REVIEWS OF EDUCATIONAL MATERIAL

Michael J. Avram, Ph.D., Editor

Germany) Monitor is also very well reviewed, although this

Dynamic and Static Parameters of Fluid
Responsiveness, Volume 48, Number 1. Edited
by Balachundhar Subramanian, M.B.B.S., M.D., M.P.H.,
and Kyung W. Park, M.D. Philadelphia, International
Anesthesiology Clinics-Lippincott Williams and Wilkins,
Winter 2010. Pages: 128. Price: $162.00.
technology is not yet widely available in the United States.
We would have liked to see more information about the
LiDCO system (Covidien, Mansfield, MA), particularly with
respect to the newer LiDCO rapid device that was only briefly
mentioned, despite its widespread use. There was also insuffi-
cient discussion of the use of stroke volume variation, as op-
posed to accurate cardiac output measurement with this system.

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Fluid management in perioperative and critically1 ill patients
The use of a noncalibrated device to trend cardiac output and
remains a highly debated topic. There is a wide variety of
optimize fluid status perioperatively during major surgery is, in
practice, even within institutions, and, if you think of fluid as
our opinion, quite different compared with needing more pre-
a drug, it is unique in that even the most junior member of
cise cardiac output values in a critically ill patient. We also be-
the team can double or triple the dose without fear of com-
lieve the editors could have included a separate article to review
ment by other members of the team. In recent years, there
the esophageal Doppler monitor. As mentioned in the final
has been a renewed interest in the assessment of fluid respon-
article, the esophageal Doppler monitor has more outcome data
siveness in critically ill patients to identify those patients for
for perioperative goal-directed fluid management than any
whom fluid therapy will be of benefit and, equally impor-
other monitor. It can also be used to assess the corrected flow
tantly, those for whom it will not. This interest has been
time, or duration of flow during systole, as a measure of preload.
driven by the emergence of a number of exciting new tech-
Using plethysmography to assess dynamic preload re-
nologies. Dynamic and Static Parameters of Fluid Responsive-
sponsiveness is an emerging area and is expertly covered, with
ness reviews these technologies and increases the reader’s un-
respect to both the possibilities and the limitations of these
derstanding of the important concept of dynamic fluid
new devices. Finally, the last article summarizes the outcome
responsiveness.
data from randomized controlled trials involving restrictive
The book is well organized into eight original articles. The
or goal-directed fluid strategies. It is noteworthy that the
first article illustrates the limitations of traditional static param-
limitations of nomenclature and fixed-volume amounts in
eters of fluid responsiveness, such as central venous pressure, and
the restrictive literature, as well as the confusion surrounding
outlines the physiologic concepts related to fluid loading. This
the third space, are well reviewed.
leads to the next article that discusses the physiology behind
Overall, the book offers a good and thorough review of the
dynamic fluid responsiveness and outlines the different technol-
subject, with the caveats mentioned above. We are delighted to
ogies available to illustrate and use this approach in routine
see an increasing interest and more publications devoted to this
clinical practice. In many ways, these first two articles are the key
important subject, with the hope that the increasing body of
to the book, providing the background information necessary to
evidence behind dynamic fluid responsiveness can be trans-
understand the subject. They are very well written and easy to
lated into a widespread change in practice. We would
understand, yet provide sufficient information to be recom-
recommend this book to anyone with an interest in this
mended reading for both novice and expert.
important subject, and it would be a useful addition to any
The next five articles look, in turn, at the different technol-
anesthesia or critical care departmental library.
ogies available to monitor fluid responsiveness. The discussion
of each device includes technical considerations behind how the Timothy E. Miller, M.B.Ch.B., F.R.C.A., Tong J. Gan,
device works as well as a detailed review of the evidence base for M.H.S., M.D., F.R.C.A.* *Duke University Medical Center,
the technology. The text is necessarily detailed at times because Durham, North Carolina. tjgan@duke.edu
the authors seek to provide the reader with a thorough under-
standing of the different systems available. The article on echo- (Accepted for publication July 1, 2010.)
cardiography was a useful inclusion and suitably brief because
this technology is not widely used to predict fluid responsiveness,
although it may have more of a role in the future as its use expands Anesthesiologist’s Manual of Surgical
into noncardiac surgery. We particularly recommend the article on Procedures, 4th Edition. Edited by Richard A. Jaffe,
the FloTrac System (Edwards Life Science, Irvine, CA), which ex- M.D., Ph.D., and Stanley I. Samuels, M.D. Philadelphia,
pertly reviews the device, particularly in relation to the different Lippincott Williams & Wilkins, 2009. Pages: 1,408.
versions available, because the company has sought to improve its Price: $169.
performance. The PiCCO (Pulsion Medical System AG, Munich,
I imagine that auto mechanics have it tough these days.
Copyright © 2010, the American Society of Anesthesiologists, Inc. Lippincott
Merely decades ago, all engines were alike and just a few repairs were
Williams & Wilkins. Anesthesiology 2011; 114: 226 –7 routinely made. Knowing how to change the spark plugs or flush

