The chapter on blood gas analysis and interpretation mentions the concept of anion gap but offers no definition or explanation. There is no discussion of hydrogen ion concentration. Three cases are presented to illustrate acid-base abnormalities, which is helpful in understanding the etiology of the abnormality of the acid-base data. This reader would have appreciated an expansion of sections dealing with latex allergy and treatment of hypertension in Chapter 4. It is probably a sign of the times that pediatric breathing circuit discussion is limited to the Mapleson D circuit or the Bain modification, as is the case in Chapter 5. A discussion of gas laws as they apply to the anesthesia machine is omitted. Chapter 6 has a somewhat limited discussion of pulmonary artery catheters and transesophageal echocardiography in view of our current usage, knowledge, and controversy.
Section III discusses drugs used in anesthesia. Chapter 7 presents a concise and easily understandable discussion of pharmacologic principles and their importance to the anesthesiologist. Chapter 8 deals with the inhaled anesthetics and presents useful data and graphics comparing their properties and effects. Sevoflurane and desflurane are more than adequately compared with the older inhalation anesthetics. Chapters 9 and 10 deal with intravenous agents. The information presented is somewhat more limited, and there is no mention of remifentanil or nalmefene. The reader is cautioned to recall that ketamine is a direct myocardial depressant and that during anesthesia or in trauma patients ketamine may result in a paradoxical decrease in blood pressure. The chapters on muscle relaxants and medical gases are concise and informative.
Section IV reviews the conduct of the anesthetic. The chapter concerning airway management contains a number of useful and informative tables and algorithms. Although the chapter addressing fluids and blood loss also contains a number of useful and concise information in tabular form, a discussion of the use of aprotinin or the thromboelastogram is lacking, and the latest reference is 1988. The chapter regarding patient positioning is very practical.
Section V is confined to discussions of regional anesthesia and local anesthetic pharmacology. Although the chapter on nerve blocks contains excellent diagrams of the anatomy of the various areas in which the block needle is to be placed, this reader believes that sensory distribution of the nerves being anesthetized would have been of value.
Section VI addresses special patient conditions or situations. The chapter on cardiopulmonary resuscitation is exceptional and contains a number of tables and algorithms, which are useful to the anesthesia provider, regardless of their level of experience. The chapter concerning respiratory disease and evaluation is equally informative and well written. The chapter on cardiovascular disease may have benefitted from a discussion of valve areas and pressure volume loops. The chapter dealing with hepatic and renal disease provides little information concerning renal protection measures and does not delineate the tests necessary to differentiate between the types of liver dysfunction or postrenal, prerenal versus renal impairment. The chapter on obstetric anesthesia does not appear to discuss the HELLP syndrome nor does the text mention subarachnoid anesthesia provided by meperidine (a unique property). This reader believes that the milligram doses of subarachnoid fentanyl and sufentanil, given on page 356, were intended to be microgram doses. With the increasing age of the population, the geriatric anesthesia chapter is timely and informative. In contrast, the outpatient anesthesia chapter is fairly limited in scope, does not discuss hard copy discharge criteria such as Digit Symbol Substitution, and, probably as a result of the timing of publication, does not cover remifentanil, which may be particularly suited to outpatient anesthesia. The chapter on neuroanesthesia provides a limited discussion of CNS monitoring or CNS protection (NMDA channels, glutamate, etc.), and the discussion of carotid endarterectomy is also somewhat limited.
The final section deals with PACU, ICU, pain management, mishaps, and medicolegal issues. The reader is cautioned to be on the watch for the rare misprint, such as that on page 437, where a dose of 40–80 mg of naloxone is recommended. With the current emphasis on pain management, the chapters addressing acute and chronic pain management are both useful. In the chapter concerning anesthesia mishaps, the issue of pacemakers is briefly covered, but the potential problems associated with automatic internal cardiac defibrillators is not. The final chapter addresses the continuum of the educational process of the anesthesia practitioner and essentially places the current text at the beginning of that process.
This text is consistent with preceding editions in that the bibliography for each chapter, although being fairly current, is also fairly limited. Additionally, individual references are not given for statements in the text, making it somewhat more difficult to pull the original source material for review.
In the preface, Drs. Longnecker and Murphy assert that the ninth edition, unlike the previous editions, which were “… a concise source of current practice for those entering the specialty.”, was to also fill the need of those “… as they prepare for the qualifying examinations or the management of a specific patient.” As the editors indicate, the ninth edition does not cover cardiac surgery, neonatal surgery, organ transplantation, or surgery involving the thoracic aorta to any degree. Although the text is an excellent source of information for the medical student or anesthesia resident beginning his or her education, this text would appear to fall short of the mark as a resource text for the management of more complex anesthetic procedures or as the sole source reference when preparing for qualifying examinations. Despite these apparent limitations, this text is an excellent value for novices to anesthesia or those early in their anesthesia residency. This reader surely referred to his earlier edition often during his residency.
John A. Youngberg, M.D.
Professor of Anesthesiology; Director, Cardiac Anesthesia; Tulane University Medical Center; 1430 Tulane Avenue; New Orleans, Louisiana 70112