Neuromuscular Block in Perioperative and Intensive Care, David G. Silverman, ed. Philadelphia: JB Lippincott Co., 1994, ISBN 0-397-51377-1, 372 pp, $45.00.
This book details the basic physiology of neuromuscular transmission, monitoring of neuromuscular response to stimulation, requirements for neuromuscular blockade, and basic muscle relaxant pharmacology and is a relatively comprehensive guide to neuromuscular blockade and clinical use of muscle relaxants. The first two chapters are devoted to the physiology of neuromuscular transmission and neuromuscular block, the following three chapters to the monitoring of neuromuscular block, and the remainder of the text to the clinical use of relaxants and their pharmacologic antagonists. The first chapter, "Anatomy and Physiology of Neuromuscular Transmission," presents a good summary of information in eight very densely written pages. For the novice, reference to original or review articles will be necessary for a more complete understanding of this important topic. The second chapter describes mechanisms of both depolarizing and nondepolarizing neuromuscular block. Again, while this is an adequate summary, reference to other work may be necessary. Monitoring of neuromuscular block is covered thoroughly in Chapters 3-5.
Chapter 6 begins the discussion of the clinical use of muscle relaxants appropriately with the perioperative monitoring and dosing of neuromuscular blocking drugs. This discussion continues in the next two chapters, where the pharmacokinetics and dynamics of relaxants are applied to the onset of and recovery from neuromuscular block. Chapters 9 and 10 list underlying disease processes and other drugs and their effects on neuromuscular block.
The side effects of relaxants are examined in Chapter 11. While this is an exceptionally important aspect of muscle relaxant use and choice, this chapter is written with a profound bias. The reader would have to refer to the original articles to draw his or her own conclusions. For example, much time and space is devoted in this chapter to descriptions of the histamine-releasing potential of benzylisoquinoliniums, the central nervous system-stimulating effects of laudanosine, and the membrane-destabilizing effects of the acrylate metabolite of atracurium, whereas the metabolites of vecuronium and the potential for vecuronium inhibition of histamine-N-methyl transferase are merely mentioned. The section describing muscle relaxant use in intensive care units is most troubling as it repeats many commonly held clinical beliefs without critically examining the evidence supporting them. For example, the reader is informed that vecuronium and pancuronium are preferred to atracurium in the intensive care unit because of vecuronium's relatively short duration of action, lack of metabolites with central nervous system-stimulating side effects, and lack of histamine release. However, the authors fail to mention the following: 1) the vagolytic side effects and long duration of action of pancuronium may not be desirable in this setting; 2) pancuronium and vecuronium have decreased clearances in patients with advanced age or end-organ disease; 3) histamine release is not associated with the administration of doses smaller than two times the ED95 of atracurium; and 4) increased seizure activity has not been reported in patients receiving atracurium. This bias is unfortunately carried into the next chapters, where a brief summary of each of the clinically available relaxants is provided. Antagonism of residual neuromuscular block is described in Chapter 15.
Chapters 16-18 describe the mechanisms of depolarizing neuromuscular block and effects of succinylcholine; Chapters 19-20 discuss malignant hyperthermia; and the remainder of the book is devoted to the use of relaxants in patients with neurologic or muscular disease, trauma, or burns. Being that the text was written principally by Dr. Silverman, with contributions from six other experts in the field, the text is stylistically consistent, with little repetition of information and adequate cross-referencing to other chapters for a more in-depth discussion of particular points, and is generally very well referenced.
The book is organized such that each chapter is a summary of basic information, followed by a list of relevant questions and answers. The questions serve to expand upon or reinforce the material in the preceding summary or to introduce new information. While this format is useful in terms of emphasizing the more important or controversial points, this reviewer would have preferred to see each answer directly follow the corresponding question. There are few tables, figures, and graphs within the text. However, three chapters, "Effects of Other Agents on Nondepolarizing Relaxants," "Effects of Patient Status and Conditions on Nondepolarizing Relaxants," and "Factors Affecting Pseudocholinesterase and the Pharmacokinetics and Pharmacodynamics of Succinylcholine," consist entirely of lists of information.
In summary, this text is broad in scope and provides a summary of information regarding neuromuscular transmission, monitoring of neuromuscular function, and use of muscle relaxants in the operating room and intensive care setting. The use of questions at the end of each chapter is an effective didactic technique encouraging the reader to evaluate the presented material. Its greatest usefulness, however, may lie in the extensive lists of references provided at the conclusion of each chapter.
Cynthia A. Lien, MD
Department of Anesthesiology, The New York Hospital-Cornell Medical Center, New York, NY 10021