Essentials of Neuroanesthesia and Neurointensive Care Gupta AK, Gelb AW eds. Philadelphia: Elsevier Saunders, 2008. ISBN 978–1-4160–4653-0. 368 pages, $52.00.
In the spirit of reaching across the aisle (or pond) to our friends, Drs. Gupta and Gelb have assembled 61 contributors from the United Kingdom and from Canada (with a few aliens from the west coast of the United States and one from New Haven). With both editors being of the commonwealth persuasion and Dr. Gelb now in San Francisco, one can understand the selection.
It is probably not unusual that while most centers insist that those who provide anesthesia for cardiac or neonatal surgery have special training in those subspecialties, almost everyone may be called upon to cover neurosurgical procedures. This reviewer has never quite understood that concept as, after all, the heart can be easily transplanted should things go wrong, but the brain is a once in a lifetime organ on which the rest of the body depends.
That said, this concise text aims to provide an overview of the essential information required to understand the basic principles of neuroanesthetic care. Thus, it starts with the fundamentals of anatomy, physiology, and pharmacology, moves on to the anesthetic management of neurosurgical procedures, and then covers neurointensive care. Monitoring is a separate section. Guillain Barre syndrome and myasthenia gravis are described separately, although this reviewer fails to see why these two rare conditions merit separate attention in a neuroanesthetic text. A description of the anesthetic management of Moya Moya disease would have been more pertinent.
The information provided is “essential” and thus the chapters are short. Each one is summarized by “key points” that should be of particular value to candidates contemplating the written board examination. For those preparing for oral examinations, the appendix offers a realistic series of case scenarios. The lone contributor from New Haven, Dr Ruskin, has added a useful section on clinical information resources and how to safeguard one’s computer.
Almost all aspects of neuroanesthetic management are covered from pediatric conditions to operative procedures to head and spinal cord injury and special procedures in remote locations. This last area is assuming increasing importance as neurosurgical procedures move out of the operating room to foreign grounds, to the great apprehension of the anesthesiologist. “Just run down and do a MAC case in interventional radiology” may be a frightening proposition for someone who has never heard of vertebroplasty or intradiscal electrothermal therapy. Perhaps the authors will cover these topics in the next edition.
Several chapters cover the management of neurotrauma. There are some areas of controversy here that are not presented as such. For example, an otherwise useful algorithm on the management of intracranial hypertension indicates propofol infusion 2–5mg/kg/h as an early strategy. The propofol infusion syndrome, a rare but fatal condition characterized by lactic acidosis, rhabdomyolysis, and cardiovascular collapse, is associated with doses higher than 4mg/kg/h.1 Also, although widely used for sedation in the head injured patient, no clinical study has shown propofol to be superior to other anesthetics in improving neurologic outcome.2 It has not been established as a clinical neuroprotectant per se. Although propofol decreases cerebral metabolic rate, it does so at the expense of maintaining coupling between flow and metabolism. Benefits may come from improved oxygenation as ventilation is controlled. Studies have concluded that the more severely injured patients do worse whatever agent is used, but early prevention and treatment of complications aimed at homeostasis lead to a better prognosis.3,4 The reader should also be aware that hypothermia, also advocated as an early intervention, is not recommended routinely.5 In fact, worse outcomes after only mild degrees of hypothermia were shown by Clifton et al. in a large multicenter trial.6
The editors note that they have tried to minimize overlap, and they have succeeded. There is only a single representation of the Glasgow Coma Scale, and even that is modified for children. Illustrations are sufficient and easily understandable.
This reviewer has often groaned before about long lists of outdated references. This book is not guilty! Each chapter has a short list of about 6 articles or book chapters for further reading. It might have been useful to include some of the recent practice guidelines and parameters from the American Society of Anesthesiologists or the Association of Anaesthetists of Great Britain on such issues as prevention of postoperative visual loss or peripheral neuropathies among other items.
Essentials of Neuroanesthesia and Neurointensive Care has met its goal of a brief overview, most suitable for residents, those preparing for board examinations, and part time neuroanesthesiologists. It is to be recommended as part of a general library for all anesthesiologists working in a hospital setting.
Elizabeth A. M. Frost, MD
Mount Sinai Medical Center
New York, NY.
1. Otterspoor LC, Kalkman CJ, Cremer OL. Update on the propofol infusion syndrome in ICY management of patients with head injury. Curr Opin Anaesthesiol 2008;21:544–51
2. Adembri C, Venturi L, Pellegrini-Giampietro DE Neuroprotective effects of propofol in acute cerebral injury. CNS Drug Rev 2007;13:333–51
3. Ghori KA, Harmon DC, Elashaal A. Effect of midazolam versus propofol sedation on markers of neurologic injury and outcome after isolated head injury: a pilot study. Crit Care Resus 2007;9:166–71
4. Pace MC, Cicciarella G, Barbato E. Severe traumatic brain injury: management and prognosis. Minerva Anestesiol 2006;72:235–42
5. Citerio G, Cormio M, Polderman KH. Moderate hypothermia in traumatic brain injury: results of clinical trials. Minerva Anestesiol 2004;70:213–8
6. Clifton GL, Miller ER, Choi SC. Lack of effect on induction of hypothermia after acute brain injury. N Engl J Med 2001;344:556–63