General Anesthesia Management Research Articles

Handbook of Neuroanesthesia, Fifth Edition. Edited by Philippa Newfield, James E. Cottrell. Philadelphia, Lippincott Williams & Wilkins, 2012. Pages: 480. Price: $60.84.

A “handbook” in medicine is almost like the “middle child” in a family: never taken too seriously but still expected to abide by the rules, never gets the spotlight but still ends up being the most successful and useful of the bunch, always by your side at times of crisis but does not get the respect it truly deserves. The fifth edition of Handbook of Neuroanesthesia, edited by Newfield and Cottrell, almost fits that bill. This book is a perfect example of what you can do right with a difficult and super-specialized subject, limited available real estate, and economy on your mind. I am not an author by any stretch of the imagination, but I can almost feel the pain of the authors while they were planning, editing, and executing this book: what to include and what to leave out!This book is structured like a typical handbook in medicine. Smaller in dimensions than a regular textbook, it has 28 chapters and approximately 500 pages. The chapters are neatly divided into logical sections dealing with general considerations, anesthetic management, and postanesthesia and intensive care. The section on general considerations deals with basic topics, such as physiology, metabolism, effects of anesthesia, improving neurologic recovery from cerebral ischemia, and pain management in neurosurgical patients. There is also a nicely written chapter by a neurosurgeon on the team approach to patient management and the importance of interdisciplinary communication. The second section deals with wide-ranging topics on modern neuroanesthetic management, including head trauma, tumors, aneurysms, strokes, pediatric cases, awake craniotomies, interventional neuroradiological diagnostic and therapeutic procedures, pregnant patients with neurosurgical conditions, positron emission tomography scan, deep brain stimulators, gamma knife, and stereotactic procedures, and many more. The third section has chapters dedicated to traditional postoperative and intensive care topics such as systemic supportive care, fluids and electrolytes, nutrition, and brain death. At the end, there are two additional chapters under the appendices section dedicated to accessing and exchanging information technology and American Society of Anesthesiologists practice guidelines on preventing postoperative visual loss and neuropathies.A unique feature of this book is that all the chapters have an illustrative clinical case description highlighting the relevant clinical points right at the beginning. This is followed by chapter highlights in all (and a summary in many) of the chapters. This early summary really helps to keep focus on the intended topic from the beginning and makes for an easy review later. At the end of every chapter, there is a list of suggested readings. Interestingly enough, many of the chapters actually have a list of suggested Internet references as well, which is sure to satisfy many of us who are hungry for more!The contents of the chapters are logical, up to date, practical, informative, and very easy to read. The authors have taken a comprehensive approach to clinical information presentation and managed to include a wide range of relevant multidisciplinary scientific information about a particular topic without losing sight of the overall goal of perioperative patient care. Almost every topic has not only discussion of perioperative issues and concerns, such as monitoring, medications, induction and maintenance, outcome, and many more but also useful information on pathophysiology, anatomy, pharmacology, diagnostic modalities, treatment and management options, and outcome and preventative data. All of this makes for a very satisfying read and makes this book feel really comprehensive yet convenient, a rare combination indeed. There is also a treasure trove of useful tables in the book, and several easy-to-understand diagrams and figures have been thrown in for good measure. In keeping up with the times, the authors have paid special attention to issues such as interdisciplinary teamwork, communication, and information technology. The chapter on online medical resources and search modalities available for clinical scientists made for an interesting read.Any shortcomings in this book? Nah!! In my humble opinion, considering the target audience and the set objectives of this text, the authors have achieved in this book what many authors hope to achieve and what most prospective authors should aspire to achieve….simplicity, balance, and objectivity. One could nitpick about lack of glossy pages and a paucity of color plates, but in today’s day and age, keeping overhead costs low is a key ingredient to success. Color, especially if zealously overdone, can be a distraction in scientific texts. Does the small print bother me? Not yet, but my days are probably numbered and hey, remember this is a handbook. Neuroanesthesiology was probably never a superstar subspecialty, but if this wonderful handbook manages to make a few converts and motivate a few uninitiated to pursue the specialty, that would be its biggest achievement. This book has that capability and then some.

