Perioperative Medicine: Managing for Outcome. By Mark F. Newman, M.D., Lee A. Fleisher, M.D., and Mitchell P. Fink, M.D. Philadelphia, Saunders, 2008. Pages: 464. Price: $179.00.
As a recent graduate of an anesthesiology residency and someone preparing to take the oral board examination, I asked one of my colleagues, “What is fair game on the oral board examination?” The answer was, “Everything!”
While at first I considered this unfair, upon further reflection I had to agree. For I have often been asked by my family and friends who are not in the medical community exactly what is an anesthesiologist and what do you do? I think a simple but valid answer is that we are primarily perioperative physicians. So while the orthopedic surgeon is busy fixing a femur fracture, who is worried about the heart, the kidneys, the brain, and the liver? We are! Our responsibilities seem overwhelming, and in many regards they are, but as one of my former attending physicians once stated so well, “It is our job to worry.” Fortunately, much of the worry dissipates as you read this very comprehensive text.
As I read this text, I found one of its best features was its sequential organization. The first four chapters discuss some of the biochemical basis of complications associated with the stress of surgery and anesthesia. From there, the book essentially will allow you to follow the patient from the preoperative screening unit to the postanesthesia care unit or intensive care unit. Chapters 5–11 discuss risk assessment for the major organ systems including cardiac, central nervous system, renal, pulmonary, and hematologic. Scientific evidence from the currently available literature is presented so that decisions can be made about which patients may benefit from further work-up and intervention and which ones will not. At this point in the timeline of patient care, you now have the information to optimize your patients before they come for surgery.
No matter how well your patients are prepared, some are still going to come to surgery with significant heart, lung, renal, or central nervous system dysfunction. Their medical conditions may be optimized, but they still have a high risk for intraoperative complications. So now the question logically arises, “What can I do intraoperatively to improve patient outcomes?” This is the heart of this text.
Chapters 12–30 deal with intraoperative management and decision-making, with the goal of improving outcomes for patients. Perioperative management to prevent dysfunction or prevent worsening of preexisting conditions is clearly detailed. But if a complication does occur, and inevitably one will, what can the anesthesiologist do? Treatment regimens are reviewed and, importantly, the level of evidence supporting these treatments is provided. These chapters are organized system by system. This allows the reader the option of reading this text cover to cover or to focus their reading on individual organ systems. This flexibility is a great asset of this text.
Eventually, the surgery will finish and the patient is off to the postanesthesia care unit or intensive care unit. What complications may occur and how do we treat them effectively? Chapters 31–37 deal with many of these problems and some of the major postoperative problems associated with specific surgeries. For completeness, there are also chapters dealing with sepsis, adult respiratory distress syndrome, endocrine/electrolyte disorders, and pain, delirium, and anxiety.
This logical progression from preoperative screening to operating room management to postanesthesia care unit or intensive care unit is one of the major strengths of this text. The text pushes anesthesiologists to consider the level of scientific evidence behind our decision-making. Too often, anesthesiology has been guided by treatments that make intuitive sense but that have been lacking in scientific scrutiny. This text has tables pertaining to each organ system that assess which treatments are beneficial, which may be beneficial, and which may be doing more harm than good. Importantly, it provides the level of evidence to support these conclusions.
In summary, this text takes you from risk assessment to perioperative decision-making to the postanesthesia care unit or intensive care unit, and provides you with the scientific support necessary to make decisions based upon good clinical evidence. This is the essence of what we are obligated to do for our patients. This textbook will undoubtedly challenge some of your beliefs and practices, but will undeniably give you the information to be a better perioperative physician.
Albany Medical College and Albany Medical Center Hospital, Albany, New York. fitzpam@mail.amc.edu.
