Miller's Anesthesia, 7th ed.
Ronald D. Miller, Lars I. Eriksson, Lee A. Fleisher, Jeanine P. Wiener-Kronish, William L. Young, Philadelphia, PA: Churchill Livingstone, Elsevier, 2009. ISBN 978-1-4160-6624-8. 3084 pages, $329 (Basic version), $429 (Premium version).
Editing a major 2-volume, multi-authored textbook is such an arduous, challenging, time-consuming task that few academicians choose to undertake it. To be an effective editor, one must have a detailed knowledge of the discipline; an awareness of those in the discipline who are doing the innovative work and have the ability, time, and interest to describe the field in appropriate detail; and a dedication to collating and editing the material to avoid needless repetition. Finally, one must have the political savvy and sensitivity to deal effectively with authors whose contributions are inappropriately late or inartfully constructed. However, once the hurdle of the first edition is out the door, subsequent editions are usually only minor revisions of the original to incorporate new information.
Such is not the case with the 7th edition of Miller's Anesthesia. When compared with the 6th edition, the 7th is in many ways a new, 2-volume textbook that is so creatively constructed that it may obviate the need for an eighth edition. With the 7th edition, Dr. Ronald Miller has demonstrated that he has the skill to take a fresh, innovative, progressive view of anesthesiology as it currently exists and what it might look like in the future, and with the able assistance of 4 associate editors constructs a textbook that may be ageless. This overview is true not only for the Miller edition, but also for the Barash text Clinical Anesthesia, 6th edition, a review of which follows the Miller review.
Before examining the chapters in detail, an overview of the structural changes in this edition is necessary so that readers will know what they will be getting if they buy it, or what they will be missing if they do not. For a start, 96 new authors have been added, and the deletion of 36 results in a net gain of 60 authors, all of whom bring a fresh approach to the field. In addition, 33 of the new authors are from foreign countries, and with the addition of Lars Eriksson from Stockholm as an Associate Editor, this becomes the first truly international anesthesiology textbook. With the world shrinking and becoming more interdependent, this is a much needed and welcomed move for our specialty. An especially valuable addition to this edition is the ability to access expertconsult.com on the Internet because it allows for continual updating of text as new information and ideas emerge. Most of the references in the texts are from 2007 or earlier, as would be expected considering the timeframe required to assemble an edition of this magnitude. However, with expertconsult.com, the authors can update their chapters as frequently as desired or indicated. This feature alone makes this edition ageless. Although the 7th edition has just been published, there are already 5 updates, dated June 4, 2009, dealing with obstructive sleep apnea, substance abuse among anesthesiologists, use of the BIS monitor and awareness, perioperative consideration of coronary stents, and preoperative statin therapy. The other valuable feature in expertconsult.com is the ability to view videos of technical procedures such as patient positioning, anesthesia machine checkout, use of the fastrach LMA, needle cricothyrotomy, and ultrasound guidance for vascular catheter placement or regional block placement. As a first pass, the videos are generally good, but with experience they can be improved. As examples, with the machine check, it is not clear whether the check relates to the Aestiva machine or is applicable to all anesthesia machines currently in use. The fastrach LMA video could be improved by such simple changes as “intubate the trachea” not the patient; eliminating the high “AH” count, stating that it is important to loosen the 15-mm connector to the tube before inserting the tube, so the struggle with this in the video is eliminated. Also, does the type of lubricant matter? The purpose of the metal handle is never mentioned, or how it is to be used to facilitate intubation of the trachea if the first pass should go into the esophagus. I believe that the needle cricothyrotomy video places more emphasis on this technique as a life-saving maneuver than is warranted either from the literature or from experience. Even in experienced hands and everything going smoothly, it will take several minutes to locate the kit, identify the target, and complete the task. If anything should go wrong, such as inability to find the trachea with a needle, which is common, or failure of the dilator to follow the wire, valuable time is lost. A much quicker and more effective technique would be to take a knife, insert it into the cricothyroid membrane, twist the knife, and insert a tube. There is no serious risk with doing this and ventilation can be established almost instantaneously. In essence, I believe this video needs a more balanced and realistic approach. Finally, in the Aintree video, it is suggested that one can ventilate the lungs once it is in place using the 15-mm connector. One cannot establish any meaningful ventilation through an Aintree catheter, but one can insufflate oxygen, which should be the focus. The beauty of the videos on expertconsult.com is that they can be revised easily to correct flaws or incorporate new technology as it emerges. This is a great improvement over the video disk that accompanied the 6th edition.