The aging brain and anesthesia

To review the neurophysiology and neuroanatomy of normal aging and the recent recommendations for the clinical management of general anesthesia and sedation in the elderly. As the population ages, the number of elderly patients having surgery is likewise increasing and with it, the prevalence of postoperative cognitive disorders. Postoperative cognitive disorders including delirium and postoperative cognitive dysfunction are common postanesthesia complications in elderly patients. Several risk factors for postoperative disorders have been identified, and anesthesiologists commonly adapt their practice habits when taking care of elderly patients to try to mitigate the effects of the anesthetics on postoperative cognitive function. These practices are reasonable and prudent; yet, they are not well supported by an understanding of the aging brain and specifics of how the anesthetic effects on the brain change with age. Through functional imaging and electrophysiological studies, much is being learned about the neurophysiology and the neuroanatomy of normal aging. Our analysis suggests that understanding the neurophysiology and neuroanatomy should be part of the standard working knowledge of anesthesiologists and that this knowledge can guide their use of the electroencephalogram to track more accurately the brain states of elderly patients receiving anesthesia care.

Anesthetic Management at Implantation of Permanent Pacemaker for Newborn with Congenital Complete Heart Block

Complete atrioventricular heart block is defined as non-conduction of electrical impulses from atria to ventricles. Atrial pace, independent from ventricles, is higher. Complete atrioventricular heart block begins at intrauterin life in newborns and it is called congenital complete heart block. Heart rate is the most important factor determining cardiac output among children and especially newborns. Newborns with congenital complete heart block have lower heart rate (<60 beat/min) and carry heart failure risk. Heart block is usually irreversible and affected newborns require permanent cardiac pacemaker from first week of their life. Understanding cardiovascular pathophysiology and knowing therapeutic approaches to congenital complete heart block are very important during perioperative management of these patients. In this case report we discussed general anesthetic management during implantation of permanent pacemaker for a newborn with congenital complete heart block. Key Words: Anesthesia; Heart block; Newborn.

Anesthetic Management and Complications of Percutaneous Aortic Valve Implantation

Background and objectiveAortic stenosis is a highly prevalent and life-threatening disease. In elderly patients with comorbidities, percutaneous valve implantation is an option. The aim of the study was to describe the anesthetic management and complications of general anesthesia. MethodCase series with 30-day and 24-month follow-ups after implantation of the CoreValve device performed at the Institute of Cardiology/University Foundation of Cardiology between December 2008 and January 2012. The patients underwent general anesthesia monitored with mean arterial pressure (PAM), electrocardiogram (ECG), pulse oximetry, capnography, transesophageal echocardiography, thermometry, and transvenous pacemaker. ResultsTwenty-eight patients, mean age 82.46 years, 20.98% mean EuroSCORE, functional class III/IV, successfully underwent valve implantation. Nine patients required permanent pacemaker implantation. During follow-up, two patients died: one during surgery due to LV perforation and the other on the third day of unknown causes. At 24 months, one patient diagnosed with multiple myeloma died. This anesthetic technique proved to be safe. ConclusionThe initial experience with percutaneous aortic valve implantation under general anesthesia has proven to be safe and effective, with no significant anesthetic complications during this procedure.

