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herself tackles the last chapter in the book, perhaps intention­ally, because evoked potential monitoring is the newestcentral nervous system monitoring modality. It is a fittingconclusion to her book, and is comprehensive and readable.

Clinical Monitoring is a well-written and annotatedtext that will best serve the anesthesiologist interested in acomprehensive reference text. The coverage provides thereader with an historical perspective of monitoring practice,as well as an understanding of state-of-the-art equipment. Itis highly recommended.

Albert C. Perrino, Jr, MDDepartment of Anesthesiology

Yale University School of MedicineNew Haven, CT

The Practice of Cardiac Anesthesia. Edited by F.A. Hensleyand D.E. Martin. Little, Brown, Boston, MA, 1990,727 pp.Residents beginning their rotations in the cardiac

operating room (OR) are presented with a new set ofcircumstances that are always challenging, but at timesoverwhelming. Although they may have mastered the"routine" anesthetic in healthy patients, they are now facedwith a population of patients who are all critically ill andrequire cardiopulmonary bypass (CPB) for their procedures.There is also the possibility of the patient presenting to theOR on an intraaortic balloon pump.

So what is this budding anesthesiologist to do? To therescue comes the first edition of The Practice of CardiacAnesthesia, a timely handbook intended to "serve as apractical reference to prepare and help manage the cardiacpatient for those beginning training." To that extent, thisbook will certainly find a well-deserved place in the library ofanesthesia residents. The two editors from the PennsylvaniaState University College of Medicine have effectively coordi­nated the contributions of 37 individuals: 29 anesthesiolo­gists,S surgeons, 2 perfusionists, and a cardiologist. Its 727pages are organized into 24 chapters, which are then dividedinto three sections. This creates a practical and easy-to-followformat.

The first section contains 10 chapters, and covers theanesthetic considerations for the cardiac patient. This sectioncould have been further divided into two parts because thefirst four chapters cover more general patient considerations,whereas the remaining six chapters are a chronologicalpresentation of a routine adult cardiac anesthetic.

I found the first chapter to be an illuminating overviewof the cardiac patient. It was easy to read and applied topatients with cardiac disease presenting for both cardiac ornoncardiac surgery. The second chapter on the cardiac ORlists among its objectives that it "allows the future practi­tioner to design a cardiac OR." It contains a nice tabledescribing commonly used drugs and an interesting discus­sion on electrical shock hazards. However, the reader isadvised to consult another text in order to properly design anOR. The third chapter on cardiovascular drugs would en­hance its value as a quick reference by the addition of moretables and charts. Chapter 4 covers monitoring and includes apractical discussion of transesophageal echocardiography.

Chapters 5 through 9 are all very good; they cover

BOOK REVIEWS

induction and the specific consideration of the pre-, intra-,and post-CPB period. Chapter 5 covers induction of anesthe­sia. It contains many informative tables, such as thosecomparing the hemodynamic effects of induction agents,inhalation agents, and muscle relaxants.

Chapter 6 is the first of four chapters in this sectionthat deals specifically with the problems that anesthesiolo­gists face during CPB. These chapters, along with chapters18 to 20, give a reasonably complete introduction to CPB.They contain good charts and diagrams as well as a referencelist. Chapter 10, on postoperative care of the cardiac patient,is somewhat repetitive of other chapters. It may be better forthe intensivist than anesthesiologist.

The next section (containing eight chapters on specificmanagement of cardiovascular disorders) was also well done.Chapter II covers anesthetic management for myocardialrevascularization, and contains a good discussion of coronaryanatomy and physiology. Chapter 12 covers anesthetic man­agement for the treatment of valvular heart disease. Itcontains a concise discussion of each valvular lesion. Thereare excellent diagrams of pressure-volume loops, and a gridpresentation of anesthetic concerns for each valvular lesion.Other topics covered include: anesthetic management forcongenital heart disease, cardiac transplantation, thoracicaneurysms and dissection, and anesthesia for patients withelectrophysiological disorders.

The final section contains five chapters covering me­chanical support of the circulation, such as the specifics of theCPB machine, extracorporeal membrane oxygenation(ECMO), myocardial and brain protection, and circulatoryassist devices. The section on ECMO is unnecessary.

In summary, the text is comprehensive and up-to­date. It is exceptionally thorough for a manual. I found thechapters addressing CPB especially helpful for my rotation incardiac anesthesia. Topics are covered with appropriatethoroughness and intelligent discussion. Most of the chaptersare well referenced, and will provide direction to those whoseek greater depth. The style is pragmatic, rather thanexhaustive. I found the book easy to read, and rarely becamemired in technical detail. The binding is acceptable, but mypreference for this type of handbook is a spiral binding.Although there is a risk of disparity in a multiauthored text,the writing is consistently lucid and concise. I highly recom­mend it to residents. Although best read prior to entering thecardiac OR, the book is a welcome companion for the residentin the cardiac OR.

