Section Editor: Paul White
Book, Multimedia, and Meeting Reviews
Miller’s Anesthesia, 7th ed.
Ronald D. Miller, Lars I. Eriksson, Lee
A. Fleisher, Jeanine P. Wiener-Kronish,
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William L. Young, Philadelphia, PA:
Churchill Livingstone, Elsevier, 2009.
ISBN 978-1-4160-6624-8. 3084 pages, $329
(Basic version), $429 (Premium version).
diting a major 2-volume, multi-
E 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. Fi-
nally, one must have the political savvy
and sensitivity to deal effectively with
authors whose contributions are inappro-
priately late or inartfully constructed. How-
ever, once the hurdle of the first edition is
out the door, subsequent editions are usu-
ally 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 text-
book 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 con-
structs 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 de-
tail, 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 Associ-
ate Editor, this becomes the first truly
international anesthesiology textbook.
Vol. 110, No. 1, January 2010
With the world shrinking and becom-
ing more interdependent, this is a much
needed and welcomed move for our
specialty. An especially valuable addi-
tion to this edition is the ability to
access expertconsult.com on the Inter-
net because it allows for continual up-
dating 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 edi-
tion of this magnitude. However, with
expertconsult.com, the authors can up-
date their chapters as frequently as de-
sired 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 anesthe-
siologists, use of the BIS monitor and
awareness, perioperative consideration
of coronary stents, and preoperative sta-
tin 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 place-
ment or regional block placement. As a
first pass, the videos are generally
good, but with experience they can be
improved. As examples, with the ma-
chine 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 tra-
chea” not the patient; eliminating the
high “AH” count, stating that it is im-
portant 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 lubri-
cant 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 em-
phasis on this technique as a life-saving
maneuver than is warranted either
from the literature or from experience.
Even in experienced hands and every-
thing going smoothly, it will take sev-
eral 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 be-
lieve 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 incor-
porate 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 com-
pletely 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 chal-
lenges 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 effi-
ciency and safety, importance of quality
improvement, human performance and
patient safety, use of simulation in teach-
ing, research, and for specialty recertifi-
cation, and the current and emerging
ethical and legal aspects of anesthesiol-
ogy. 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 read-
ability of the illustrations.
The 2-volume edition is divided into
9 major sections: Introduction, Anes-
thetic Physiology, Anesthetic Pharma-
cology, Anesthesia Management, Adult
Subspecialty Management, Pediatric
263
 Book and Multimedia Reviews
Anesthesia, Postoperative Care, Critical
Care Medicine, and Ancillary Respon-
sibilities and Problems. Within these 9
sections, there are 102 chapters, grouped
according to interrelated subjects. There
is a Table of Contents and complete In-
dex with each of the volumes, so the
reader can access all topics from either
volume. The top and fore edge of the text
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blocks are color coded to facilitate find-
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ing 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 type-
set. The “basic version” of the 7th edi-
tion 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 pre-
mium version. The ability to receive
timely revisions, updates, and new ver-
sions 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 in-
clude the e-mail addresses of the au-
thors so that readers can communicate
directly with them regarding unantici-
pated 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 chap-
ters and perusing others. Overall, the
editors have done an excellent job of
minimizing duplicate material, altho-
ugh some repetition is desirable to al-
low for expression of different points of
view. Section II on Anesthetic Physiol-
ogy 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 para-
sympathetic nervous system, a more
detailed consideration of the neuropep-
tide transmitters and actions, and a
good review of ␤-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 substan-
tially different organization and content
from the prior edition. Included is a
discussion of respiratory function both
awake and anesthetized, and review of
264 Book and Multimedia Reviews
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 preoxy-