Marfan’s Syndrome During Pregnancy

Marfan's syndrome is characterized by progressive dilatation of the aortic root. This dilatation is accelerated by pregnancy, exposing patients to an increased risk of aortic dissection. Literature on the anesthetic management of delivery in patients with Marfan's syndrome consists only of case reports. We therefore conducted a retrospective review of medical records focusing on anesthetic management of delivery in patients with Marfan's syndrome in a national referral center. We reviewed the medical records of all pregnant women with Marfan's syndrome who were followed at their institution over a 6-year period. Sixteen pregnancies in 15 patients were analyzed. The initial aortic root diameter was larger than 40 mm in 9 patients and larger than 45 mm in 1 patient. Two patients did not receive β-blockers throughout pregnancy because of poor tolerance. One patient with an aortic root diameter of 47 mm did not receive β-blocker before 33 weeks' gestation because of late referral. This woman developed acute type 1 aortic dissection at 37 weeks, requiring emergency cesarean delivery under general anesthesia followed by aortic repair. Thirteen other patients underwent cesarean delivery, 1 under spinal anesthesia and 12 under general anesthesia. General anesthesia management included close arterial blood pressure monitoring, avoidance of high blood pressure, administration of opioids before delivery, and titrated nicardipine administration. Two patients (including one with intrauterine fetal death) underwent vaginal delivery under epidural analgesia. There were no maternal deaths. Pregnant women with Marfan's syndrome who received care in a multidisciplinary tertiary care setting that included active peripartum involvement of anesthesiologists had good clinical outcomes.

Anesthesia for a patient of acromesomelic dysplasia with associated hydrocephalus, Arnold Chiari malformation and syringomyelia

Acromesomelic dysplasias are autosomal recessive osteochondrodysplasias. Acromesomelic dysplasia Maroteaux-type (AMDM), also known as St Helena dysplasia, is of two types: The classical and the mild variety. About 50 cases of AMDM have been reported till date, most of them being the classical variety. There is scarcity of literature on anesthesia for such patients. We are reporting a case of general anesthetic management of AMDM, associated with hydrocephalus, Arnold Chiari malformation type-1 and syringomyelia. The patient was a 10-year-old short-statured boy who presented with symptomatic thoracic kyphoscoliosis, gibbus deformity and back pain. On examination, there was no neurological deficit. Radiology revealed thoracic kyphoscoliosis, mild ventriculomegaly and upper cervical syringomyelia. The patient underwent posterior fossa decompression in the prone position under general anesthesia. We will discuss the anesthetic considerations for such patients and review the pertinent literature.

Anaesthetic management in emergency cesarean section: Systematic literature review of anaesthetic techniques for emergency C-section

The literature related with the anesthetic management of emergent C section is limited, for which reason we proposed the systematic evaluation of the existing literature on anesthetic management of obstetric patients undergoing emergency cesarean section in order to define the most appropriate interventions based on evidence. A systematic review of the literature was undertaken in MEDLINE, 1966 to December 2010, Cochrane Collaboration registry of clinical trials, Cochrane systematic review database, and LILACS. The study selection process was undertaken independently by two researcher-reviewers, who identified controlled clinical trials and cohort studies of anaesthetic management in emergency C-section. The data were extracted, reviewed and subjected to quality evaluation in duplicate fashion. In total, 2,297, 36, 221 were examined, respectively, and of those 16 potentially relevant papers, 9 clinical trials and 7 observational studies were included in the study. A heterogeneity analysis was done using I2, with a result of 52%, and for this reason no meta-analysis was conducted. ConclusionsThe anaesthetist plays a critical part in mother-and-child care, prioritization of the C-section urgency, peridural anaesthesia extension with 2% lidocaine plus adjuvants (fentanyl plus fresh adrenaline), the use of vasopressors (phenylephrine, ephedrine) for the aggressive management of hypotension, the use of oxygen supplementation and the adequate management of general anaesthesia when indicated, contributing to a favourable impact on the outcome for both the mother and the baby. Long-term neonatal outcomes are not influenced by the type of anaesthesia given to the mother.

Manejo anestésico para operación cesárea urgente: revisión sistemática de la literatura de técnicas anestésicas para cesárea urgente

