Brain, Vol. 122, No. 1, 171-174,
January 1999
© 1999 Oxford University Press
Book Reviews |
TRAUMA ANESTHESIA AND CRITICAL CARE OF NEUROLOGICAL INJURY.
Edited by Kenneth J. Abrams and Christopher M. Grande. 1997. Pp. 553. Armonk, NY: Futura Publishing Company. Price $98.00..
Leeds General Infirmary, Leeds, UK
This book has 33 contributors and two senior consulting editors, Elizabeth Frost and Donald Prow, and comprises 18 chapters. The majority of the authors are from the USA and other contributions are from Norway, France and Japan. The book is presented on behalf of the International Trauma Anaesthesia and Critical Care Society and follows the 1993 textbook of Trauma Anaesthesia and Critical Care as a specialized volume written predominantly by anaesthetists and critical care specialists and addressing the management of neurological injury.
The book is prefaced with a list of contents, providing page references to each of the 18 chapters and their authors. The book has been edited to provide the reader with a chronological account of the critical care of head injury, beginning with prehospital anaesthetic management, passing through various aspects of early trauma care, investigation, surgery and critical care, and finally dealing with the issues of brain death and organ procurement. Each chapter is extensively referenced and at the end of the book there is a 14-page subject index.
From the outset I found the concept of a single textbook of critical care management of neurological trauma for the anaesthetist an exciting project. However, while there can be no doubt that this textbook contains a substantial amount of useful information, my overall impression was a mixture of enthusiasm and disappointment. This may in part be cultural since the substantial American contribution to this textbook undoubtedly flavours priorities for certain aspects of head injury care rather differently than would a more European perspective. However, it is my opinion that a reader coming to this subject for the first time would be unaware of the one-sided arguments occasionally presented.
One of my other disappointments about this textbook is the considerable variation in the composition and content of the individual chapters. In this respect the book is extremely difficult to read because different authors have presented information from very different points of view. The first two chapters, for example, on the prehospital anaesthetic management of neurological trauma and transport, are written very much in the style of a hands-on approach, and it is evident that the European authors are involved on a daily basis in this kind of work. Thus, while the reader is presented with theoretical material the overall thrust is that of a very practical chapter providing useful tips in the management of this problem.
In stark contrast, chapters 3–5 present perioperative management and resuscitation in a predominantly theoretical style, where the American authors provide options of treatment without a `how to do it' approach. This is no way detracts from the information provided but there remains a deficiency in providing the reader with simple algorithms of how to do such procedures and how to ensure that complications do not arise as a result of them.
Chapters 6, 7 and 8 are written almost entirely from a theoretical perspective, covering neuronal cell pathophysiology and the concepts of brain protection and fluid management and resuscitation. I found the information comprehensive but the reader might be disappointed that there are few hints about the clinical application of this material. Thus, the chapter on fluid management contains vast amounts of information concerning experiments on various fluid resuscitation regimes in a variety of animal models, but lacks discussion on the relative merits of hypervolaemic and normovolaemic resuscitation or a debate on the potential disadvantages of fluid restriction, which is so prevalent in some European intensive care units.
Diagnostic imaging in neurotrauma and the provision of anaesthesia for neurodiagnostic evaluation is discussed in chapters 8 and 9. There are excellent descriptions of the potential imaging modalities available but minimal perspective on the indications and priorities for investigation and how these would fit into an overall strategy for neurotrauma management. A similar criticism might be made of the chapter on anaesthesia for neurodiagnostic evaluation where much of the discussion is more appropriate to anaesthesia for neurodiagnostic evaluation in general rather than that specifically related to trauma.
Contraindications to neurodiagnostic evaluation after trauma and the limitations of a neuroradiology suite environment in facilitating the management of patients with neurotrauma are mentioned only in passing.
Chapters 10 and 11 deal with the intraoperative management of closed head injuries and spinal cord injury, respectively. In my opinion the chapter on intraoperative anaesthetic management of closed head injury is woefully inadequate, giving the reader no real idea of how to set up an anaesthetic for this type of patient, what kind of monitoring is of high priority and what monitoring techniques are of interest but predominantly of a research nature.