genation or during clinical anesthesia to
minimize loss of lung volume or atelec-
tasis, 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 substan-
tially revised, and contains a good re-
view 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 con-
tains 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 pharmacol-
ogy of anesthesia. The first chapter pro-
vides an excellent synopsis of the basic
principles of drug action using pharma-
cokinetic and pharmacodynamic mod-
eling. This is followed by a new chapter
on the molecular sites of anesthetic ac-
tion, 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 bron-
chospasm, but it omits any discussion
of the relationship of airway size to
lung volume. The Cardiovascular Phar-
macology section has an extensive up-
date on anesthetic protection from
myocardial ischemia. The chapter on
delivery systems for inhaled anesthesia
has been extensively revised to incorpo-
rate 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 chap-
ter on opioids contains many new illus-
trations dealing with the pharmacology
of opioids, drug interactions with opi-
oids, 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 effective-
ness of all nondepolarizing NMBs is
dependent not only on dose adminis-
tered, 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 rocuro-
nium with a small amount of sodium
bicarbonate does not abolish the pain
on injection. Finally, there is a new
chapter on inhaled pulmonary vasodi-
lators 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 oper-
ating 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 pro-
vider, 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, formulat-
ing evidence-based evaluation proto-
cols for various diseases to minimize
last-minute cancellations, and use of
electronic media to transfer information
rapidly and accurately among caregiv-
ers. The chapter on Anesthetic Implica-
tions of Concurrent Diseases has been
condensed and more than 500 refer-
ences 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 re-
lates to the fact that no mention is made
of the use of a wire-reinforced endotra-
cheal 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 incor-
porates a consideration of neuromuscu-
lar disorders. The remaining chapters
on Monitoring Instrumentation, Moni-
toring Depth of Anesthesia, Cardiovas-
cular, Renal, Respiratory, Neurologic,
Neuromuscular, and Temperature Moni-
toring, Transesophageal Echocardiogra-
phy, and Electrocardiography have all
been updated and improved. This sec-
tion concludes with chapters on Acid-
Base Balance, Airway Management,
Regional Anesthesia including use of
ultrasound guidance, Fluid and Blood
Therapy, and Coagulation. Despite rap-
idly changing technology, the chapter on
Airway Management is current, compre-
hensive, and balanced in its approach to
dealing with the difficult airway. The
ANESTHESIA & ANALGESIA

chapter on Ultrasound Guidance for Re-
gional 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,
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hepatic surgery, and transplantation,
trauma care, or those undergoing lapa-
roscopic, robotic, or laser surgery. Each
of these operative procedures has their
own special needs of which the compe-
tent anesthesia provider must be aware.
Reading these chapters in advance of
initiating an anesthetic plan will alert
anesthesia providers as to what to an-
ticipate 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 inten-
sive care, cardiac surgery, and use of
regional anesthesia. As with the other
chapters, the illustrations are abundant
and easy to interpret. Section VII ad-
dresses the many issues in postopera-
tive care including acute pain, nausea
and vomiting, fluid therapy, and infec-
tion 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 iden-
tifies 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 comprehen-
sive, evidence based, and provides the
reader with a clear understanding of
what the issues are, but unfortunately
not how to prevent it. Section VIII fo-
cuses on issues related to intensive care,
including protocols for managing respi-
ratory failure, weaning of patients from
ventilator therapy, use of scoring sys-
tems for categorizing patient acuity and
likelihood for recovery, CPR, and brain
death. Section IX addresses the remain-
ing issues of operating room manage-
ment, fire safety, substance abuse, and a
brief primer on statistical analysis.
In summary, the 7th edition of Mill-
er’s Anesthesia could serve as a model
for how to assemble a multi-authored
text that is fresh, comprehensive, pre-
cise and articulate in content, evidence
based, beautifully illustrated, and per-
haps 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
Vol. 110, No. 1, January 2010
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
plarson@ucla.edu
Clinical Anesthesia
(6th Edition)
Paul G. Barash, Bruce F. Cullen, Rob-
ert K. Stoelting, Michael Cahalan, M.
Christine Stock. Philadelphia, PA:
Lippincott Williams & Wilkins, 2009.