There are no recent evidence-based publications containing specific information about the anaesthetic management in emergency C-section. Hence the decision to carry out a systematic evaluation of the existing literature on the anaesthetic management of obstetric patients undergoing emergency C-section, in order to determine the most adequate evidence-based intervention. A systematic review of the literature was undertaken in MEDLINE, 1966 to December 2010, Cochrane Collaboration registry of clinical trials, Cochrane systematic review database, and LILACS. The study selection process was undertaken independently by two researcher-reviewers, who identified controlled clinical trials and cohort studies of anaesthetic management in emergency C-section. The data were extracted, reviewed and subjected to quality evaluation in duplicate fashion. In total, 2,297, 36, 221, and 16 potentially relevant papers were found, respectively, 9 clinical trials and 7 observational studies. A heterogeneity analysis was done using I2, with a result of 52%, and for this reason no meta-analysis was conducted. ConclusionsThe anaesthetist plays a critical part in mother-and-child care, prioritization of the C-section urgency, peridural anaesthesia extension with 2% lidocaine plus adjuvants (fentanyl plus fresh adrenaline), the use of vasopressors (phenylephrine, ephedrine) for the aggressive management of hypotension, the use of oxygen supplementation and the adequate management of general anaesthesia when indicated, contributing to a favourable impact on the outcome for both the mother and the baby. Long-term neonatal outcomes are not influenced by the type of anaesthesia given to the mother.

Management of general anesthesia for a patient with Maroteaux type acromesomelic dysplasia complicated with obstructive sleep apnea syndrome and hereditary myopathy

To the Editor: Oropharynx abnormality may lead to difficult intubation in patients with osteochondrodysplasia [1]. For the very rare disease, acromesomelic dysplasia Maroteaux-type (AMDM), which is one such abnormality, however, there is no report whether special consideration is needed in airway management. AMDM is seldom combined with other significant disease [2]. We report the first case of a patient with AMDM complicated by severe obstructive sleep apnea syndrome (OSAS) and hereditary myopathy undergoing smooth management of general anesthesia for elective L4–S1 laminectomy and discectomy. AMDM, which was first described by Maroteaux et al. in 1971 [3], is a very rare autosomal recessive disorder of progressive osteochondrodysplasia with a prevalence of about 1 in 2,000,000 [2]. It is characterized by severe dwarfism and acromesomelia, which presents with disproportionately shortened middle and distal segments of the four limbs. The 33-year-old female patient suffered from AMDM, which was diagnosed 13 years ago based on gene mapping (Affymetrix Genechip Mapping 100K set), in which the linkage data showed abnormality in chromosome 9 [4], and on typical clinical features, such as short stature with disproportionately shortened distal part of limbs (Fig. 1). She also had severe OSAS with apnea-hypopnea index up to 48, and had received treatment of bi-level positive airway pressure for 3 years [5]. Muscle biopsy performed 2 years ago in response to progressive muscle weakness had suggested hereditary muscle atrophy, which was not considered AMDM related. Preoperative evaluation revealed no significant head deformity except prognathia. Neck range of motion was normal. Mallampati classification was grade 2. Muscle power of the four limbs was four, worse in the distal parts. Preoperative laboratory data, chest X-ray, and pulmonary function test were unremarkable. Under train-of-four (TOF) monitoring over the adductor pollicis, induction agents of fentanyl 100 lg, 2 % lidocaine 40 mg, propofol 100 mg, and cisatracurium 7 mg were given intravenously after sufficient preoxygenation. When the patient was apneic, an oropharyngeal airway was necessary for mask ventilation. When the second twitch of TOF disappeared, endotracheal intubation using direct laryngoscope was performed uneventfully under the view of Cormack and Lehane classification grade one. After a 2-h surgical procedure, tracheal extubation was performed under fully awake conditions and recovery of TOF in the operating room. The patient was then discharged smoothly on the fourth postoperative day without any sequelae of general anesthesia. As this is a very rare case report, we do not know whether patients with AMDM may have a difficult airway. In such a situation, succinylcholine may be the first choice P.-C. Huang J.-H. Chang K.-B. Chen (&) Department of Anesthesiology, China Medical University Hospital, No. 2, Yuh-Der Road, North District, Taichung 40447, Taiwan, ROC e-mail: pppat21@yahoo.com.tw

Anesthetic Management of Myasthenia Gravis: COPD and Asthma Patient

Abstract Introduction Conduction of general anesthesia and perioperative management of the patients with compromised lung functions and myasthenia gravis, presented for major abdominal surgery, pos...

