This comprehensive reference presents all of the information necessary for the proper anesthetic management of all cardiac patients*regardless of what type of surgery they are undergoing. It also addresses high-risk anesthesia and surgery in the ambulatory, neurosurgical, thoracic, vascular, and obstetrical suites. Conveniently organized, Section I examines pre-operative evaluation, medications, and monitoring. Section II reviews specific cardiac conditions and how best to manage them during surgery. Section III covers a variety of cardiac procedures, and Section IV reviews non-cardiac procedures for patients with cardiac disease.
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Christopher A. Troianos, MD, Department of Anesthesiology, The Mercy Hospital of Pittsburgh, Pittsburgh, PAFrom The New England Journal of Medicine:
Only over the past quarter-century have we come to appreciate the extreme, diverse, and persistent stresses associated with surgery. They can last from days to months and affect nearly every organ. The patients who are most susceptible to these stresses are older patients with atherosclerosis, who are least likely to be able to tolerate precipitous alterations in blood flow, excitotoxic stimuli, inflammation, reperfusion phenomena, and the traumatic assault of surgery. Since one of the organs that is the least resistant to such perioperative stress is the heart, we must regularly revise tactics and strategies for the estimated 35 million high-risk patients undergoing noncardiac surgery annually throughout the world and for the 1 million patients undergoing cardiac surgery. These considerations require immediate attention, for the population of elderly patients who undergo surgery, many of whom are quite ill, is growing rapidly. The number and complexity of procedures performed in this population are increasing commensurately, resulting in an increased likelihood of perioperative cardiac injury. Fortunately, clinicians and researchers have had to develop guidelines for the care of elderly patients undergoing surgical revascularization and, as a byproduct, recommendations for patients with atherosclerosis who undergo noncardiac surgery. Important advances in risk assessment, online monitoring, and postoperative care have evolved, as a result, over these past four decades, and a sizable literature has emerged, including more than a dozen textbooks addressing these issues. Do we need another? Perhaps. In this book, Dr. Troianos and 31 collaborators from 14 medical centers address matters relevant to patients with cardiac disease who are undergoing surgery -- thereby distinguishing their textbook from those that focus specifically on cardiac surgery. Their consideration of patients who undergo a number of dissimilar procedures (part IV) -- including, for example, vascular surgery, surgery for cardiac trauma, neurosurgery, obstetrical procedures, and thoracic surgery -- is unique. Particularly useful are the commentaries specific to each of these diverse subdisciplines, which heretofore have not been given appropriate individual consideration. Only recently have we fully understood that the cardiovascular stresses associated with these kinds of surgery most likely share only one characteristic: they are extreme. The information contained in these chapters will be particularly useful to physicians who are responsible for perioperative care, especially to those who are not familiar with the details of a specific surgical procedure and the associated physiological implications. The discussions are novel and reasonably comprehensive. Another notable feature is the section on preoperative assessment, which nicely presents and analyzes a number of recommended practice guidelines, comparing and contrasting their strengths and weaknesses. Other useful commentaries include the discussions of pacemakers, transesophageal echocardiography, and analgesic techniques, particularly as applied to patients undergoing noncardiac surgery. All these discussions are comprehensive, well referenced, and informative. In addition to these sections, and representing most of the material covered, are discussions pertinent to the care of patients undergoing cardiac surgery -- a subject that has been more than amply addressed in previously published textbooks. Nevertheless, this book is unusual in its detailed, unambiguous presentation of technical details regarding surgical approaches, bypass apparatus, and transplantation techniques (part III). There are comprehensive reviews of perioperative dysrhythmias (newer therapies) and clinical trials (antiischemic therapies), as well as guidelines for preoperative and postoperative care. The discussion of preoperative risk assessment would have been improved by the integration of surgical and anesthetic techniques into the risk model. Another subject deserving more attention is perioperative disease, especially reperfusion, inflammation, and thrombosis. Because the character, time course, and treatment of perioperative ischemic injury are likely to be different for cardiac surgery and noncardiac surgery, each merits separate discussion. This textbook has a number of strengths, the most important being the discussions of the care of patients with cardiac disease who undergo various types of surgery. It also deals with a very different population: patients undergoing cardiac surgery. In that sense, it is comprehensive, but its breadth is both a strength and a weakness. Recommendations for patients undergoing cardiac surgery have been well described in other textbooks, whereas the guidelines provided here for noncardiac surgery could have been more comprehensive. Even so, the editor and contributors are to be congratulated for their effort to provide a comprehensive treatise on the perioperative care of patients with cardiac disease. Dennis T. Mangano, M.D., Ph.D.
Copyright © 2003 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
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