REVIEWS of Educational MATERIAL
Michael J. Avram, Ph.D., Editor
Anaesthetic and Perioperative Complications.
Edited by Kamen Valchanov, M.D., F.R.C.A., F.F.I.C.M.;
Stephen T. Webb, M.B., B.Ch., B.A.O., F.R.C.A.,
E.D.I.C., F.F.I.C.M.; Jane Sturgess, M.B.B.S.,
F.R.C.A., M.R.C.P. New York, Cambridge University
Press, 2011. Pages: 272. Price: $79.00.
Anesthesia, like most fields of medicine, has now become
evidence based. Protocols are established for management of
scenarios ranging from conscious sedation to cardiac arrest.
The chapters of the Clinical Aspects of Complications sec-
tion of Anaesthetic and Perioperative Complications begin
with the ABCs of anesthesia: airway, breathing (respiration),
and circulation. They are organized in the format of preven-
tion, recognition, and management of anesthetic-related
complications. Checklists are included in several chapters,
but are sorely missed in others.
The chapter devoted to airway complications lists the
Difficult Airway Society algorithm for managing unantici-
pated difficult intubation. It wisely includes the point of not
making more than three attempts at rigid laryngoscopy and
the need to use an alternative laryngoscope (either video or
fiberoptic through a laryngeal mask airway). The chapter
includes the caveat from the American Society of Anesthe-
siologists closed claims studies showing that fatal complica-
tions can occur after oversedation during attempts at awake
intubation. In the presence of a compromised airway, less
sedation and more cooperation are better than obtundation
and airway obstruction.
The sections on cardiovascular complications include a
table on the differential diagnosis of intraoperative hypoten-
sion and an excellent table covering perioperative pharmaco-
logical cardiac protection. It would have been useful to have
included a forest plot of the efficacy of the various therapies
of antiplatelet, antithrombin, β blockers, and statins in pre-
venting perioperative myocardial ischemia.
The obstetric anesthetic chapter makes the recommenda-
tion that the conversion rate of regional to general anesthesia
should be less than 3%. This is a laudable goal, considering
that the National Audit Project (NAP4) found that two out
of four failed intubations for cesarean section occurred in
association with failed regional anesthesia. The paragraph
on providing adequate doses of local anesthetic states that
fentanyl 10 mg given intrathecally needs to be corrected to
10 mcg. This chapter lacks a section on the prevention and
management of postpartum hemorrhage, now a major cause
of maternal mortality.
Copyright © 2013 , the American Society of Anesthesiologists, Inc. Lippincott
Williams & Wilkins. Anesthesiology 2013; 118:1242-3
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The chapter devoted to perioperative neurological
c­omplications presents several current controversies in the
realm of whether more monitoring can prevent complica-
tions. Logically, one would suspect that operative spinal
cord injury should be reduced by monitoring somatosensory
evoked potentials, motor-evoked potentials, and electromy-
ography, but this information is not referenced.
The B-Aware and B-Unaware trials failed to show that
awareness occurs more often with solely monitoring end-
tidal concentrations of volatile anesthetics compared with
the bispectral index monitor. However, many anesthetics
are delivered as total intravenous agents, with propofol pro-
viding amnesia and remifentanil supplying the analgesia, so
there is no vapor level to measure, thus making the bispectral
index an essential monitor of anesthetic depth.
A good part of the regional anesthesia complications
chapter is devoted to vertebral canal hematomas after epi-
dural placement. A table listing drugs acting on the coagula-
tion cascade and their half-lives should have been provided.
Instead, a figure, labeled management of leg weakness fol-
lowing epidural anesthesia, lists pager numbers of the acute
pain team at Derriford Hospital, Plymouth, England. How-
ever, the table devoted to management of local anesthetic
toxicity is well annotated.
The drug reaction chapter clearly states that two thirds
of allergic anaphylactic reactions in anesthesia are due
to succinylcholine and rocuronium. Serum tryptase lev-
els should be measured to confirm an immunoglobulin
E–mediated reaction.
The last portion of the book discusses the legal
ramifications of anesthetic mishaps. The case of Mrs. Elaine
Bromiley, the 37-yr-old wife of an airline pilot, is presented.
As the result of a “can’t intubate, can’t ventilate” situation,
multiple attempts at intubation were made, rather than an
emergency cricothyroidotomy. Despite all the algorithms
and training, perhaps our basic equipment needs updating
to the 21st century. Would this complication have been
avoided if the initial attempt at intubation was with a
video laryngoscope or an inexpensive disposable video
bronchoscope?
With the advent of electronic medical records, it will be
possible to monitor performance of individual anesthesiolo-
gists, especially when complications occur. This book out-
lines potential pitfalls. We would be wise to read it carefully
and incorporate its lessons into our daily practice.
Raymond Glassenberg, M.D., Northwestern University Fein-
berg School of Medicine, Chicago, Illinois. rayglass@northwestern.edu
(Accepted for publication November 10, 2012.)