There are many other substantial changes in the 7th edition that are worth mentioning. The first 10 chapters of the text are for the most part completely new or greatly revised from the 6th edition. In addition, they have been moved from the back of the text to the front, acknowledging at the outset the importance of existing and future challenges and how we might address them. These include emphasis on the need for research, evolving anesthesia practices worldwide, growing use of medical informatics to improve efficiency and safety, importance of quality improvement, human performance and patient safety, use of simulation in teaching, research, and for specialty recertification, and the current and emerging ethical and legal aspects of anesthesiology. The key points of each chapter have been moved from the back of the chapter to the front, so the reader can get a snapshot view of the issues in that chapter. A very substantial change is the number of new illustrations and tables included in both the new and revised chapters. The colors used in the illustrations have been changed from mostly red and white to primarily blue and gold (with occasional yellow, brown, or green), perhaps a subtle reminder that this book had its genesis at the University of California. The color change is striking, and through contrast greatly enhances the ease of interpretation and the readability of the illustrations.
The 2-volume edition is divided into 9 major sections: Introduction, Anesthetic Physiology, Anesthetic Pharmacology, Anesthesia Management, Adult Subspecialty Management, Pediatric Anesthesia, Postoperative Care, Critical Care Medicine, and Ancillary Responsibilities and Problems. Within these 9 sections, there are 102 chapters, grouped according to interrelated subjects. There is a Table of Contents and complete Index with each of the volumes, so the reader can access all topics from either volume. The top and fore edge of the text blocks are color coded to facilitate finding the section of interest. The weight of the 2 volumes has been decreased from just under 18 lbs for the 6th edition to just under 16 lbs for the 7th. This weight loss has been accomplished in part by using a somewhat smaller typeset. The “basic version” of the 7th edition provides 2 volumes and access to the full text online, and is priced at $329. The “premium version” provides the basic version plus the many add-ons noted above and is priced at $429. Without question, I would urge the potential buyer to consider the premium version. The ability to receive timely revisions, updates, and new versions of the text and videos makes the extra $100 a very smart investment in the future. Something that the editors might consider for the future is to include the e-mail addresses of the authors so that readers can communicate directly with them regarding unanticipated or outlier issues that always emerge with any topic.
It is impossible to review a textbook of this magnitude in chapter by chapter detail, so I will highlight the images that emerged while reading some chapters and perusing others. Overall, the editors have done an excellent job of minimizing duplicate material, although some repetition is desirable to allow for expression of different points of view. Section II on Anesthetic Physiology is highlighted by a new chapter that provides a comprehensive analysis of the anatomic sites and physiological functions of normal sleep, memory, and consciousness, and how they compare and contrast with the anesthetic state. This is followed by a chapter on the Autonomic Nervous System, which has much improved illustrations of the anatomy of the sympathetic and parasympathetic nervous system, a more detailed consideration of the neuropeptide transmitters and actions, and a good review of β-adrenergic blockade. The chapter on Cerebral Physiology contains an excellent discussion of the pathophysiology of cerebral ischemia and the status of brain protection. The chapter on Respiratory Physiology is written by a new author with a substantially different organization and content from the prior edition. Included is a discussion of respiratory function both awake and anesthetized, and review of the relationship of airway size to lung volume, a key relationship that is often forgotten in reviews of bronchospasm. The author suggests that it might be appropriate to use less than maximal concentrations of oxygen during preoxygenation or during clinical anesthesia to minimize loss of lung volume or atelectasis, or consider using CPAP to mitigate the oxygen effects on lung volume. The Hepatic Physiology has been extensively revised and includes a greater focus on the gross and microscopic anatomy of the liver, perhaps due in part to the use of partial livers for transplantation. The Renal Physiology chapter is substantially revised, and contains a good review of renal toxicity of anesthetics. However, the author still clings to the recommendation that the total gas flow during sevoflurane anesthesia should be 2 L/m to eliminate the possibility of Compound A toxicity, despite the fact that sevoflurane has been administered to more than 250 million patients worldwide without any documented evidence of renal impairment from Compound A. Also, the chapter contains no mention of the effects, if any, of body position (prone, lateral, sitting) on renal function, perhaps because this is an unexplored issue.
