Perioperative Medicine: Managing for Outcome

Perioperative Medicine: Managing for Outcome Newman MF, Fleisher LA, eds. Philadelphia: Saunders/Elsevier, 2007. ISBN 978-1-4160-2456-9. 723 pages, $179.00. The operating room, traditionally, has been the predominant focus for anesthesiologists. New evidence is challenging this narrow view, however, by demonstrating the impact that perioperative decisions can have on long-term outcome. The editors of Perioperative Medicine: Managing for Outcome have done an excellent job of organizing these data and examining their influence on outcome. Indeed, the chapter authors within this text present a strong argument for expanding our traditional focus to include expertise in all facets of perioperative care. In addition to serving as editors, Drs. Fleisher and Newman set the tone for the entire text by providing an excellent initial chapter to this book. This chapter links key biochemical and neuropsychological markers of organ dysfunction to long-term morbidity and mortality data across multiple organ systems, supporting the central assertion that perioperative actions can influence long-term patient outcome. Following this lead, contributing authors invest the remaining text with the same attention to clinical data, buttressed appropriately by supporting physiologic and biochemical correlates. Figures and tables consistently aid understanding and assimilation of the material, and the text is extremely well-referenced. Three sections devoted to preoperative evaluation, intraoperative issues, and postoperative management, respectively, constitute the majority of the 723-page book; individual chapters are presented by organ system. A short introductory section contains background information relating ischemia, reperfusion injury, inflammation, and coagulation to peri- and postoperative morbidity; an equally brief concluding section is devoted to economic analysis and the relationship between outcome and pay-for-performance incentives. While these sections are a welcome addition, the main attribute of this text is clearly its devotion to and presentation of clinical data regarding immediate and long-term operative outcome. Preoperative risk assessment and evaluation are considered across the major organ systems with the notable exception of the GI tract. Cardiac and noncardiac surgical evaluations are considered independently, with the discussion for noncardiac assessment closely mirroring the recent AHA/ACC guidelines. The chapters presenting pulmonary, renal, and hematologic risk assessment are particularly noteworthy. Operative impact on lung and kidney function is well described, and data on evaluation and prediction of postoperative dysfunction are excellent. The hematology chapter provides excellent figures regarding assessment and treatment of low platelet states and other coagulopathies, and includes a well-referenced discussion regarding perioperative management of antiplatelet medications. Strategies for preservation of organ function and management of perioperative organ dysfunction are presented in a similar fashion to those for preoperative assessment. Separate consideration is devoted to all of the previously mentioned organ systems. Prevention of GI morbidity and perioperative protection for the parturient and fetus are also discussed. Cardiovascular, neurologic, and renal issues are emphasized, and individual topics within these areas are parsed into more manageable pieces. For example, individual chapters are devoted to prevention of ischemic injury during cardiac and noncardiac surgery, management of dysrhythmias, and patients with valvular heart lesions. The CNS-related chapters are equally diverse, considering neuroprotection during carotid, intracranial, traumatic, and cardiac surgical cases. Spinal cord protection in instances of traumatic injury and aortic surgery is also thoroughly reviewed. The last of the major sections explores issues in early postoperative care. These are grouped by organ system or surgical specialty, and include orthopedic surgery and solid organ transplantation. Specific issues related to postsurgical care are also delineated including pain, delirium and anxiety, endocrine and electrolyte abnormalities, and common issues in critical care, including septic shock and adult respiratory distress syndrome. Nausea, vomiting, and aspiration are covered in the chapter on preventing GI morbidity. Some important topics could profitably be added to the next edition. These include a discussion of the relative benefits of regional and general anesthesia in inpatient and outpatient orthopedic surgery and long-term quality-of-life benefits attributed to well-functioning epidurals. Recent outcome data regarding the cardiopulmonary benefits of local or regional anesthetic techniques for endovascular procedures is noticeably absent. A reference table to detail the criteria for determining the strength of evidence-based ratings would have aided the interpretation of data in several chapters. A working definition and consistent application in all chapters is desirable. Specific criticisms of the written text are relatively few. For example, the section on anesthesia for carotid endarterectomy was brief, ignored any role for dexmedetomidine, and appeared to substitute institutional preference for clinical data. The chapter on operative management of valvular disorders did not include the most recent recommendations for endocarditis antibiotic prophylaxis and figures detailing an evidence-based approach to anesthetic management were crowded and difficult to follow. Also in this chapter, the intraoperative transfusion discussion provided institutional algorithms for transfusion following cardiac surgery almost to the exclusion of any discussion regarding noncardiac cases. Despite these minor detriments, Perioperative Medicine: Managing for Outcome admirably achieves its objective of successfully integrating data across multiple disciplines into a single resource for improving surgical outcome. Trainee and graduate anesthesiologists and surgeons would benefit from it. James L. Helstrom, MD Staff Anesthesiologist, Massachusetts General Hospital Instructor, Harvard Medical School Boston, MA