James C. Eisenach, M. D., Editor

Regional Anaesthesia for Babies and Children. Edited by Jane M. Peutrell and Stephen Mather. 1997. Pages: 259. Price:$65.00.

As yet another sign of the steadily increasing interest for pediatric regional techniques, two well-known British pediatric anesthesiologists, Drs. Peutrell and Mather, have supplied a new addition to the textbook literature concerning pediatric regional anesthesia. According to the preface of the book, the aim was to provide a practical manual regarding the special aspects of regional blocks in children, primarily aiming for an audience of residents and fellows or the anesthesiologist who is not performing these techniques on a regular basis.

The merit of the book is primarily in the care taken to explain that pediatric blocks should be learned not only by reading a book, but should be complemented by hands-on training supervised by experienced pediatric anesthesiologists. It also underline the strict indications that should be met before performing thoracic epidurals in anesthetized children. Also, the chapters describing the very useful peripheral nerve blocks (e.g., ilioinguinal, penile, and lower limb blocks) and the chapters discussing various aspects of caudal blocks are all of very high quality.

However, in the reviewers opinion, there is considerable room for improvement for a second edition of the book. Because the reader should already have a basic knowledge of regional anesthesia before starting to practice pediatric regional anesthesia, some chapters provide unnecessary detail about fundamental issues (e.g., the pharmacology of local anesthetics and the anatomy of the brachial plexus). A much sharper focus on the details that are truly special in the setting of pediatric blocks would be a substantial improvement.

Although regional anesthesia for dental procedures is of great value also in pediatric patients, the large section concerning these blocks appears to be better suited for a textbook about pediatric odontology because these blocks are almost exclusively performed by the pediatric dentist and not the anesthesiologist.

The illustrations in the book are clear and have few and minor errors. However, in this day and age of computerized printing, it is very disappointing that the pictures and illustrations are in black and white. To include good quality color illustrations would make for a tremendous improvement of the book.

To the reviewer's disappointment the book also contains some very controversial statements, mainly regarding the central blocks. Without further discussion, the authors recommend and claim the superiority of the use of air, compared to saline, for the loss-of-resistance technique in pediatric epidurals. This is highly controversial, and the reader should be alerted that this by no means represents an international consensus. In fact, great caution has been recommended regarding the use of air for this purpose by many international authorities in the field of pediatric regional anesthesia.

Despite numerous international experts finding lumbar epidural blocks to be very useful, even in neonatal surgery, the authors, without any specific reference, suggest a younger age and lower weight limit for epidural blockade in children (6 months, 5 kg). This limit might represent a good rule for the nonpediatric anesthesiologist but should not be viewed as an absolute limited for more experienced practitioners.

Regarding the issue of the possibility to reliably thread epidural or caudal catheters to a more cranial level, the authors' statements again are controversial. Numerous reports found this method to be very useful and reliable, but more recent publications have shown less favorable results with this technique. A more moderated phrasing in this regard would be more appropriate, including a recommendation to check the true location of the tip of the catheter by radiography if cranial advancement of the epidural catheter is important to the clinical use of the catheter.

In summary, is this book worth buying? The price is not prohibitive, considering the general pricing of medical textbooks. Despite some important beauty spots, the text contains a lot of valuable information and should be included in the library of any anesthetic department performing pediatric anesthesia. However, residents, fellows, and the occasional pediatric anesthesiologist perhaps should await a second, more condensed, color-illustrated, and balanced edition before buying a personal copy.

Per Arne Lonnqvist, M.D., D.E.A.A., Ph.D.

Associate Professor; Department of Paediatric Anaesthesia and Intensive Care; Astrid Lindgren Children's Center at the Karolinska Hospital; Stockholm, S-171 76, Sweden