General anesthetic management of Prader-Willi syndrome patient undergoing middle cerebral artery-superficial temporal artery anastomosis

We experienced a case of a 17-year-old patient with genetically proven Prader-Willi syndrome who had left middle cerebral artery-left superficial temporal artery anastomosis surgery under general anesthesia with a non-depolarizing muscle relaxant. Prader-Willi syndrome is a genetic disorder associated with hypotonia. Using general anesthesia with a non-depolarizing muscle relaxant in these patients is difficult due to hypotonia. We, therefore, monitored the status of muscle relaxation with a train of four (TOF, TOF-Watch®, Organon, Ireland) during general anesthesia. Unlike infants, adolescents can have the muscle relaxation monitor on their body surface. Because lengthy, complex microsurgery was required for this vascular surgery, we had to use a muscle relaxant. However, when using a muscle relaxant, predicting the extent of the effect and the recovery time are difficult. The TOF ratio was 0.85 in the preanesthetic state. Anesthetic induction was done using the total intravenous anesthesia of the target concentration infusion method. Propofol target concentration at 4 µg/ml was initially injected. Remifentanil was injected at 0.15 µg/kg/min. Five minutes after an atracurium 15 mg injection, the TOF watch count was still at 2. Therefore, an additional 15 mg of atracurium was injected for intubation. When the TOF watch count was over 4, during the operation, an additional 5 mg of atracurium was injected. For the entire surgery, 65 mg of atracurium was used. The operation lasted for 2 hours and 50 minutes. After the operation, when the TOF ratio was 0.85, glycopyrrolate 0.4 mg and pyridostigmine 15 mg were injected. The endotracheal tube was removed once the patient regained spontaneous respiration and was fully awake. After extubation, the patient was arousable using painful stimulation. In the post anesthetic care unit, the patient had no respiratory problem and his TOF ratio was 0.85. The patient was then transferred to the general ward. Prader-Willi syndrome is a genetic disorder classically characterized by hypotonia, hypomentia, and hypogonadism that is associated with obesity [1]. The cause of hypotonia, muscle weakness, and motor problems in Prader-Willi patients are not clear. The contributing factors may be the abnormal body composition found in Prader-Willi patients, an increase in fat mass and a decrease in muscle mass, and, possibly, some degree of neuromuscular abnormality [2]. It has been reported that the motor problems are still present in childhood and adulthood, which causes the decrease in physical activity in Prader-Willi patients [3]. Thus, the hypotonia makes the choice of muscle relaxant difficult. Anesthetic management using atracurium and rocuronium have been reported [4,5]. However, few reports are available on using the intraoperative monitoring of the neuromuscular blockade for Prader-Willi patients. In this case, though the patient had hypotonia, anesthesia was successfully used with a dose adjusted muscle relaxant using the TOF watch.

Anesthesia management in a pediatric patient with Dandy-Walker syndrome

General anesthesia management of patients with Dandy-Walker syndrome is important since intubation may be difficult due to concomitant anomalies such as hydrocephalus, micrognathia and cleft palate. It should be considered that these patients may require postoperative intensive care support. In this article, anesthesia management of a patient with Dandy-Walker syndrome underwent persistent ventriculo-peritoneal shunt was presented.

Pain and symptom assessment during multiple fractions of gynecologic high-dose-rate brachytherapy

