Lowenstein, Edward MD; Thomas, Stephen J. MD
Henry Isaiah Dorr Professor of Anaesthesia, Professor of Medical Ethics, Harvard Medical School, Boston, MA, firstname.lastname@example.org (Lowenstein)
Topkins-Van Poznak Distinguished, Professor of Anesthesiology, Weill Medical College of Cornell University, New York, NY, email@example.com (Thomas)
Cardiac Anesthesia, 5th ed.
Kaplan JA, Reich DL, Lake CL, Konstadt SN, eds. Philadelphia: Saunders/Elsevier, 2006. ISBN 13 978-1-4160-0253-6. 1424 pages, $249.00.
Kaplan’s 1979 text, Cardiac Anesthesia, reflecting the experience of the cardiac anesthesia service at Emory University, was the first cardiac anesthesiology textbook of the modern era of cardiac surgery. It was published after a decade of surgical myocardial revascularization had led to explosion of the field and represented an important step in establishing the legitimacy of this subspecialty. Dr. Kaplan has recruited as editors and authors distinguished clinicians and researchers in anesthesiology and other disciplines for the subsequent four editions. This fifth edition is no exception, with many new contributors.
The last three editions, published in 1993, 1999, and 2006 have each had a similar number of pages divided into 41 or 42 chapters. The authors deserve praise for resisting the temptation to continue to expand the book beyond a manageable size. They have attempted to incorporate knowledge and experience reflecting continuing evolution of the field. The first section of four chapters elegantly describes the past and boldly predicts the future; the last section addresses quality, errors, money, and qualifications for practice and teaching. The intervening six sections, each of four to nine chapters, contains the “nuts and bolts.” They are entitled molecular biology, preoperative evaluation, monitoring, anesthesia techniques, extracorporeal circulation, and postoperative care.
Each chapter begins with a table entitled “Key Points” that presents a summation of take home lessons from that chapter. The chapter itself contains figures, tables, and “Boxes.” The latter summarize some important portion of the text and represent a fine teaching tool. For instance, Box 19-1, four full pages in length, provides an outstanding précis of the management of myocardial revascularization surgery. A casual reader could gain an elementary knowledge of the topic in many chapters merely by reading the Key Points and Boxes. However, the consistency and usefulness varies in different chapters.
Color figures of seven chapters are at the front of the book, including many echocardiographic images. This is particularly conspicuous since Chapter 15, Perioperative Transesophageal Echocardiography, includes color plates. This adds emphasis to what appears to be a poor editorial decision undoubtedly based on cost. While it is mitigated somewhat by including black and white duplicate figures in the body of the chapters where the plates are at the front, the quality of the black and white figures compares unfavorably to that of the color plates.
As is appropriate in a reference text, the number of references is generous, exceeding 500 in many chapters. A considerable majority is over a decade old; the same is true for figures. This may reflect a combination of not omitting out of date articles that are no longer relevant, the dependence of the field on a relatively aged database and/or the maturity and stability of much of it, with few important recent advances. The reader will need to make these judgments. It left the reviewers aching for an electronic version of this edition with links to the original articles so a curious reader could seamlessly access them as well as easily finding similar or related topics in other chapters. While the index is competent, it does not approach what we have come to expect using electronic information technology.
As with any reference text, reviewers must address the question of whether large areas of deficit exist and which other texts or media are required. Table 15-3 does as good a job as possible of describing intraoperative TEE examination in print. However, its utility would be enhanced if integrated with the succeeding diagrams and figures of TEE views and supplemented by electronic recordings of exemplar echocardiograms. In contrast, extracorporeal circulation is presented in sufficient detail for virtually any cardiac anesthesiologist.
Cardiac anesthesiology as an identifiable field is now approaching four decades of age. It has been characterized by periods of seeming stability and maturity followed by periods of intense challenge. The challenges of the past 15 years have included the failing heart, off pump and minimally invasive cardiac surgery, fast tracking with the need for new approaches to pain management, and echocardiographic guidance of valve repair. The book treats each of these in varying depth.
Reading the book, however, makes clear that outcomes from different strategies of anesthetic management remain unknown. A legitimate criticism of our field is that we have not sufficiently heeded Arthur Keats’ injunction to pursue meaningful outcomes research. Thus, we are often left with individual and local options, not knowing which is more advantageous. For instance, ischemic preconditioning by inhalation anesthetics is comprehensively discussed, but research defining the effects on outcome in patients has not been performed, so the consequences for our patients remain unknown. Perhaps the field should now concentrate on determining the value of different strategies and techniques.
In the Foreword to the first edition of Cardiac Anesthesia, cardiologist J. Willis Hurst wrote, “My surgical and cardiology colleagues give credit to our cardiac anesthesiologists for lowering operative mortality of CABG surgery at Emory from 2–5% to 0.2–1.2%.” Cardiac anesthesia 25 years ago influenced the entire field of anesthesia by defining controllable factors that apparently decrease morbidity and mortality. It is now our challenge both to demonstrate that we have made similar advances in the intervening years and can do so in the future.
The fifth edition of Kaplan’s Cardiac Anesthesia is thus an ambitious book that achieves many of its aims, foremost, to ‘maintain its place as the standard reference textbook‘ (as stated in the Preface of both the 4th and 5th editions) in cardiac anesthesiology. It contains a wealth of information regarding cardiology, cardiac surgery, cardiopulmonary bypass, and cardiac anesthesiology. Therefore, it should be available in all anesthesia libraries and to all interested in the field. Those with intense interest, such as cardiac anesthesiologists and fellows, may wish to have a copy of their own for immediate access. Cardiac anesthesiology fellows will likely also need a multimedia text devoted solely to echocardiography, given the emphasis placed on that topic in the new RRC curriculum. The neophyte, generalist anesthesiologist, and rotating resident will probably wish to seek one of the less comprehensive books for an introduction to the subspecialty.
Edward Lowenstein, MD
Henry Isaiah Dorr Professor of Anaesthesia
Professor of Medical Ethics
Harvard Medical School
Stephen J. Thomas, MD
Topkins-Van Poznak Distinguished
Professor of Anesthesiology
Weill Medical College of Cornell University
New York, NY