Anesthesiology, V 114 • No 1 226 January 2011

 REVIEWS OF EDUCATIONAL MATERIAL
the carburetor in one model would translate to the next car in the
service bay. Alas, times have changed. Nowadays, many cars no
longer have oil dipsticks, and some don’t even run on gasoline!
Just as modern-day auto mechanics need detailed service
manuals to cover all of the different repairs performed, so too do
modern-day anesthesiologists. The inconvenient truth is that an
anesthesiologist’s understanding of a surgical procedure may
not be much more than “having a liver resection” or “getting a
craniotomy.” In addition, many procedures are infrequent in a
broad practice—when was the last time you saw a mandibular
osteotomy and genioglossus advancement? Although a standard
anesthetic plan will suffice in many instances, every anesthesiol-
ogist would like to have a deeper understanding of the operation
at hand. For example, we would like to know that a Pringle
maneuver may drastically alter preload during liver resections or
to be reminded that a rectal cancer resection may also have a
perineal incision, before planning only a low thoracic epidural
for postoperative pain control. The reality is that surgery has
become fantastically complex, and anesthetic plans need to evolve
accordingly—we need expert explanation from both sides of
the ether screen. Jaffe and Samuels’ now-classic Anesthesiolo-
gist’s Manual of Surgical Procedures is the resource required.
Now available in its fourth edition, the text has been updated
every 5 yr since its introduction in 1994. It provides the reader with
thoughtful considerations from both surgeons and anesthesiologists
for virtually every operation performed today. Obviously, clarity
and readability in such a tome (more than 400 procedures are de-
tailed) depend on organization and consistent thematic presenta-
tion across authors. Thankfully, the text remains as clearly orga-
nized as it was in previous editions. The 15 sections are based on
surgical specialty (otolaryngology, cardiovascular surgery, out of op-
erating room procedures, etc.); pediatric surgery gets its own sec-
tion. Each section is broken into 5–10 subsections (e.g., general
surgery has peritoneal surgery, breast surgery, and trauma surgery).
Finally, within each subsection are 2–5 pages for each operation.
The index is superb and allows for directed reading on a single
procedure. Appendices cover topics ranging from latex allergy to
herbal drug interactions and perioperative acupuncture. One nota-
ble advantage to the previous edition was a (now absent) lengthy
appendix defining the many acronyms used throughout the text.
The book was written by more than 180 authors. With so many
contributing to the text, the editors are to be highly commended for
keeping the voice consistent. The individual chapters are organized
similarly. The description of each procedure has a separate section
for surgical and anesthetic considerations. The surgical portion in-
cludes a brief background on the disease process and then follows
with two tables, one summarizing the procedure and another listing
the patient characteristics and comorbidities. The tables are invalu-
able, detailing operative length, positioning, predicted blood loss,
closing time, preferences at emergence, and more. The chapter con-
tinues with the anesthetic considerations broken into preoperative,
intraoperative, and postoperative epochs. Grouping is judi-
ciously used to avoid repetition where anesthetic considerations
overlap between procedures. Each procedure concludes with
suggested additional readings.
Anesthesiology 2011; 114:226 –7
The fourth edition represents a significant update. It is now
approximately 300 pages longer and contains approximately 40
new procedures, many addressing laparoscopic and endovascu-
lar surgery. This edition is much improved by the new applica-
tion of color to the tables, text, and figures. The surgical section
headings and tables are in green, whereas anesthesia sections are
in orange. Figures (almost all are surgical illustrations) are in full
color. The book is dense, but the eye falls easily to each particular
section. As in previous editions, figures are not unique to the text
but are referenced from other publications.
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As with any important contribution to the literature, a few
quibbles still arise. The text and the tables are significantly im-
proved from the aesthetic perspective, but some of the figures
are starting to appear dated. A fair number of the surgical illus-
trations are taken from outdated editions of other texts and
peer-reviewed publications from the 1980s and 1990s. A pic-
ture detailing the relationship of the mediastinoscope to the
trachea and great vessels comes from a 1979 publication, and a
schematic representation of a cardiopulmonary bypass circuit
comes from a text published in 1988. Although such figures are not
misleading per se, updated images would lend a consistently modern
appearance to the text. This might be a focus of the next edition.
Several additional chapters would be useful, including an
expanded handling of neurologic monitoring for spine and in-
tracranial surgery. In addition, an expansion of the hemodialysis
access chapter, focused on pairing commonly used peripheral
nerve blocks with each of the approximately five common he-
modialysis access procedures, would be useful.
Weighing in at 7.29 pounds (I used the scale at my local
butcher’s shop), the text is not readily portable. This is unfortu-
nate because the book is not just another dust-gathering refer-
ence work—it really is to be used on a daily basis! The publishers
have addressed this unavoidable reality by establishing elec-
tronic access that is free of charge with a code inside the front
cover. The electronic version includes printable full text with
images. A separate image bank allows flash-based downloads in
.jpg or .pdf format. The full-format text with figures can be read
from a smartphone or e-reader’s browser but requires the usual
slow scrolling and frequent zooming. A mobile site or dedicated
“app” would be most welcome to end users, affording portabil-
ity and catering to a modern learner’s reading preferences. I
hope this would be in place by the next edition, if not sooner.
As Jaffe writes in the preface, this is not a text of anesthe-
sia, nor is it a text of surgery. It is, however, a great reference
from which to formulate an informed, procedure-specific
anesthesia plan. In a few minutes a day, reading from Anes-
thesiologist’s Manual of Surgical Procedures can only deepen
understanding, increase collegiality and confidence in the
operating room, and make us all better physicians.
Derek T. Woodrum, M.D., University of Michigan, Ann
Arbor, Michigan. dwoodrum@med.umich.edu
(Accepted for publication July 8, 2010.)
227 Reviews of Educational Material