ISBN-10/ ASIN: 0781787637, ISBN-13/
EAN: 9780781787635. 1760 pages, $199.
t is very unusual for anesthesiology to
I have 2 major textbooks published
within a matter of a few weeks of each
other, but this has happened, and it gives
both this reviewer and potential buyers a
wonderful opportunity to compare and
contrast these 2 comprehensive anesthe-
sia textbooks and determine which one
best serves their clinical needs. There are
many similarities and some striking dif-
ferences between this new edition of
Clinical Anesthesia and Miller’s Anesthe-
sia (7th Ed.). First, Clinical Anesthesia is a
single-volume book with 1640 pages
of text, illustrations, and references,
weighing in at about 7.5 lbs. Although
considerably more portable than the
Miller 2-volume edition, it still does not
lend itself to being carried about for
quick review or referencing between
cases. There are a total of 141 authors,
most of whom are extremely well-
known and recognized experts in the
fields about which they are writing.
Some authors contributed to both major
textbooks but generally not in the same
subject. About a third of the authors are
new to this edition, which gives a fresh
approach to those topics. This edition
does not have the international flavor of
the Miller edition in that there are only
4 foreign authors: 2 from Canada and 1
each from India and Thailand. This
edition was edited by 5 very talented
senior authors who are also experi-
enced scientists and educators in anes-
thesiology. As a result, the chapters are
tightly structured with a minimum of
overlap or repetition. As much as pos-
sible, the authors and editors have tried
to emphasize the clinical relevance of
the scientific material being presented.
Barash and his coeditors have very
wisely utilized the Internet to enhance
the value of the textbook. Purchase of
the book provides the owner with an
access code to a bank of “add on”
features. There is a text bank that allows
the reader to obtain the complete text
online. There is also a podcast bank that
© 2009 International Anesthesia Research Society
Book, Multimedia, and Meeting Reviews
allows the reader to download text to
an iPhone, iPod, or Blackberry. There is
a quiz bank of questions and answers
relevant to each of the chapters. To my
knowledge, the podcast and quiz banks
are unique to the Barash edition. And
finally, there is an image bank that is
not yet available. Although the contents
of this bank are not evident from re-
viewing the text, presumably it will
include video images of technical pro-
cedures being performed. The Internet
access will allow the authors and edi-
tors of Clinical Anesthesia to update and
revise their contributions as necessary
to keep the book timely and relevant to
clinical practice.
There are a total of 60 chapters orga-
nized into 8 different sections. Each
chapter starts with a brief itemization of
the contents of that chapter followed by
a list of key points that form the basis of
the subsequent text. The key points are
numbered, and these numbers reappear
at the appropriate points in the text. The
typeset is very readable, and most chap-
ters have an abundance of colorful, well-
designed illustrations that enhance the
text. There seems to have been a con-
scious effort on the part of the authors
and editors to utilize references judi-
ciously to substantiate their key points,
and they are to be commended for this.
A nice feature for the reader is that the
major references are highlighted in the
reference list for each chapter. Many of
the key references are from 2007 or
earlier, so updating will be necessary
through the Internet to keep the book
current.
Section I gives the reader an over-
view of anesthesiology including its
history, scope of practice, and anesthe-
sia risk and liability for both the patient
and the anesthesia provider. Section II
focuses on the scientific foundations of
anesthesia, and contains 5 chapters, 2 of
which deserve special emphasis. One
chapter contains an excellent review of
the mechanisms of action of anesthetics
and their relationship to what is known
about consciousness. The other chapter
is a unique and intriguing consider-
ation of the genetic basis of disease, and
how pharmacogenomics may relate to
anesthesia. This is a unique chapter that
is well worth every anesthesia provider’s
consideration. Section III contains 7 chap-
ters on the anatomy and physiology of
anesthesia including cardiovascular, re-
spiratory, autonomic, and acid-base
physiology, along with wound heal-
ing and coagulation. The chapter on
infection and wound healing is new,
and emphasizes the need for anesthesia
providers to be aware of their impact
on this issue. Section IV addresses the
265