Recent Advances in Anaesthesia & Analgesia, Number 20. Edited by A. P. Adams and J. N. Cashman. Edinburgh, Churchill Livingstone, 1998. Pages: 264. Price:$75.00.

Ask counsel of both times: of the ancient time, what is best; and of the latter time, what is fittest. [1]

Francis Bacon

In recognizing that "medical knowledge is constantly changing," the contributors, primarily from the United Kingdom, to the 20th book in the Recent Advances in Anaesthesia & Analgesia series seek to illuminate the latest progress in the field. Reflective of the diverse nature of anesthesia, the book presents 13 chapters, each written by a different author, ranging from basic molecular investigations into the mechanisms of general anesthesia and neuromuscular transmission to advanced clinical interventions with nitric oxide, inotropic support, and noninvasive cardiac output monitoring. To provide cohesion, each chapter concludes with key points, which are used responsibility; on rare occasion, however, a concept not previously explained appears.

There are successes within this book. To the credit of the authors and editors, the writing is clear and readable, has global relevance, and summarizes the literature succinctly and coherently. The chapters on nitric oxide in acute respiratory distress syndrome and recent discoveries in neuromuscular transmission translate complex physiologic mechanisms with remarkable clarity. The chapter on the economics of anesthesia introduces basic concepts on cost analysis without distilling our worth to simple formulaic measures. Furthermore, the authors show great care in evaluating and not overextrapolating the literature and monitoring data. The chapters on fetal sentience (the capacity to experience pain) and learning, memory, and awareness under general anesthesia show remarkable insight into the weaknesses and potential biases in existing studies. The chapter on the "golden hour," alluding to the critical time after traumatic injury, laments the heavy use of retrospective analyses and reviews, replete with their inadequate controls, in establishing guidelines. Finally, in keeping with the title, the references are timely, with most from the mid-1990s.

A few limitations, perhaps imposed by the "update" focus of this book, appear in the form of inadequate depth of coverage. The chapter on inotropic support in the critically ill patient mentions phosphodiesterase III inhibitors collectively but neglects the various clinical trials that have observed differences in inotropism, vasodilation, and side-effect profiles. The chapter on noninvasive monitoring of cardiac output craftily introduces several formulas used in analysis; however, a few would benefit from an expanded description. Furthermore, perhaps in an attempt to be succinct, the book does not provide relevant references and misses opportunities to guide interested readers to other sources of information. The chapter on ventricular fibrillation and transthoracic defibrillation alludes to several statistics and therapeutic strategies, but the sources, dates, and study methods are not referenced. The chapter on the anesthetic management of patients with brain injury who are having non-neurologic procedures provides only limited support for statements such as "there may be theoretic reasons for preferring an IV technique in these patients" and "the routine use [of prophylactic hyperventilation] is not recommended for head-injured patients."

Several imperfections exist. One particular statement neglects the health and vigor of our specialty and the service of its practitioners. The chapter on the economics of anesthesia introduces the topic by stating, "Anesthesia is unusual within the spectrum of healthcare in that it has little if any therapeutic benefit in its own right, and is only of value in that it permits treatment, usually of a surgical nature." This statement rejects the modus operandi of the obstetric anesthesiologist and pain management specialist, which suggests that pain relief alone is a noble, worthy goal and dismisses the advances in critical care and perioperative medicine, which include the novel technique of drug withdrawal under anesthesia. In addition, a few chapters, such as the one on fetal sentience, gives little for the practicing consultant anesthesiologist to grasp: What does this information mean in terms of specific medications that should be given or avoided? The chapter on pain management in the intensive care unit does not triage modalities in terms of effectiveness or particular advantages. In contrast, the chapters on stabilization and transportation of children requiring admission to a pediatric intensive care unit and learning, memory, and awareness during anesthesia provide wonderful, clinically relevant examples.

Recent Advances in Anaesthesia & Analgesia provides a friendly, current review for the resident in training, the generalist, and the subspecialist consultant anesthesiologist who need a taste of the complex body of anesthesia. Although the price of the book may be a bit taxing and encouraged me to think of other, more necessary texts, I, a Bostonian, found it to be a satisfying cup of tea.

Lawrence C. Tsen, M.D.

Department of Anesthesiology, Perioperative and Pain Medicine; Brigham & Women's Hospital; Instructor in Anaesthesia, Harvard Medical School; Boston, Massachusetts;

(Accepted for publication April 29, 1999.)

Bacon F: Of great place, The Essays or Counsels, Civil and Moral, of Francis Bacon, 1905, p 48. As quoted in Respectfully Quoted, Washington, DC, Library of Congress, 1989, p. 374