Neurosurgical Anesthesia and Critical Care, Vol. 25, No. 3 in Anesthesiology Clinics

Neurosurgical Anesthesia and Critical Care, Vol. 25, No. 3 in Anesthesiology Clinics Bambrink AM, Kirsch JR, eds. Philadelphia: Saunders/Elsevier, 2007. 307 pages, $180.00 annual subscription for four issues or $84.00 for single issue. Neurosurgical anesthesia and critical or intensive care of patients with central nervous system disease has a long history (at least by North American standards). Probably the first designated recovery area was established by Walter Dandy and Warfield Firor, both neurosurgeons, as a 3-bed neurosurgical unit at the Johns Hopkins Hospital in 1923. The specialty of neuroanesthesia was defined by A. R. Hunter in England and R. G. B. Gilbert in Montreal by 1960. In that same year, the Commission of Neuroanesthesia, comprising anesthesiologists from nine countries was founded in Belgium on July 9th1 and from that, many societies have been established, including the Society of Neuroanesthesia and Critical Care in the United States in 1973. The first book devoted exclusively to neuroanesthesia (if one excludes the Edwin Smith papyrus, compiled about 3,000 BC, and dealing with the care of 48 types of injuries, 34 of which were of neurosurgical origin) was published in 1964.2 Since those early days, there have been many advances, several of which are addressed in this latest Clinics issue, including an update of the key topics in neuroanesthesia and perioperative care. The authors have also attempted to identify areas of practice with limited aggregate information such as the long-term outcome of decompressive craniotomy. Some of the common problems in daily practice are considered, such as choice of reliable and practical monitoring techniques and their appropriate application and pain management. D. R. Fleisher notes in the Forward that the 21st century has been described by many as the era of neuroscience. Actually, the proclamation by President George Bush declared 1990–9 as the “decade of the brain.” During this period, the Library of Congress and the National Institute of Mental Health of the National Institutes of Health sponsored an interagency initiative to advance research and understanding of the central nervous system. No doubt we are now seeing some of the fruits of those efforts. Several of the contributors point out, correctly, that many disease states, once the sole domain of the neurosurgeon, have now drifted, and in some cases, charged, to the care of other specialists. Tumors, arteriovenous malformations, and trauma often are treated first by neuroradiologists and emergency room physicians. Intensive care and perioperative management is provided by intensivists and internists. Pain management specialists today are rarely neurosurgeons. Anesthesiologists must, therefore, be prepared to move out of the operating room to follow the patients and acquire an understanding of the disease processes, including pathophysiology, diagnostic requirements, and treatment options to better prepare themselves for adapting and working in new environments. It is only fitting that the first two chapters deal with the realm of shadows. Once one locates the sub-basement and summons up the strength to go there, it is amazing what one finds. The interventional radiologist does remarkable things in identifying pathology, obliterating or reestablishing blood supplies, and placing balloon catheters and coils, among many other procedures. Patients are often very sick, frequently with comorbidities. Unlike in the operating room, these patients are not expected to lie in one place; rather, the table is moved frequently, and flexibility (especially dodging around multiple screens and imaging devices) is required. An omission in this section is a discussion of the requirements for vertebroplasty and kyphoplasty, procedures which carry several major anesthetic considerations and are usually performed under “conscious” sedation in geriatric patients who are often in severe pain. From the radiology department to intraoperative management of cerebrovascular disease is a rather short step as often both areas are involved. Treatment of intracranial aneurysms has long been controversial, whether it be early clipping, coiling (more preferred now), and how best to manage vasospasm. The authors recommend specific calcium channel blockers (although “specific” is not identified) and “triple H therapy.” More recent research may cast some doubt on the benefit of hypervolemic hemodilution, which has been shown to impair dynamic cerebral autoregulation clinically.3 Craniosynostosis occurs in about 1:2,000 births and repair is always a rather nerve-racking anesthetic procedure. A very small person with congenital anomalies is undergoing a procedure with major blood loss. This reviewer had some difficulty in understanding one statement … “a red cell volume loss of 91 in plus or minus 66% of estimated red cell volume perioperatively.” Review of the quoted reference was still not entirely clear, but a later reference by the same authors helped. “Whatever the type of craniosynostosis, mean blood loss corresponding to 90% of estimated red cell mass has to be anticipated.”4 A slightly anomalous chapter considers the perioperative care of patients with neuromuscular disease. As the authors note, many of these conditions are rare (Lambert Eaton, Charcot Marie Tooth, etc.). Even more common conditions such as multiple sclerosis do not usually require either the expertise of a neuroanesthesiologists or intensive neurocare. The syndromes are covered in short paragraphs, leaving much of the print space to be taken up by the 235 references. This reviewer looks forward to the day when editors and publishers insist on limited, accurate, and recent citations. A review of airway management for cervical spine surgery offers a few relevant radiographs. Missing are any illustrations of the more recently developed devices used to secure the difficult airway. Of the topics covered in this volume, the chapters devoted to monitoring are probably the most cutting edge. Monitoring is certainly an exciting part of anesthetic care. Who does not like to try out new gadgets? The reviews presented in this section are well written and succinct. The final chapter is entitled “Controversies in Neurosciences Critical Care.” Some of the topics considered such as management of vasospasm are covered in earlier chapters. This reviewer would have liked to have read a more extensive discussion of controversies surrounding the causes of postoperative visual loss. Rather, the topic was dismissed in the penultimate paragraph of the chapter on airway management in spinal surgery. There, the authors noted that the complication occurs rarely and in generally healthy patients. But it is not such a rare occurrence, with an incidence quoted as high as 1:100, and patients are usually obese, diabetic, and hypertensive, with a smoking history.5 Major advances in the establishment of neurocritical care have certainly been made as a multidisciplinary science, but there is still a road to travel. It takes little to set thinking on an erroneous track for years. Consider that day in 1969 when an anonymous editorial, published as a result of multidisciplinary collaboration in the British Journal of Anaesthesia, condemned the use of all volatile anesthetic agents, noting that even hyperventilation could not prevent the devastating effects of inhaled agents on intracranial pressure.6 Nevertheless, 40 years later and despite innumerable reports that inhalational agents, especially sevoflurane, administered at low dose do not increase and may even decrease cerebral blood flow, several contributors to this issue still warn about the vasodilating effects of these agents.7 As there are no pain endings in the brain, the level of anesthesia required is certainly not the same as that used for hip replacement. Amnesia and additional analgesia can readily be provided by opioids and benzodiazepines. Many interesting and innovative topics are covered in this volume of Anesthesiology Clinics that will provide useful current information for neuroanesthesiologists.

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