Anaesthesia for the High Risk Patient. By Dr. Ian McConachie, F.R.C.A. Greenwich Medical Media Limited, London and San Francisco, 2002. ISBN: 1841100722. Pages: 265. Price: $39.95.
This pocket-sized quick reference text is chock-full of useful information. The 17 chapters span 265 pages and are written and edited by physicians and nurses from a single medical center. The text provides an initial overview on the epidemiology and identification of high-risk surgical patients, followed by chapters focusing on specific organ systems, complimented by chapters on systematic approaches to the elderly patient, hemodynamic optimization, pain management, and proper use of regional and local anesthetics. The presentation is logical and the bedside practitioner will find it helpful. The book is punctuated with a dry wit; for example, in reviewing priorities in the severely traumatized patient, the author reminds us to see the forest for the trees and wisely counsels “there is no merit in delivering a corpse with an arterial line to the operating table.” The final chapter, “The Meaning of Risk,” presents a succinct perspective on perioperative risk, reviews the presentation of risk to patients and their families, and emphasizes the spectrum of relative risk comparing the risk of death by murder versus flying versus driving versus receiving a general anesthetic.
The text nicely distills practical guidelines from larger textbooks and evidence-based treatises, state-of-the-art commentaries, and appropriately selected trials and meta-analyses. The authors cut to the chase with their recommendations and, for the most part, provide accepted references while identifying areas of ongoing controversy. Although the chapter entitled “The Critically Ill Patient in the Operating Room” is well written and includes a wealth of information, it could be strengthened in the second edition. The addition of specific references on the risk of relative adrenal insufficiency in the critically ill, perioperative glucose control, and clinical use of vasopressin, along with recent references on the use of protective ventilatory strategies and the pulmonary artery catheter (beyond the 1996 American Society of Anesthesiologists guidelines), would be helpful. However, in all fairness, many of these areas are undergoing rapid change with continual presentation of new data.
As in any multi-authored text, there is a moderate amount of redundancy, but this is mainly appreciated if the text is read in a single sitting. Most of the repetition is in the area of perioperative cardiac assessment and risk stratification, the most common cause of major perioperative morbidity and mortality. The overlap tends to be consistent, so there is little room for confusion or misinterpretation of data.
American readers might not be familiar with some of the terminology used throughout the text or with the focus on National Health Service practices, such as the allocation of limited resources, less common use of intensive care unit (ICU) beds (only 1–2% of hospital beds are identified as ICU beds in the United Kingdom), increased stratification of patient placement [use of high dependency units (HDU)], and the national schemes for identification of problems in patient management and those at high risk. Therefore, chapter 3 (“National Confidential Enquiry into Perioperative Deaths”) and chapter 16 (“Admission Criteria for HDU and ICU”) are mainly directed to British practitioners; however, they contain insights into recently identified causes of perioperative morbidity and mortality as well as useful bedside tools to determine whether admission to a step-down unit, monitored bed, or ICU would be a judicious choice for recovery room or postoperative patients. In chapter 16, the authors emphasize the oft-overlooked point that postoperative patients who come to the ICU from the ward frequently have worse outcomes than those directly admitted to more intensely monitored units. They advocate preemptive care and the concept of taking critical care from the ICU to the ward so that appropriate early assessment, intervention, and transfers are accomplished in a timely fashion. They also present a modified early warning score (MEWS) as a handy bedside scale comprised of seven readily measured variables (respiratory rate being the most predictive) used to promote identification of patients requiring increased care and intervention.
McConachie et al. meet their goals of providing a useful refresher on “recent concepts and advances” that provides practical pearls on the care of high-risk surgical patients, the means to optimize patient status, and the ways to identify postoperative patients who would benefit from intermediate or critical care. Although the text is not a substitute for major tomes on anesthesia or critical care, the book is a cost-effective, helpful addition to any student's, trainee's, or practitioner's library. I recommend it to you and have already put it to good use in my day-to-day assessment of patients. Hopefully, the text will be updated frequently, since the references and recommendations may become rather quickly dated. The inclusion in future printings of selected Web sites should be provided. This will allow rapid procurement of important established guidelines (e.g. , endocarditis prophylaxis, low molecular weight heparin use, and regional anesthesia) and retrieval of current recommendations that continue to evolve about the optimization of hemodynamics, utility of the pulmonary artery catheter, and transfusion indications.