Salvatore Vitale, MDFellow in Cardiothoracic Anesthesiology

Mount Sinai School of MedicineNewYork,NY

Critical Care Cardiology. Edited by Henning and Grenvik.Churchill Livingstone, New York, NY, 1989, $79.95.The past decade has been one of rapid technological

advances in our ability to medically and surgically supportand treat patients with life-threatening cardiovascular dis­ease. Developments in many areas have made possible thewidespread use of modalities such as thrombolysis, angio­plasty, implantable defibrillators, ventricular assist devices,and cardiac transplantation. The care of patients with these

BOOK REVIEWS

interventions requires a coordinated effort on the part ofcardiologists, cardiothoracic surgeons, anesthesiologists, andcritical care physicians. Critical Care Cardiology, edited bytwo respected experts in cardiovascular disease and criticalcare medicine, is an ambitious attempt to summarize theserecent advances and provide a useful current reference forcritical care physicians dealing with the adult patient withmajor cardiac disease. Drs Henning and Grenvik haveassembled contributions from 25 authors, including some ofthe most respected names in cardiology and cardiovascularsurgery. Along the way it appears that the editors lost controlover the focus and content of contributions such that somechapters succeed in providing current information at the levelof the subspecialist, whereas others appear directed more tothe medical student or represent reworking of previous bookchapters or review articles. Ultimately, it is difficult to discernwhether these inconsistencies are due to variety in back­ground and approach of the multiple authors or the problemin defining the knowledge base of the targeted audience.

The text is organized into 13 chapters covering a widediversity of topics in cardiology and cardiac surgery, withmost of the chapters having multiple authors. The initialchapter on monitoring contains thorough sections on theclinical applications of echocardiography and nuclear medi­cine, but the discussions of electrocardiography and pressuremonitoring are quite basic and the issues of pulse oximetryand continuous ST segment analysis receive no mention. Thechapter on dysrhythmias is divided into three separatesections dealing with supraventricular and ventricular dys­rhythmias and cardiac pacing. The first two sections ondysrhythmias are very elementary and fail to address impor­tant new topics such as the role of electrophysiologicaltesting, expanding options in dysrhythmia surgery, and theuse of implantable defibrillators. There is limited or nomention of new advances in pharmacotherapy of dysrhyth­mias such as esmolol, amiodarone, or mexiletine. The sectionon pacing is well organized and up-to-date, with usefulpractical insights into indications and applications of newtransvenous pacing modalities, although a discussion of theapplication of external pacing in the acute management ofbradydysrhythmias might have been of interest for criticalcare physicians. The chapter on hypertensive emergencies is afairly standard review of a common intensive care unitproblem, in which management has been facilitated by a widevariety of new antihypertensive agents. Surgical manage­ment of aortic dissection is graphically and succinctly de­scribed in a chapter coauthored by Drs Duncan and Cooley.This chapter clarifies in text and illustration many issues thatare often confusing to the nonsurgeon. The two editorscombined to contribute the next two chapters on congenitalheart disease in the adult and valvular heart disease. Thematerial presented is fundamental in content and focusesmore on classical diagnostic approaches to these diseasesrather than critical care management. They fail to addresssome important issues, such as valve repair versus valvereplacement, the use of aortic homografts, or the postopera­tive care of the patient after valve surgery. The chapter onendocarditis that follows is a lengthy review of the microbiol­ogy of the problem with little relevance to intensive caremanagement. It concludes with a set of over 400 references,only 4 of which postdate 1980 and one of those is a reference

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to a similiar review by one of the authors in another textbook.The next two chapters, though out of sequence, provideexcellent discussions of the diagnosis, treatment, and currentapproaches to the patient with an acute myocardial infarc­tion. The chapter on thrombolysis and angioplasty in acuteinfarction is a well-written, state-of-the-art review of recentdevelopments in this area. The authors provide a well­grounded rationale for aggressive management of the patientwith an acute infarction that is soundly based on recentliterature. Dr John Kirklin and four other authors contrib­uted a very brief presentation on surgical interventions forcomplications of acute infarction that is superficial in itsapproach with only five pages of text, half of which is a casereport; the authors only briefly touch on the topics of acuterevascularization and mitral insufficiency. The textbook fin­ishes strongly with high-quality pragmatic reviews of cardiactrauma, mechanical support of the circulation, and cardiactransplantation.

In light of the tremendous relevance of the subjectmatter, well-respected editors, and illustrious contributorsthis text could have been a major addition to the critical careliterature. As it stands, the book contains several well-donechapters that meet the goals set forth in the introduction, butthere are an equal number of chapters that detract from thebook either because they are very basic in approach, superfi­cial in content, or dated in the information they contain. It isultimately up to the purchaser to decide whether the severaluseful sections are worthy of the list price of$79.95.

Joseph P. Coyle, MDCleveland Clinic Foundation

Cleveland,OH

Manual of Cardiorespiratory Critical Care. Edited by M.P.Guzman, A. Hedley Brown, S. Cook, C. Wren, and D.Richens. Butterworths, London, England, 1989, 313pp.In their preface, the editors direct the manual "at

those who are at the 'sharp end' of the very acute medicineand surgery practised nowadays." Although this aim ispraiseworthy, the result is a textbook that will strike theAmerican reader as provincial and applicable primarily tocritical care practice in Great Britain. This problem ishighlighted by some of the recommendations for treatmentand associated drug regimens that would be out of place inthe United States. For example, the prescription of intrave­nous diamorphine (heroin) as the preferred analgesic follow­ing myocardial infarction may interest the DEA investigatorsif written here. Also, the plans to expedite extubationfollowing routine cardiac surgery not only are debatable onmedical grounds as being the most efficient, but also couldpostpone the discharge of some patients from the ICUunnecessarily. At a time in which the DRG-based reimburse­ment system is driving medical practice, the recommenda­tions for this and other situations could prove costly. Recom­mendations to admit pediatric and adult patients 2 days priorto scheduled cardiac surgical procedures strike a false note ina time of same-day admit philosophies for these procedures.The ethic of the open ward is noted in these comments,especially when preoperative and postoperative relationships