The chapter on intraoperative management of spinal cord injury provides substantial detail on the anatomy and mechanisms of damage to the spinal cord at various levels of the vertebral column, and provides an excellent theoretical overview. However, anaesthetic management aspects are confined to only three pages, which would be inadequate to equip the anaesthetist with a detailed idea of how to set about managing these patients. In my opinion these aspects would have been better presented as a literature review based on a critique of the authors' own regime for anaesthesia.
Critical care issues in the management of closed head injury and spinal cord injury are comprehensively reviewed, with some inevitable overlap of information in chapters 12, 13 and 14. This section of the book gives a comprehensive theoretical overview of many of the dilemmas facing the intensivist with this complex group of patients. However, the value of these chapters to the practising intensivist is limited because the authors have failed to discuss their own management regimes in the context of current medical opinion.
For example, the chapter on nutritional care presents detailed accounts of nutritional requirements and different feeding techniques in general but fails to emphasize current opinion on the predominant value and use of enteral nutrition in neurotrauma patients.
Chapters 15 and 16 deal with therapeutic advances in neurotrauma and advances in the monitoring of the central nervous system. Although there is considerable repetition of material presented earlier in the book, both of these chapters are well worth reading as they provide a comprehensive and realistic overview of areas of current interest. Unfortunately, the chapter on central nervous system monitoring is somewhat outdated, with no mention of monitoring the oxygen tension of brain tissue, laser doppler technology for cerebral blood flow estimation, microdialysis or brain temperature monitoring.
I would recommend any anaesthetist working in this field to read chapter 17 since it highlights a number of problems that the intensivist may not be aware of that are of long-term and ongoing relevance in head-injured patients. However, a large proportion of this chapter deals with the issue of local anaesthetic nerve blocks for pain management, a subject that is covered in most good textbooks of anaesthesia or pain management.
It seems rather sad to end a textbook of neurocritical care with a chapter not on the outcome but rather on death and organ donation. Those interested in prognosis after head injury and the likelihood of a good or bad outcome, which of course is a major issue in the management of head-injured patients during intensive care, will be disappointed by this textbook since such information can only be gleaned by skimming through a number of chapters, and much of it is neither comprehensive nor up to date.
My overall impression is that the editors have attempted to bring together writings from a number of experts, each with very different styles, to produce a textbook which chronologically looks over the early, middle and later aspects of management of head-injured and spinal cord-injured patients from an anaesthetic perspective.
In my view this book fails in many ways. There is considerable repetition of information in different chapters and very few of the chapters give a practical overview of the major issues facing the anaesthetist in a clinical setting. Some of the chapters contain information which, while interesting, is of little relevance to the management of neurological injury. Despite a good index it is extremely difficult for the anaesthetist to be able to obtain comprehensive information about certain aspects of management from a single chapter because some subjects are covered in a rather piecemeal fashion in different sections of the book.
I was left with the overall impression that the book contains considerable amounts of useful information, but I was concerned that the authors had not been given a clear description of what was required of them in order to accomplish the main aims of the book. The book is neither a manual which could be useful in the management of individual patients, nor is it a sufficiently comprehensive overview to assist the reader interested in certain aspects of the management of neurologically injured patients.
In summary, my initial excitement at the prospect of being able to read a textbook of trauma written for anaesthetists has been quelled somewhat in the reading. Nevertheless, certain chapters in this textbook are outstanding, particularly the early chapters on prehospital management, which are clearly written by persons with day-to-day practical experience, and I would strongly recommend anybody working in the field of neurointensive care to read this section. The rest of the textbook contains information that can be found in most non-specialist textbooks of trauma care and, more importantly, large sections of the book are not clearly dedicated to the specific issue of neurological trauma but rather discuss trauma in a wider context.
The US list price for this textbook is $98. I think I could find better accounts of the management of neurological injury from the literature on which to spend this kind of money.
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