Book Review

Blood: Hemostasis, transfusion, and alternatives in the perioperative period

N Engl J Med 1996; 334:999April 11, 1996

Article

Blood: Hemostasis, transfusion, and alternatives in the perioperative period
Edited by Carol L. Lake and Roger A. Moore. 554 pp., illustrated. Philadelphia, Lippincott–Raven, 1995. $129. ISBN: 0-7817-0287-4

Throughout the world, a large proportion of all transfused blood is given to patients undergoing surgery. Responsibility for decisions about transfusion therapy during surgery frequently falls to the person in charge of the patient's anesthesia and life support. Thus, it is appropriate that a textbook on transfusion therapy focus on the perioperative period from the perspective of the anesthesiologist. Indeed, 37 of the 44 contributing authors are anesthesiologists who practice and teach in leading programs around the United States. The book's 27 chapters, organized into five sections, cover hemostatic mechanisms, the clinical evaluation of patients with suspected coagulopathies, and transfusion therapy and its alternatives. The intellectual content serves as a foundation for the clinical approach to hemostasis for surgical patients.

The editors have assembled experts whose presentation is above all practical. Chapters are packed with useful information, and much of the text is richly illustrated with informative tables and graphs. Figures presenting original data are reproduced from the primary literature. Standard topics such as the preoperative assessment of the risk of bleeding and the interpretation of common coagulation tests are thoroughly addressed. The book distinguishes itself from others by the extent to which it covers areas often omitted in conventional textbooks on blood transfusion. The effect of hypothermia on blood coagulation as demonstrated by experimental data, the prevention of bleeding by induced hypotension, the proper use of a tourniquet to limit blood loss during orthopedic surgery, devices designed for bedside and intraoperative coagulation monitoring, and a clinical approach to perioperative obstetrical coagulopathies are examples.

The principal drawback of this book is that the editors failed to organize and edit the chapters sufficiently so that each one would have a distinct focus. Topics such as congenital and acquired disorders of hemostasis, heparin-associated thrombocytopenia, and the laboratory approach to the diagnosis of coagulopathies are discussed in multiple chapters. On more than one occasion, a figure used to illustrate a point in one chapter is used again by another author to make the same point. Not only is the redundancy of content annoying, but the reader pursuing a particular topic finds it scattered in various locations. A second drawback is an unevenness of style more extreme than usual in multiauthored books. For example, an extensive chapter on blood-bank topics runs 50 pages and offers nearly 500 references, but the next chapter, on blood components, is 12 pages long with only about 50 citations. There is an authoritative chapter on protamine, but less than half a page is devoted to warfarin in the chapter on pharmacologic manipulation of hemostasis. Whereas 35 pages deal with the questionable practice of intraoperative hemodilution, there are only 6 pages on blood support for solid-organ transplantation. What should have been a key chapter on the approach to bleeding patients contains only a few references. A table within this chapter takes a “shotgun” perspective, with the author suggesting that the approach to patients with a history of bleeding who face urgent surgery is to “order readily available hemostatic products (platelet concentrate, FFP [fresh-frozen plasma], cryoprecipitate, fresh whole blood) and treat hemodynamically, destabilizing bleeding empirically while awaiting test results/consultation.” In general, the book is reasonably up to date. The majority of citations are from the late 1980s, but several are as recent as 1992 and 1993. However, some recent information is lacking. For example, the chapter on hypercoagulation does not include resistance to activated protein C, and tissue-factor–pathway inhibitor is only briefly mentioned.

Despite these criticisms, I would recommend this book to practicing anesthesiologists, surgeons, hematologists, and specialists in transfusion medicine. Its strong clinical orientation and wealth of practical information set it apart from others in this field.

Walter Dzik, M.D.
Deaconess Hospital, Boston, MA 02215