Pediatric Anesthesia: Principles and Practice

Abstract

Pediatric Anesthesia: Principles and Practice B. Bissonnette and B. Dalens, editors New York, New York: McGraw-Hill Publishing Division, 2002. ISBN 0-07-135454-9. 1618 pp, $195.00. Pediatric anesthesiology has evolved over the past 50 years as both a viable clinical and academic subspecialty of anesthesiology. This maturation of the subspecialty includes increased sophistication of clinical care, automation, clinical and bench research, and scholarship. The pediatric anesthesiologist must be facile in providing empathetic, efficient care for a wide gamut of procedures (e.g., the healthy infant or toddler for insertion of pressure equalization ear tubes to the small premature [1000 g] for a variety of procedures). In addition, many surgical procedures are increasingly performed on an outpatient basis and major surgical procedures are performed as A.M.-admits. Thus there are a tremendous number of technical skills and a body of knowledge to be mastered about the totality of pediatric anesthesia. The growth of pediatric anesthesia as a specialty might be measured in part by the texts that support its clinical and intellectual fabric. Contrast Hewer’s Pediatric Anaesthesia (111 pages, 1923) and Leigh and Belton’s somewhat larger book (240 pages, 1948) to the current major texts. In addition, smaller anesthesia books defining critical clinical niches, pediatric surgery texts, and critical care texts are available. Pediatric Anesthesia: Principles and Practices provides an up-to-date, detailed, global overview of the true scope and depth of pediatric anesthesia practice. This task has been greatly facilitated by having 143 authors from various pediatric centers worldwide contribute their expertise. For example, 39 authors are from Canada, 21 from the United States, 18 are from the United Kingdom and Ireland, 47 are from continental Europe, and a few are from South Africa, Israel, Brazil, Australia, New Zealand, Singapore, and Japan. The text is well written, lucid, and largely uniform in style. The text is tightly written and not chatty. The bibliography seems appropriate and up to date. Multiple well-drawn illustrations, pictures, and tables are included. The book is divided into six major sections: 1) developmental considerations, 2) pharmacology, 3) anesthetic management and techniques, 4) special monitoring and resuscitation techniques, 5) surgical and anesthetic considerations for procedures, and 6) the future of pediatric anesthesia. In the fifth section various surgeons, pediatric cardiologists, dentists, interventional radiologists and other specialists provide a thoughtful companion overview of various topics prior to a discussion of the appropriate anesthetic management. There is little redundancy between these companion chapters. Most of these chapters outline subtle differences in anesthetic management that might be used by various practitioners. One way perhaps to review this book and other pediatric anesthesia texts is to test its usefulness in supporting either a formal didactic program or alternatively mini-topics appropriate for clinical teaching. This text quite nicely supports to an admirable degree this list of topics. However, the unique framing of the topics by this reviewer presented an occasional problem. It is somewhat unclear if morphine is less safe in neonates because of its highly variable kinetics or because of differences in dynamics. However, the issues describing the safety of inhalation anesthetics in infants are quite clear. Fluid therapy for infants and small children is nicely developed. One doubts that lactated Ringers is metabolized to glucose to any great extent since gluconeogenesis from lactate is such a high-energy process. Likewise, one might better describe the role(s) of carbon dioxide production, minute ventilation, and fresh gas flow as they relate to the isobars of carbon dioxide in the variants of the Mapleson D systems. The chapter on regional anesthesia techniques was well illustrated and provides useful surface landmarks for a variety of blocks. There may be a larger role for long-term caudal analgesia in infants that the author suggests. This thought is mentioned in the chapter on pediatric pain management. The chapter on the clinical use of muscle relaxants is markedly reduced in neonates. However, the notion that only one molecule of relaxant is needed to produce a competitive block in neonates whereas two molecules are required in older patients is probably too simplistic a concept. None of these comments should be construed as overly critical or pejorative. There may be honest differences in opinion about the relevance or significance of certain issues. The only somewhat disappointing feature of the book is a short disclaimer from the publisher. For years infants and small children were seemingly therapeutic orphans. One suspects that many of the drugs discussed in the text still have no label in infants or small children; thus, their very use in pediatric patients is off-label. Therefore it is not helpful to refer us to the manufacturer’s label for this information. Similar disclaimers exist in other texts and are clearly a sign of our increasingly litigious society. This book will fill a useful place in the libraries of pediatric anesthesiologists, pediatric anesthesia residents or fellows, and major departments. Most anesthesia residents spend only 2 to 3 months in pediatric anesthesia in the first 2 years of their clinical programs. It is, thus, nearly impossible to provided a structural educational program that provides more than an overview of needed information. This text may be too dense as a primer but is clearly a major resource.