The

n e w e ng l a n d j o u r na l

of

m e dic i n e

b o ok r e v ie w s

Complications in Anesthesiology
Edited by Emilio B. Lobato, Nikolaus Gravenstein, and
Robert R. Kirby. 1008 pp., illustrated. Philadelphia, Lippincott
Williams & Wilkins, 2008. $169. ISBN 978-0-7817-8263-0.

ontemporary anesthesia is an important safety paradox of excellent outcome

despite routine risk. Although it carries perhaps
the greatest potential for hazard for millions of
patients annually, anesthesia also has medicines
best track record for the safety of patients. Gone
are the days of patients taking a bad anesthetic
and nothing more being said. Now the clinician
rightly carries the burden of accountability, and
nothing less than near-perfection is satisfactory.
Even though some interventions in Western medicine are believed perhaps naively to have the
potential to save thousands of lives if added to
conventional practice (e.g., proprietary care bundles for patients suffering from sepsis), conventional anesthesiology performs very well indeed.
We know this from epidemiologic data, and for
those less easily persuaded, the reduction in anesthesiologists malpractice premiums over the past
decade should convince.
This book is about complications, and it is the
prevention of complications that makes a practice
safe. The recent film Awake initially scared the
profession and shocked the public about safety
in anesthesia. But it did much more than scare
it focused attention on the potential for harm
in an area that most see as harmless. This is crucial, because anesthesia has advanced to a stage
where it appears simple and is practiced largely
in the background. Indeed, many people do not
know that anesthesiologists are physicians, do
not know the difference between nurse anesthetists and anesthesiologists, and have little idea
about what is done during the induced coma
that constitutes their general anesthetic.
In this sense, anesthesia is a victim of its own
success, building on decades of overwhelming
accomplishment in the safety of patients, to the
extent that studies of adverse events in anesthesia are difficult to perform because serious
adverse events, although dangerous, are rare.

Beyond the public perception, the safety paradox

has an unfortunate association with research and
further improvement; anesthesia shares (with orthopedic surgery) the ignominy of being allotted
the least funding through the National Institutes
of Health research training grants. Thus, assump
tions of safety perhaps coupled with ignorance
of risk may have translated into thinking that
ongoing research and development in anesthesiology do not matter.
Against this background, Complications in Anesthesiology is a welcome addition to the literature.
Although written for the anesthesiologist, it contains chapters that should be read and understood by many across todays health care spectrum,
including providers, administrators, regulators,
payers, and perhaps journalists and even patients.
The format is systematic and works well; the
book is anything but dull. A clinical summary
starts off each chapter, followed by essays of
generally high quality, with each chapter summarized by a final analysis and an enumeration
of key points.
The first chapter, Anesthesia, Perioperative
Mortality and Predictors of Adverse Outcomes,
is a gem, and it sets the tone and the standard for the book. We live in days of dubiously defined access and outcomes, and here
the real meanings of numerators and denominators in the guessing game of anesthesia performance are laid bare. Anyone who has witnessed
the superficiality of statements that claim no
difference in outcome when only crude data are
used to compare alternative models of anesthesia care will appreciate the clarity in this chapter.
The authors differentiate among complications
attributable to anesthesia, surgery, or characteristics of patients, as opposed to system failures
or situations where attribution is not possible (or,
as is often the case, not useful). These are recurrent themes, and the overlap with other chapters
in this book integrates and never irritates.
The section on pharmacology reflects editorial
imagination, with discussion of herbal remedies
and over-the-counter drugs. Finally, the book
takes a thoughtful look at complications to which

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The

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the anesthesiologist may be susceptible. Thoughtprovoking essays place bioterrorism and exposure
to fatigue into perspective, as well as that everpresent threat to the health of all anesthesiologists
and those around them: substance addiction.
I liked this book; the content is clear yet not
naive, and the format is thorough while maintaining interest. If you think that anesthesia is
usually safe, you are basically correct. However,
if you think that anesthesia is necessarily safe
or you dont understand why it isnt then
you should read this book carefully.
Brian P. Kavanagh, M.D.
Hospital for Sick Children
Toronto, ON M5G 1X8, Canada
brian.kavanagh@utoronto.ca

Current Therapy of Trauma

and Surgical Critical Care
(Current Therapy.) Edited by Juan A. Asensio and Donald D.
Trunkey. 785 pp., illustrated. Philadelphia, Mosby, 2008. $139.
ISBN 978-0-323-04418-9.

Trauma: Contemporary Principles

and Therapy
Edited by Lewis Flint, J. Wayne Meredith, C. William Schwab,
Donald D. Trunkey, Loring W. Rue, and Paul A. Taheri. 784 pp.,
illustrated. Philadelphia, Lippincott Williams & Wilkins, 2008.
$199. ISBN 978-0-7817-5650-1.

he statistics alone are daunting. In

the United States, traumatic injury is the leading cause of death in the first four decades of life.
On average, approximately 2 people are killed and
350 people have a debilitating injury every 10
minutes. Trauma accounts for more than 25% of
all visits to emergency departments and about 12%
of all hospital admissions, and the costs of caring for these patients are enormous. Practitioners
who care for traumatically injured and critically
ill surgical patients now have some assistance in
the form of two new reference sources.
Critical care and trauma are vast subject areas,
so much so that it is challenging to identify and
then create a compelling blend of scientific theory
and relevant research findings to inform an audience about safe, evidence-based approaches to
diagnosis and treatment. It appears that the
editors of these two books hope that theirs will

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serve as useful references for most practitioners

(and especially for surgery trainees) and will organize their thinking by presenting the necessary
fundamentals as guides to in-depth study. In
each instance, authors with diverse backgrounds
and expertise were recruited to contribute to the
books.
There are other similarities between the two
books. Each attempts to address the major relevant subject areas, though in many instances the
treatment is abbreviated. Both books are somewhat plain, sparsely illustrated, monochromatic,
and weighty tomes, with multiple chapters, written by many authors, that span more than 700
pages of text. Trauma has the advantage of being
printed in a larger and more readable font, as
well as providing access to an interactive Web
site containing the entire content of the book,
which facilitates study and enhances portability
and accessibility.
Trauma also differs from Current Therapy of
Trauma and Surgical Critical Care by taking a more
holistic approach to the subject. There are major
sections on the trauma system, the prevention
and control of injury, the trauma center, and the
trauma team, as well as discussions of ethics
and compassionate care that constitute about a
third of the books content. Information on the
optimal design and management of the modern
trauma center is well considered and nicely presented. About 300 pages are devoted to the organization of the trauma team, the evolution of
trauma nursing, and the training and development of trauma surgeons. The remainder of the
book, in its longest sections, addresses specific
issues regarding the care of patients. In these
sections, there is a concerted effort to emphasize
the scientific foundation underlying the modern
approach to caring for the severely ill patient,
including nonoperative management techniques.
The book has some editorial inconsistencies, and
its graphics tend to be rudimentary, but overall
the presentation is sound.
In his preface to Current Therapy of Trauma and
Surgical Critical Care, editor Juan Asensio explains
that the book is an extension of four highly successful previous editions of another book published by Mosby, entitled Current Therapy of Trauma,
last updated in 1998. Unlike its predecessors,
this latest book addresses critical and rehabilitative care in addition to trauma. The table of

n engl j med 359;10 www.nejm.org september 4, 2008

The New England Journal of Medicine

Downloaded from nejm.org on May 10, 2015. For personal use only. No other uses without permission.
Copyright 2008 Massachusetts Medical Society. All rights reserved.