Purpose A prospective assessment of tolerability of gynecologic brachytherapy was completed to determine adequacy of analgesia and symptom control for patients undergoing CT-guided brachytherapy, with multiple fractions delivered during a single applicator insertion. Methods and Materials Seventeen patients receiving high-dose-rate brachytherapy for gynecologic cancer (other than vaginal vault) completed ratings of pain intensity, anxiety, and nausea at five key time points before, during, and after brachytherapy. Symptoms were assessed with patient-reported scores using an 11-point numeric rating scale. The patient population included cervical ( n = 12), endometrial ( n = 3), and vulvar-vaginal ( n = 2) malignancies. Patients underwent general anesthesia for applicator placement. Analgesia consisted of subcutaneous route opioid, and oral opioid and/or nonopioid as needed for the duration of the treatment planning and delivery. Results The mean scores for pain were highest after patients were transferred to the CT scanner, 3.3 ± 2.6, compared with baseline scores of 0.9 ± 1.7. Pain scores were 2.3 ± 2.3 during the remainder of the procedure, and 2.7 ± 2.1 after the removal of the applicator. The highest mean anxiety scores occurred before the brachytherapy procedure, 4.3 ± 3.4, with resolution of anxiety during the procedure to 1.3 ± 1.6. The mode of nausea scoring during the procedure was 0. Conclusion For most of the patients, the delivery of multiple fractions of image-guided high-dose-rate brachytherapy is well tolerated with maximum scores of mild-moderate pain and distress, and no significant nausea. This can be accomplished with applicator placement under general anesthesia and standard medical management.

Anesthetic experience of a patient with Ohtahara syndrome -A case report-

Ohtahara syndrome (OS) is a rare epileptic encephalopathy that is characterized by an abnormal electroencephalogram (EEG) and intractable seizures in the neonatal and early infantile period. The patient of this reported case was delivered normally at 39 weeks of gestation without any complication. One week after birth, seizures that were refractory to anticonvulsants started with repetitive clustered tonic spasms. The child had no abnormal findings on the initial laboratory investigations. But he was diagnosed with OS according to the frequent tonic spasms, an abnormal EEG pattern of suppression-burst and magnetic resonance imaging of cortical dysplasia. He was planned to undergo an operation for brain lesion. This report describes our experience with the general anesthetic management when we performed craniotomy and right hemispherotomy for a patient with OS.

Comparative evaluation of ketamine - propofol, fentanyl - propofol and butorphanol-propofol on haemodynamics and laryngeal mask airway insertion conditions

Laryngeal mask airway is a non invasive supraglottic device which has led to a radical change in the management of modern general anaesthesia. Propofol as a single agent is unsatisfactory and to overcome problems associated with LMA insertions. In the present study, we evaluated the haemodynamic changes and laryngeal mask airway insertion conditions comparing ketamine and opioids as adjuncts to propofol. 90 patients were randomly divided into 3 groups of 30 each. In Group PK-ketamine 0.5mg kg(-1), in Group PF-fentanyl 1ug kg(-1) and in Group PB - butorphanol 20ug kg(-1) was given intravenously immediately before induction with propofol 2.5 mg kg(-1). Jaw relaxation was assessed according to Young's criteria and the overall conditions according to modified Scheme of Lund and Stovener. The mean total dose of propofol required in Group PK was 160.37 ± 15.75mg, in Group PF 156.22 ± 17.18 mg and in Group PB 140.08 ± 18.97 mg. The incidence of absolute jaw relaxation was highest in Group PB (93.33%) patients, intermediate in Group PF (53.33%) patients and lowest in Group PK i.e. 36.66% patients. Excellent insertion conditions were observed in 12 (40%) patients in Group PK and 13 (43.33%) patients in Group PF and in 26 (86.67%) patients in Group PB. Group PK showed more rise in systolic and diastolic blood pressure and heart rate post LMA insertion as compared to Group PF and Group PB. It is concluded that addition of butorphanol to propofol for LMA insertion provided absolute jaw relaxation and excellent insertion conditions with stable haemodynamics Side effects like coughing, gagging, lacrimation and laryngospasm were lower as compared to the other two groups.

General Anaesthesia for Laparoscopic Cholecystectomy in a Patient with the Kearns-Sayre Syndrome

We report a case of a 40-year-old man affected by the Kearns-Sayre syndrome who underwent an elective laparoscopic cholecystectomy under general anaesthesia. We describe the management of general anaesthesia in this rare myopathy, with emphasis on the use of rocuronium as muscle blocking agent. Induction was achieved with propofol and fentanyl, and general anaesthesia was maintained with fentanyl and sevoflurane/N2O/O2 mixture. The anaesthetic plan proved to be safe and effective, and extubation was achieved in the operating theatre. The postoperative recovery of the patient was satisfactory and uneventful.

