Reviews of Educational Material  |   February 2005
Anesthetic Pharmacology: Physiologic Principles and Clinical Practice.
Author Affiliations & Notes
  • Hugh C. Hemmings, M.D., Ph.D.
  • *Weill Medical College of Cornell University, New York, New York.
Article Information
Reviews of Educational Material / Pharmacology
Reviews of Educational Material   |   February 2005
Anesthetic Pharmacology: Physiologic Principles and Clinical Practice.
Anesthesiology 2 2005, Vol.102, 485. doi:
Anesthesiology 2 2005, Vol.102, 485. doi:
Anesthetic Pharmacology: Physiologic Principles and Clinical Practice.  Edited by Alex S. Evers, M.D., and Mervyn Maze, M.B., Ch.B. Philadelphia, Churchill Livingstone, 2004. Pages: 1,000. Price: $99.00.
The new textbook Anesthetic Pharmacology: Physiologic Principles and Clinical Practice  , ably edited by Alex S. Evers, M.D. (Chairman, Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri), and Mervyn Maze, M.B., Ch.B. (Sir Ivan Magill Professor of Anesthetics, Imperial College of London, London, United Kingdom), is an impressive addition to the anesthesiologist’s library. For nearly two decades, the standard text covering pharmacology and physiology as they relate to the practice of anesthesiology has been Stoelting’s Pharmacology and Physiology in Anesthetic Practice  . In contrast to that volume, Anesthetic Pharmacology  is a multiauthored work with 110 contributors, most of whom are well-recognized authorities writing in their field of expertise. With so many authors, there is less cohesion and more repetition than in a single-authored text; however, the excellent breadth and detail of this book could only be accomplished with the outstanding team of experts assembled by the editors.
The textbook has three sections: I. Principles of Drug Action (7 chapters, 118 pages), II. Physiologic Substrates of Drug Action (15 chapters; 245 pages), and III. Pharmacologic Basis of Clinical Practice (32 chapters, 505 pages). The first two sections provide basic principles of pharmacology and physiology, and the third section covers the clinical pharmacology of major drug classes. Section I (chapters 1–7) is a concise but thorough review of basic pharmacokinetics and pharmacodynamics and includes current topics such as pharmacoeconomics and pharmacogenomics. Section II covers physiology at both the cellular and systems levels. Section III presents clinical pharmacology by drug classification (e.g.  , “Inhalational Anesthetics”), use, or target organ (e.g.  , “Myocardial Protection”). This organization results in some overlap between the two background sections and the chapters on clinical practice. The division of part III into chapters based on specific drug uses also results in some repetition for drugs employed in multiple contexts. For example, β blockers are covered with similar tables in chapters 34 (“Sympatholytic Drugs”), 35 (“Antiarrhythmic Agents”), 36 (“Agents Used to Treat Myocardial Infarction”; n.b.  error in esmolol dosing in table 36-1), and 38 (“Myocardial Protection”). In other cases, the clinical practice chapter contains even more scientific detail than the basic physiology chapter (e.g.  , the role of endocannabinoids in synaptic transmission is discussed in detail in chapter 29 (“Analgesics: Cannabinoids”) but goes unmentioned in chapter 9 (“Synaptic Transmission”). However, these problems do not detract from the overall utility of the book.
There is a uniform feel throughout the book; each chapter follows the same basic outline and is subdivided into sections on Mechanisms of Action, Clinical Pharmacology, Adverse Effects, Practical Aspects of Drug Use, and Dosage and Administration. Unfortunately, this format was not consistently followed, and many authors wandered from the editors’ well-organized chapter structure. The book is designed as “A Companion to Miller’s Anesthesia”  to provide “the depth of pharmacologic information to satisfy the needs of the sophisticated clinician.” It is indeed a worthy companion to Anesthesia  in dimensions and heft (7.4 lb), but some form of cross-referencing between the texts would greatly facilitate this function.
There are a few notable omissions for a complete textbook of anesthetic pharmacology. For example, the anesthetic implications of statin therapy for hyperlipidemia and anitiviral therapy for HIV infection and their effects on cytochrome P-450–mediated drug interactions are not discussed despite the prevalent use of these drugs by patients treated by anesthesiologists. Other topics that receive short shrift include dantrolene and treatment of malignant hyperthermia, properties of commonly used and abused opioids (e.g.  , codeine, oxycodone, hydromorphone, methadone, heroin), depth of anesthesia monitoring, anesthetic effects on electrophysiologic monitoring, and the physiology and pharmacology of spinal and epidural anesthesia, inter alia  . Cross-references with Miller’s Anesthesia  might obviate the need for duplicate discussion of many of these topics.
As with many works of this size, the quality of individual chapters is variable, but there are many gems. Sections I and II are consistently excellent, whereas section III is more variable. Chapter 25 (“Sedatives, Anxiolytics, and Amnestics”) is superbly written and provides a thorough overview of the molecular, cellular, and clinical pharmacology of benzodiazepines (although providing fractional coefficients may be overly ambitious). Similarly, chapter 52 (“Red Blood Cell Substitutes”) is an excellent overview of an important topic and provides a thoughtful and reasoned assessment of the current state of clinical relevance and applicability. In contrast, parts of chapter 44 (“Antimotility and Antisecretory Agents”) and chapter 51 (“Chemotherapeutic Agents”) read like a selection of package inserts (are dosing schedules of chemotherapeutic agents important to most anesthesiologists?). The editors cannot possibly check every fact or citation, and some errors have crept in. Thus, it is unlikely that bronchospasm after rapacuronium administration is due to histamine release as suggested in chapter 33, but rather is the result of selective muscarinic receptor type 2 blockade; fortunately, such mistakes seem to be rare. Minor errors are present throughout the text (including the title page) and citations (e.g.  , two of the three authors are listed incorrectly in the figure legend on page 248). There is also some inconsistency in terminology (e.g.  , adenylate, adenyl, and adenylyl cyclase all appear). The immense time and effort required to produce this book is likely the reason for the paucity of references later than 2001.
Despite these concerns, readers will find Anesthetic Pharmacology  a valuable reference irrespective of level of training or experience. It certainly deserves a place in every anesthesia departmental library and is highly recommended for those interested in staying on the leading edge of the specialty. This represents a fine start to what we fully anticipate will become the classic text on pharmacology and physiology as they relate to the practice of anesthesiology.
*Weill Medical College of Cornell University, New York, New York.