Section III deals with the pharmacology of anesthesia. The first chapter provides an excellent synopsis of the basic principles of drug action using pharmacokinetic and pharmacodynamic modeling. This is followed by a new chapter on the molecular sites of anesthetic action, and where we are and need to go with our research into how anesthetics work. The Pulmonary Pharmacology chapter has an expanded section on ventilator mechanics and acute lung injury. There is also a section on bronchospasm, but it omits any discussion of the relationship of airway size to lung volume. The Cardiovascular Pharmacology section has an extensive update on anesthetic protection from myocardial ischemia. The chapter on delivery systems for inhaled anesthesia has been extensively revised to incorporate the anesthetic work stations with automatic machine checkout systems, no bellows visible in the ventilators, and new types of vaporizers. The 2007 checkout guidelines and additional checkout notes are provided. The chapter on opioids contains many new illustrations dealing with the pharmacology of opioids, drug interactions with opioids, and their use in total IV anesthesia and as transdermal patches. The section on neuromuscular blocking drugs (NMBs) provides a detailed discussion of sugammadex, as well as the expected pharmacology of NMBs. What does not come across clearly is that the effectiveness of all nondepolarizing NMBs is dependent not only on dose administered, but also depth of anesthesia. Also, nothing is mentioned about not using rocuronium for priming because of the severe pain associated with its injection. Even alkalinizing the rocuronium with a small amount of sodium bicarbonate does not abolish the pain on injection. Finally, there is a new chapter on inhaled pulmonary vasodilators with a special emphasis on nitric oxide.
Section IV deals with Anesthesia Management and is the largest section in the 2-volume edition. It contains 25 interrelated chapters dealing with operating room care in the broadest sense. It includes an updated chapter on the Risk of Anesthesia as it relates to the location of surgery, the anesthesia provider, and the drugs and monitoring used. The chapter on Preoperative Evaluation is written by a new group of authors and represents an excellent source for learning how to establish an efficient preoperative clinic, formulating evidence-based evaluation protocols for various diseases to minimize last-minute cancellations, and use of electronic media to transfer information rapidly and accurately among caregivers. The chapter on Anesthetic Implications of Concurrent Diseases has been condensed and more than 500 references have been deleted. The chapter on Patient Positioning is totally revised, with new authors and much improved illustrations of patient positions and safety precautions. One oversight relates to the fact that no mention is made of the use of a wire-reinforced endotracheal tube when positioning a patient prone to avoid kinking of the tube if it exits the mouth at a right angle to the head-holder. The chapter on Malignant Hyperthermia has been rewritten by a new set of authors and logically incorporates a consideration of neuromuscular disorders. The remaining chapters on Monitoring Instrumentation, Monitoring Depth of Anesthesia, Cardiovascular, Renal, Respiratory, Neurologic, Neuromuscular, and Temperature Monitoring, Transesophageal Echocardiography, and Electrocardiography have all been updated and improved. This section concludes with chapters on Acid-Base Balance, Airway Management, Regional Anesthesia including use of ultrasound guidance, Fluid and Blood Therapy, and Coagulation. Despite rapidly changing technology, the chapter on Airway Management is current, comprehensive, and balanced in its approach to dealing with the difficult airway. The chapter on Ultrasound Guidance for Regional Anesthesia is new, and the text and illustrations are excellent.
Section V is titled Adult Subspecialty Management, and includes 23 chapters that focus specifically on the unique or special anesthetic or patient requirements encompassing the whole spectrum of surgical procedures including cardiac, thoracic, bariatric, vascular, renal, or hepatic surgery, and transplantation, trauma care, or those undergoing laparoscopic, robotic, or laser surgery. Each of these operative procedures has their own special needs of which the competent anesthesia provider must be aware. Reading these chapters in advance of initiating an anesthetic plan will alert anesthesia providers as to what to anticipate and expect as the operation proceeds so that they can maximize their effectiveness as members of the surgical team.
Section VI is a new section devoted entirely to Pediatric Anesthesia, and includes pediatric and neonatal intensive care, cardiac surgery, and use of regional anesthesia. As with the other chapters, the illustrations are abundant and easy to interpret. Section VII addresses the many issues in postoperative care including acute pain, nausea and vomiting, fluid therapy, and infection control. Of special importance is the recent recognition that anesthesia and surgery can produce long-term cognitive dysfunction, especially in the elderly. The chapter on this topic identifies what we do and do not know about why it occurs or how to minimize or prevent it. Finally, the chapter on postoperative blindness is comprehensive, evidence based, and provides the reader with a clear understanding of what the issues are, but unfortunately not how to prevent it. Section VIII focuses on issues related to intensive care, including protocols for managing respiratory failure, weaning of patients from ventilator therapy, use of scoring systems for categorizing patient acuity and likelihood for recovery, CPR, and brain death. Section IX addresses the remaining issues of operating room management, fire safety, substance abuse, and a brief primer on statistical analysis.
In summary, the 7th edition of Miller's Anesthesia could serve as a model for how to assemble a multi-authored text that is fresh, comprehensive, precise and articulate in content, evidence based, beautifully illustrated, and perhaps most importantly has the capacity to be revised as needed. The “Premium Edition” is not only a valuable resource to the current students and teachers of anesthesiology, but with the ability to update text and videos, could remain a bible of anesthetic care for future generations.
C. Philip Larson, Jr., MDCM
Professor of Clinical Anesthesiology
David Geffen School of Medicine at UCLA
Los Angeles, California