Frontiers in Anesthesia; Volume 12, Number 1 of Problems in Anesthesia Lee A. Fleisher, MD and Donald C. Prough, MD, editors.Philadelphia: Lippincott, Williams & Wilkins. ISSN 0889-4698. 112 pp. $134 annual subscription for four issues or $56 per single issue.
The editors note in the preface of Frontiers in Anesthesia that the future of anesthesiology as a specialty depends on how well we address the “complex political, professional, and economic environment” in which we practice, and they have devoted this issue to address “several political, professional, and economic issues, as well as a few evolving clinical issues.”
The first three chapters deal in turn with the history of anesthesiology as a specialty, the role of organized medicine, and business perspectives in anesthesiology. Significant decreases in anesthesia-related morbidity and mortality in the last half of the 20th century are reviewed. Attracting the best and brightest medical students into anesthesiology residencies, securing increased sources of funding for anesthesiology research, encouraging more activity by clinician-scientists, and improving the professional image of anesthesiologists are presented as priorities for the specialty moving into the future. The role of organized medicine, in particular the American Society of Anesthesiologists, in preparing the specialty to meet the challenges of the 21st century is reviewed. A discussion of the high costs of, and limited resources available for, research leading to the commercialization of new drugs, devices, and biologics follows, with a call for clinicians and private industry to work collaboratively to achieve advances in anesthesiology.
The fourth chapter looks at the impact of cardiac morbidity and mortality, and the use of well-designed outcome studies and guidelines to improve clinical outcomes. Following are three chapters devoted to the role of anesthesiologists as perioperative physicians. Both “pro” and “con” perspectives for such a role are presented, and both provide cogent arguments for and against the involvement of anesthesiologists outside the immediate operative period. However, as an intensivist, this reviewer failed to be swayed by the arguments on the “con” side. Following is a history of anesthesia training in Europe and a look at the current role of anesthesiologists there. The conclusion states that “the days when anesthesiologists simply ‘put a patient to sleep’ ceased several decades ago, and it is now time to fully recognize the specialty of anesthesiology as one that embraces total perioperative care.”
The next section of the book includes four chapters on topics of emerging clinical issues. “A Clinical Guide to the Internet” is written in plain English and will provide even the least computer-literate reader with a basic understanding of the role of the Internet in education and communications and as a clinical resource. An expanding role for alpha-2-adrenoceptor agonists in anesthesia is discussed, beginning with the basic structure and cellular effects of these molecules. The cardiovascular, sedative, antishivering, analgesic, and anesthetic-sparing effects are then reviewed and the clinical benefits outlined. The third of these chapters addresses the problem of awareness under anesthesia and the direction of monitoring anesthetic effect. The use of electroencephalographic Bispectral Index, or BIS, monitoring is described, along with the conclusion that sufficient evidence exists to supporting the efficacy and utility of BIS monitoring. The last of these clinical issue chapters is devoted to a review of the risks of blood transfusions and of not transfusing, and the role of blood substitutes with oxygen carrying and delivery properties. All four of these chapters are presented in basic, yet not oversimplified, manners, providing useful, clinically relevant information that will be understandable even to those not already familiar with these subjects.
The provision of anesthesia services in developing countries is the topic of the next chapter. Issues surrounding the medical infrastructure, the extent of anesthesia services available, the relative lack of specialty-trained physician providers, modern anesthesia equipment, standards for such equipment, and drugs are addressed. Opportunities for anesthesiologists from developed countries to work in developing countries and ways to donate equipment and supplies are described. This is certainly an important topic when considering the future of anesthesia in the 21st century, and this chapter provides a thought-provoking look at the unique problems faced in the provision of anesthesia care in the developing world.
The final chapter addresses what is perhaps the most important issue for the future of anesthesiology, the risks of anesthesia and patient safety, including the provisions of anesthesia services in the office setting. This discussion brings the reader full circle to the first chapter and its discussion of the history of anesthesia and improvements in patient safety and outcomes during the 20th century. It is fitting that a look at the “frontiers” of anesthesia concludes with the importance of ensuring that “the delivery of anesthesia and perioperative care continue to be safe.”