Laparoscopic diaphragmatic pacer placement – a potential new treatment for ALS patients: a brief description of the device and anesthetic issues

The Diaphragm Pacing Stimulator (DPS) has been used to treat ventilatory insufficiency in quadriplegic patients. The FDA approved a trial using the DPS in patients with amyotrophic lateral sclerosis (ALS). Three patients with advanced ALS, who underwent laparoscopic diaphragmatic pacer placement, and their general anesthetic management, are presented.

The use of entropy and bispectral index in the monitoring of CNS reaction during introduction to general anaesthesia and airway management

The use of entropy and bispectral index in the monitoring of CNS reaction during introduction to general anaesthesia and airway management

Neurologische Erkrankungen – Allgemeinanästhesie bei neurologischen Erkrankungen

The term neurological diseases includes a lot of disorders concerning both the central and peripheral nervous system. Low incidence on the one hand and anaesthetic relevance on the other hand requires special attention in preoperative preparing and management of general anaesthesia. The following paper presents special problems of neurodegenerative disorders, which anaesthetic relevance is of growing interest in the changed elderly population.

Lecture Notes: Clinical Anaesthesia, 3rd Edition.

Lecture Notes: Clinical Anaesthesia, 3rd Edition. Edited by Carl L. Gwinnutt, M.B., M.R.C.S., L.R.C.P., F.R.C.A. Oxford, England, Wiley-Blackwell, 2008. Pages: 172. Price: $36.95.Medical students are challenged by the limited number of textbooks that provide quick and practical introductions to anesthesiology. Lecture Notes: Clinical Anesthesia introduces medical students, nurses and nurse anesthetists, and nonanesthesiologist general practitioners to the current practices of clinical anesthesiology. The textbook is also a useful tool to instructor anesthesiologists searching for a core text to recommend to their rotating medical students.In addition to concepts in general anesthesia administration and management, Lecture Notes: Clinical Anesthesia provides a fair content of pain management principles and peripheral nerve blocks. In its six chapters, the book places emphasis on the role of anesthesiologists as perioperative physicians, not just operating room anesthesia providers. Three chapters of the book concentrate on perioperative medicine: chapter one, Anesthesia Assessment and Preparation for Surgery; chapter five, Recognition and Management of the Acutely Ill Patient on the Ward; and chapter six, Management of the Critically Ill Patient.Although Lecture Notes: Clinical Anesthesia has been condensed in its third edition to 172 pages, it did not lose its standards of clear diagrams, photographs, and key facts boxes. These traits have to be some of the strongest features in earlier editions of this book. The photographs and diagrams assist learners, particularly visual learners, to comprehend key principles in anesthesiology such as applying mask ventilation, performing correct chest compression during cardiopulmonary resuscitation, and inserting laryngeal mask airways. In addition, the book contains self-assessment questions at the end of each chapter that focus the students’ attention on the important concepts, with answers provided at the end of the book. In the reference section of each chapter, useful Web sites related to the chapter are provided as an excellent feature for modern learners who are very comfortable using technology and the internet for learning purposes.Although Lecture Notes: Clinical Anesthesia contains a fair amount of pharmacology, it falls short of providing any significant content in physiology. In addition, other than a quick review on obstetric anesthesiology, the book does not provide any content regarding other subspecialties in anesthesiology such as pediatric or cardiothoracic anesthesiology.In summary, Lecture Notes: Clinical Anesthesia offers a comprehensive review of general anesthesiology principles and practices in a quick and easy-to-read style. I recommend it as an excellent first-step for students and other medical professionals who are interested in the field of anesthesiology. The book provides principles of clinical anesthesiology in text, tables, and photographs, but students are encouraged to expand beyond this book for more in-depth knowledge of the medical specialty of anesthesiology.*Oklahoma University Health Sciences Center, Oklahoma City, Oklahoma. mohanad-shukry@ouhsc.edu