Day-Case Anaesthesia and Sedation

Abstract

Assistant Professor, Department of Anesthesiology and Critical Care Medicine Johns Hopkins University School of Medicine 601. North Caroline Street Baltimore, Maryland 21287–0712.Carol A. Hirshman, M.D., EditorDay-Case Anaesthesia and Sedation. Edited by J. G. Whitwam. Oxford, Blackwell Scientific Publications, 1994. Pages: 424. Price:$85.00.This first-edition British text is designed to provide a general perspective of the current principles of ambulatory anesthesia and sedation. The rapid changes occurring in outpatient medicine with advancement in technology (e.g., laparoscopic cholecystectomy) and cost containment have fostered the development of this book. Day-Case Anaesthesia and Sedation offers a comprehensive approach to ambulatory practice and provides a framework for ambulatory anesthesia as a designated subspecialty.The book is divided into four sections: general principles of ambulatory anesthesia, pediatric and adult anesthesia, procedural safety, and legal issues. In Part I, there is an instructive review of the history and evolving status of ambulatory anesthesia. Several chapters review pharmacologic principles in the adult and pediatric outpatient. As a foundation for effective ambulatory anesthesia practice, these chapters provide a targeted discussion of basic anesthetic agents and considerations for their use in the pediatric population. Other chapters in this section deal with topics that are integral to the practice of anesthesiology but do not pertain to ambulatory practice per se (anaphylactic and anaphylactoid reactions and cardiopulmonary resuscitation). Although these topics have been covered in more detail elsewhere, both chapters provide useful synopses. There may be some variance among countries with respect to ethics (appropriateness of complying with “do not resuscitate” mandates for patients undergoing outpatient surgery) and resuscitation guidelines (according to new American Heart Association standards). The inclusion of this material, addressed by the editor's comments in the preface, is based on the book's projected audience, which includes all clinicians (in addition to anesthesiologists) who are responsible for administering sedation. There also is a chapter dealing with pain treatment that provides a necessarily brief overview.Part 2 focuses on common areas of practice, including laparoscopy, ophthalmic surgery, and dental surgery. Otolaryngology and, specifically, endoscopic sinus surgery are not discussed, although these areas comprise a large percentage of our outpatients and would be fertile soil for review. The important role of local or regional anesthesia in the ambulatory surgery patient is highlighted in this section. This chapter reviews applications of local anesthetics in the context of ambulatory management with respect to technique as well as risk and benefit. The chapter on sedation and sedoanalgesia is useful but does not present the full breadth of the literature of a major aspect of ambulatory anesthesia practice. Although some of these subjects are covered in the chapter on pharmacology and day-case anesthesia, it would be beneficial to have had an in-depth discussion of sedation principles for the various agents, modes of administration, potential drug interactions, and recovery characteristics. The chapter on patient-controlled sedation presents an interesting concept that may have broad future applications. Another chapter (curious from an American perspective for its inclusion) deals with anesthesia circuits and ventilation systems. Although our British colleagues obviously employ a wider range of circuit options in their practices, the discussion of the Cuirass ventilator raises questions regarding its potential applications in an outpatient setting. The pediatric subsection covers general principles of pediatric anesthesia and provides a useful overview.Part 3 highlights issues of critical importance to safe practice as well as nursing and trait organization. These chapters present information for the sage and efficient management of an ambulatory facility. Part 4 reviews the important legal aspects of caring for the ambulatory patient. The final section. Appendices, succinctly reviews a series of selected topics ranging from malignant hyperthermia to semantics.The text is very pleasant to read and presents a wide range of topics in a thoughtful manner. While it succeeds in providing a contemporary overview of the rapidly expanding field of ambulatory procedural medicine, it occasionally lacks details and fails to delineate controversies in ambulatory anesthesia. This approach offers the distinct advantage of presenting “take-home” messages that could be otherwise obscured in a text that painstakingly reviews the most recent findings but does not offer qualification. For these reasons, the book is effective as a text introducing new residents or long-time practitioners of anesthesia to the new field of ambulatory anesthesia. An additional strength undoubtedly lies in its use as a summary text for practitioners without anesthesia training who are responsible for administering sedation in their own practices. Several statements highlight differences in practice across the Atlantic, but these often are matters of opinion and should be apparent to the reader.Douglas S. Snyder, M.D., Assistant Professor, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 601 North Caroline Street Baltimore, Maryland 21287–0712.