A Practical Approach to Pediatric Anesthesia
Holzman RS, Mancuso TJ, Polaner DM.
Philadelphia: Lippincott Williams & Wilkins, 2008. ISBN 978-0-781-77943-2. 690 pages, $89.95.
A Practical Approach to Pediatric Anesthesia is designed as a reference textbook for pediatric anesthesiologists. This book reflects the authors’ collective experience in the practice of pediatric anesthesia. The textbook bridges the basic science of anesthesia with the realities of the current practice of perioperative medicine. There is a heavy focus on embryology and anatomy as the basis for understanding congenital abnormalities, as opposed to the usual physiological and pharmacological approach. At the same time, the book provides a detailed manual for management of uniquely pediatric surgical procedures, which are not otherwise described in more general manuals of surgical procedures.
The textbook is divided into four parts (and includes an extensive index).
Part I—Approach to the Pediatric Patient
These introductory five chapters include applied pediatric physiology and pharmacology that emphasize clinically important distinctions between pediatric and adult anesthesia. In addition, this section also includes a well annotated chapter on risk management and quality improvement, as well as a discussion of some of the ethical and legal issues surrounding concerns in pediatric anesthesia.
Part II—Clinical and Operational Aspects of Pediatric Anesthesia
The next six chapters deal with specific issues involving anesthetic equipment, general and regional pediatric anesthesia, postanesthesia care, and chronic pain management. Although the chapter on anesthetic equipment includes an informative discussion on the pediatric cuffed versus uncuffed tracheal tube debate, minimal information was provided regarding the use of some of the newer video laryngoscopes in the management of the difficult pediatric airway. The chapter on regional anesthesia had a strong focus on ultrasound for many of the upper extremity nerve blocks more common to the adult population, but did not review the benefits of ultrasound for placement of the classical pediatric nerve blocks such as the ilioinguinal rectus sheath, or for caudal catheter placement.
Part III—Anesthetic Management of Normalities and Abnormalities
These 18 chapters give the book its added value. The authors approached each system from an embryologic perspective, describing in their introduction that, philosophically, “a child’s job is growth and development,” and hence, the chapter divisions are written from this perspective. Most of these chapters are similarly organized and begin with a few pages explaining the basic embryology of the organ system, followed by headings (in small print leading to difficulty in locating the beginning of each heading) of particular disorders, the surgical treatment, and the anesthetic management. Many of these chapters were written in exhaustive detail, especially the craniofacial and cardiac chapters. This reviewer particularly enjoyed the discussion of the management of epidermolysis bullosa in the integumentary system chapter and found the discussion of moyamoya disease in the neurosurgical chapter to be particularly informative. One of the book’s shortcomings was the fact that, in some of the chapters, management decisions appeared to be institutionally dependent. Some examples include the implied recommendation of prophylactic dantrolene for a patient susceptible to malignant hyperthermia before choosing a nontriggering anesthetic, the routine use of succinycholine for rapid sequence intubation in pyloric stenosis, and the lack of distinction between the need for total IV anesthesia for motor-evoked potentials versus the ability to use a low-dose inhalational agent for somatosensory-evoked potentials.
Part IV—Special Situations in Pediatric Anesthesia
These eight chapters discuss assorted topics such as pediatric and neonatal resuscitation, laparoscopic surgery, off-site anesthesia, and a short review of anesthesia for organ transplantation. A chapter on fetal surgery is included, a welcome addition for those pediatric anesthesiologists who do not routinely manage these procedures. The discussion on trauma reviewed the different types of traumatic injuries, but this reviewer was disappointed with the lack of inclusion of the intraosseous approach as a possibility for emergent vascular access.
A user-friendly index was also included in the text.
In summary, this reviewer felt that most of the chapters were written in excellent detail, and that the book as a whole was informative and easy to read. The relatively minor criticisms of the book include, first, the small font headings made it difficult to find the particular disorder (even within the correct chapter). Second, the opinions of the authors in a number of instances seemed to reflect personal or institutional approaches rather than common evidence-based practices in pediatric anesthesia. Finally, there was little mention of the relatively new α-2 agonist agent dexmedetomidine, a drug that may have significant impact in pediatric anesthesia in the future. In conclusion, this textbook, with its unique embryologic basis, will serve as a helpful addition for the practicing pediatric anesthesiologist interested in achieving a greater understanding of congenital diseases and their implications for the anesthetic management of pediatric patients.
Jay B. Tuchman, MD
Department of Pediatric Anesthesiology
Children’s Hospital of Pittsburgh
University of Pittsburgh Medical Center