Book and Multimedia Reviews
Clinical Pharmacology of Local AnestheticsTetzlaff JE. Boston: Butterworth, 2000. ISBN 0-7506-9797-0. 258 pp. $50.00.
Clinical applications of regional anesthetic techniques for intraoperative anesthesia and postoperative analgesia have increased dramatically in the last decade. Definitive texts on the pharmacology and physiology of local anesthetics are often too complex and comprehensive for the anesthesia resident in training. In addition, surgical specialties requiring knowledge of local anesthetic pharmacology, such as dentistry, orthopedic surgery, and obstetrics, may include only a superficial instruction. Dr. Tetzlaff states that this book is designed to provide background information, describe the physical properties, and discuss the clinical applications of local anesthetics. The text is well structured; key words are bold-faced throughout, and each time a new term is introduced, it is defined. The book is directed toward the surgical community, students and residents, and those in the clinical practice of anesthesia.
The text is divided into sections on physiology, pharmacology, additives and compounds, and surgical applications of local anesthetics. The section on physiology describes the characteristics of conduction block and details the effects of local anesthetic pharmacology on neural blockade. Diagnosis, prevention, and treatment of systemic local anesthetic toxicity are thoroughly discussed. In addition, the pathophysiology of local anesthetic allergy and the use of skin testing are described.
One third of the text reviews the characteristics and physical properties of local anesthetics. A brief history of the molecule, the pharmacology (including toxicity and maximum recommended dose), and the clinical uses are presented for each agent. The discussion of neurologic injury after the administration of intrathecal lidocaine does not clearly distinguish between the etiology/risk factors for cauda equina syndrome and those of transient neurologic symptoms, making comprehension of lidocaine toxicity difficult for nonanesthesiologists. A section on stereoisomerism would also be relevant to ropivacaine pharmacology. Those criticisms aside, the chapters devoted to the individual local anesthetics are practical and informative.
The section on additives and compounds of local anesthetics includes an exhaustive description on the conduction and systemic effects of epinephrine, phenylephrine, norepinephrine, and clonidine. Unfortunately, only adjuvants that increase the speed of onset of conduction block are considered; there is no discussion on the use of additives (such as opioids) to decrease local anesthetic concentration, dose, and complications. The effect on conduction block with compounding/mixing local anesthetics, as with tetracaine-adrenaline-cocaine, cutectic mixture of local anesthetics, and local anesthetic mixtures during peripheral block represents the existing knowledge on the subject.
The final chapters on surgical applications of local anesthetics involve the use, indications, and complications associated with regional anesthesia and specific surgical subspecialties. Although this section may not be sufficiently comprehensive for anesthesia care providers, the section is well referenced and provides a background for those in the surgical subspecialties and documents the advantages of local anesthetic techniques for both anesthesia and analgesia.
In summary, this text presents both basic science and practical clinical uses of local anesthetics. It fulfills the author’s primary goal to educate and serve as a reference to anesthesiologists and surgeons interested in the applications of regional anesthesia, and it will be an invaluable tool in the multidisciplinary approach to patient management.