Klimkina, Oksana MD; Johner, Jennifer T. MD; Hessel, Eugene A. II MD
Department of Anesthesiology University of Kentucky Lexington, Kentucky firstname.lastname@example.org (Klimkina, Johner, Hessel)
Cardiopulmonary Bypass was edited by Sunit Ghosh and Florian Falter of the Department of Anaesthesia at the Papworth Hospital in Cambridge, United Kingdom (UK), and David J. Cook of the Department of Anesthesiology at the Mayo Clinic in Rochester, Minnesota, United States. This is a new publication in the international cardiothoracic literature that was designed to provide a practical overview of clinical perfusion and serve as a guide for a wide range of specialists including perfusionists, anesthesiologists, and surgeons. According to the editors, it is meant to be “an easily readable source of material for the everyday practice of clinical perfusion,” as well as a useful practice tool for both “newcomers to the subject” and experienced clinical staff.
The book has 15 chapters written by 29 experts in multidisciplinary fields from the UK and the United States. Chapter 1 on “Equipment and Monitoring” provides a good overview using a reasonable number of tables and pictures; however, the information seems to be somewhat condensed, especially for first-time learners. In contrast, the second chapter on “Circuit Setup and Safety Checks” has abundant information for perfusionists, including the London Perfusion Science Protocols, but does not include enough emphasis on the role of the anesthesiologist and surgeon for the safety support. Chapter 3 gives valuable and concise information on priming solutions for cardiopulmonary bypass (CPB) circuits with excellent suggestions for further reading. Chapter 4 is entitled “Anticoagulation, Coagulopathies, Blood Transfusion and Conservation.” It is a short chapter but provides precise information and gives a full picture of the contemporary approach to the topic. The chapter includes not only a review of “pharmacological strategies for anticoagulation during CPB,” but also useful data on monitoring of coagulation and “management of the bleeding patient.” The information in Table 4.2 on point of care devices to assess platelet function is particularly useful to practitioners involved in CPB procedures.
Chapters 5 and 8, entitled “Conduct of Cardiopulmonary Bypass” and “Weaning from Cardiopulmonary Bypass,” respectively, provide a good overview for beginner residents and students. They provide an orderly approach to the initiation, conduct, and weaning from CPB in an easy-to-read, clear, and descriptive format for the neophyte. However, they do not provide all of the details necessary for the anesthesiologist to safely monitor CPB. Although the role of transesophageal echocardiography (abbreviated as “TOE” in the UK) is mentioned in a number of places throughout this book, it is not as strongly advocated as the recent American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists guidelines suggest, and its important role in facilitating the conduct of CPB (e.g., in guiding retrograde coronary sinus cannulation, assessing adequacy of left ventricular decompression, and detection of aortic dissection), as well as its usefulness in combination with epi-aortic ultrasound for assessing the ascending aorta (as related to cannulation and clamping) are largely neglected. The summary about vasopressors and inotropes is too superficial to be a useful guide for clinical decision making. Chapter 6 on “Metabolic Management During CBP” has some information that overlaps with Chapters 3 and 10. The latter chapter on deep hypothermic circulatory arrest is well written and organized with several helpful tables and figures, and good suggestions for further reading. However, one could debate its conclusion as to the safe duration of deep hypothermic circulatory arrest. Chapter 7 on “Myocardial Protection and Cardioplegia” is one of the best chapters in the book. Although somewhat short on alternative techniques of myocardial protection, it gives an excellent evaluation of cardioplegia components and their delivery. This chapter could serve not only as a solid review article for one of the major Journals, but also as a useful teaching source.
Chapters 9 and 14 on “Mechanical Circulatory Support” and “Extracorporeal Membrane Oxygenator,” respectively, have just enough information for beginning-level anesthesia trainees. Even though the choice of the ventricular assist devices (VADs) described in detail (e.g., Levitronix, Thoratec PVAD and IVAD, and Heart Mate II) seems to be somewhat arbitrary, there is a good summary of preoperative, perioperative, and postoperative VAD management that can be useful for review in hospitals with small numbers of emergently placed VADs. Chapters 11, 12, and 13 are dedicated to “Organ Damage During Cardiopulmonary Bypass,” “Cerebral Morbidity,” and “Acute Kidney Injury” during bypass, respectively, and are excellent sources for review and teaching. The figures in chapter 11 are very clear and informative, easy to understand, and are great additions to the text. However, the section on pulmonary dysfunction was a little disappointing. Additional data could have been provided on early postbypass ventilation, and particularly on tidal volumes and recruitment maneuvers, to reflect more contemporary clinical practices related to this topic. Chapter 13 could use more information, statistics, and suggestions regarding optimization strategies for management of dialysis-dependent patients because these patients are encountered more frequently in current practice. The last chapter, chapter 15, entitled “Cardiopulmonary Bypass in Non-Cardiac Procedures,” sets out to cover a huge topic, but ends up being a rather superficial review.
Apparently in the interests of brevity, many of the issues and topics that we consider important have been left out or inadequately addressed. For example, the important topic of bypass techniques for descending thoracic and thoracoabdominal aortic surgery is inadequately covered and probably deserved a separate chapter, and the essential topic of safety, incidence of adverse events, and complications associated with CPB (including detection and management) received virtually no attention and is the most glaring deficiency of this work. We also encountered a number of misstatements and typographical errors in the book, and we were disappointed by the authors' failure to consistently include references to cited work and to some of the figures.
We found it is difficult to identify the specific role for this book in the resources for anesthesiologists in training or beginning clinical practice. This may be related to the stated purpose of the editors to provide a brief overview for a diverse audience. From an anesthesiologist's point of view, it provides far too much detail regarding perfusion technology and circuitry (which would be of great interest to their perfusionists readers), and not enough information regarding the conduct of CPB and the role that the anesthesiologists should play in guiding, monitoring, and trouble-shooting CPB, as well as the management of anesthetic drugs.
Despite these limitations, residents or practitioners just starting cardiac anesthesia and surgery may find this text a less intimidating introduction to this topic than other texts because of its small size, easy portability, and straightforward format. Therefore, Cardiopulmonary Bypass should be available as a basic teaching tool for young practitioners in anesthesia. For the more experienced anesthesia trainee, Cardiac Anesthesia by Hensley et al. is recommended as an alternative source for information on CPB because it not only includes most of the material related to CPB, but also covers many other important aspects of cardiothoracic anesthesia. For the serious practitioner of cardiac anesthesia, Kaplan's Cardiac Anesthesia also provides a more in-depth discussion of this important topic.
Oksana Klimkina, MD
Jennifer T. Johner, MD
Eugene A. Hessel, II, MD
Department of Anesthesiology
University of Kentucky