Low Flow Anaesthesia: The Theory and Practice of Low Flow, Minimal Flow and Closed System Anaesthesia, Second Edition.  By Jay A. Baum, with the English text revised by Goeffrey Nunn. Butterworth-Heinemann, Boston, 2001. Pages: 303. Price $80.00.

The first edition of Low Flow Anaesthesia  was printed three times in German and twice in English. It was translated into Italian, Chinese, and Korean. The popularity of that edition reflects the importance of the subject. The second edition aims to meet a continued and apparently increasing interest in low flow anesthesia, an interest also indicated by the existence of a society dedicated to its advancement (the Association for Low Flow Anaesthesia). Baum nicely outlines the case for lower flows (Chapter 6, Advantages of the Rebreathing Technique in Anaesthesia.) Low flow–closed circuit anesthesia should appeal to the politically correct (it spares the environment from the burden of unnatural gases that may injure the atmosphere), the frugal (it saves money), and the adventuresome (many souls I've met are uncomfortable even thinking of how to apply a closed system). Numerous figures and tables compliment the text. However, although the text covers all issues germane to low flow–closed circuit anesthesia, doing so in great detail, it will not bring tranquility to those first considering low flow–closed circuit anesthesia.

The limitations of the book are technical and philosophical. The book has a European focus, in part the product of its origin as a German text, and in part because the interest in low flow–closed circuit is greater across the Atlantic. The result is that the syntax can be obscure:“From the pharmacokinetics point of view, closed and low flow systems are nothing but a special parameter selection with respect to the rebreathing fraction in establishing the desired alveolar concentration of the inhalational anesthetic.” (p 45). The sentence is better in context, but not much. The European focus also means that the book emphasizes European equipment, not, however, to the exclusion of equipment used in North America. The liberal use of figures is not always complimented by sufficiently detailed legends or explanations in the text. Too often, the reader is left guessing.

What I find most limiting is, perhaps, merely philosophical. The book makes a simple subject appear complicated. This was appropriate before the widespread use of anesthetic and respiratory analyzers. But why is it necessary now? Today, anyone can easily control anesthetic and respiratory gas concentrations by referring to monitors that provide accurate values on a breath-by-breath basis at any inflow rate. There are a few tricks one needs to know, but these can be expressed in three (well, maybe six) pages rather than three hundred. The consequence of the appearance of great complexity is that it may dissuade the timid anesthetist from adopting a useful technique.

Nonetheless, for the anesthetist deeply interested in low flow–closed circuit anesthesia, this single-authored book offers a wealth of information. It provides a reference that supplies all of the details needed for delivery of anesthesia by low flow techniques.