Neuroanesthesia contains the edited presentations of the 42nd Annual Postgraduate Course in Anesthesiology given by the Department of Anesthesiology at the University of Utah School of Medicine, February 1997. The chapters reflect recent advances in neurophysiology, pharmacology and monitoring related to the practice of neuroanesthesiology. The sections on central nervous system trauma, intraoperative management, brain protection and postoperative care provide a conceptual framework for current clinical practices. This textbook is the fifteenth in a continuing series documenting the proceedings of the Postgraduate Course of the Department of Anesthesiology of the University of Utah School of Medicine. It reflects, as well as past and future volumes, the rapid and continuing evolution of anesthesia in the last years of the twentieth century.

Rarely have the many mechanisms that might underlie neural plasticity been examined as explicitly as they are in this broad, lavishly illustrated treatment of plasticity in the somatosensory system. The reader is provided with state-of-the-art knowledge of connections at all levels of the somatosensory system. The authors examine the propensity for changes of connectivity in both the mature and developing mammal and make clear proposals regarding the mechanisms underlying these changes. Their functional significance to relevant psychophysical and neurological observations is also discussed.

Nitric Oxide (NO) is a free radical, a gas, and a pluripotent product of mammalian cells. Only a few years ago, scientific discussions of NO were largely held in the context of the chemistry of air pollution. Now, however, the great significance of NO as a signalling and cytotoxic molecule has captured the attention of the biomedical community. This book provides a very up-to-date review of the role of NO in sepsis and ARDS. Consideration is given to NO both as a pathophysiologic mediator as well as a therapeutic agent. An internationally recognized group of scientists and clinicians have contributed chapters dealing with cutting-edge science and practical clinical strategies. Numerous tables and charts have been included to aid the reader in understanding this fascinating and important subject.

I am very happy and honoured to have so many famous contrib utors from around the world presenting their knowledge and experience in this book, including Dr. Rufer who, as early as 1967, attempted to improve the pressure-volume curve of a child dying from RDS using dried surfactant from dogs; Drs. Enhorn ing and Robertson who were the first to treat rabbit fetuses with surfactant replacement and impressively demonstrated that sur factant improved lung mechanics; and Dr. Fujiwara who at the end of the 1970's had already successfully treated the first babies with surfactant replacement and published this work al ready in 1980. Thus, the idea of surfactant replacement therapy is now more or less 20 years old and almost 10 years have passed since the first publication by Dr. Fujiwara of his impressive clinical results. Up to now (September, 1988) about 2,200 babies have been treated worldwide with tracheal instillation of surfactant, with most promising results. The type of surfactant used varies from pure natural extracts from bovine or pig lungs, to surfactant extracted from human amniotic fluid, to pure phospholipids. To date, however, there is still no surfactant commercially available (except in Japan), in spite of the fact that it is urgently awaited by neonatologists and intensive care doctors throughout the world. This volume is based on the contributions presented at the international congress on Surfactant Replacement Therapy which was held in Rotterdam, The Netherlands, in November 1987."

Pediatric and Obstetrical Anesthesia comprises the edited presentations of the 40th Annual Postgraduate Course in Anesthesiology, February 1995. The book reflects the most recent advances in the physiology, pharmacology and anesthetic management of patients with central nervous system disease. Subjects such as central nervous system trauma and brain protection are also dealt with. Obstetrical and pediatric patients constitute important and often challenging cases for the practicing anesthesiologist. This textbook is the thirteenth in a continuing series documenting the proceedings of the Postgraduate Course of the Department of Anesthesiology of the University of Utah School of Medicine.

New findings involving the brain in traumatic and septic shock and after brain injury are reported in this book, including pathophysiological and pathohistological results. An experimental and clinical approach to treatment is presented together with specific results obtained from the encephalogram and from histopathological study with regard to the immunohistochemistry of toxic lipid peroxidant products. The latest results of clinical and experimental pathophysiology in inflammatory processes after traumatic brain injury and the therapeutic effects of hypertonic fluid therapy are also discussed.

This atlas offers a collection of EEG spectral analyses and their corresponding conventional recordings under anes thesio10gical procedures. The EEGs presented here were re corded on general surgical and gynecological patients during the last few years. Premedication, induction and maintenance of anesthesia, recovery the immediate postoperative period, and intensive care are covered. Techniques for operating the necessary equipment and artefacts relevant to the routine clinical use of EEG are briefly outlined. Typical examples of characteristic EEGs are presented at the beginning of each chapter, followed by illustrations of deviations from the norm showing the great variety of anesthesiologically induced changes of cerebral function. The description of each EEG course is assessed in relation to clinical parameters. Sometimes no satisfactory interpreta tion can be made, because many physiological and patho physiological causes of alterations in cerebral function are unknown. Time and again it proves impossible to estimate wether deviations from the norm have their origin in cerebral changes or are secondary to extracerebra1 disturbances. The atlas comprises a complete survey in itself, but it can also be seen as a supplement to the book The Electroenceph alogram in Anesthesia by I. Pich1mayr, U. Lips, and H. Kunkel (Springer, 1983), in which detailed lists of references are quoted that are omitted here."

Assisted Circulation 4 is an authoritative review of the progress which has been achieved in the last 5 years since the publication of "Assisted Circulation 3" in 1989. The present book highlights the work of well-known experts on indications for assisted circulation, cardiac support devices such as bridges, devices for transplantation, devices for chronic mechanical support, biological energy sources, cardiomyoplasty, extracorporeal membraneoxygenation and an overview of cardiac devices support with a specific emphasis on xenotransplantation. Assisted Circulation 4 is the latest product of an ongoing effort by the editors to keep readers regularly informed of recent developments in the field. Assisted Circulation is a standard technology in cardiac surgery and especially in cardiac transplantation.

This volume on the processes of transformation of mechanical stimuli into electrical activity in various mechanoreceptors comprises the authors investigations as well as relevant literature data. It deals mainly with initial electrical processes from stimulus of the mechanoreceptor to receptor potential. For the first time the connection between passive and active ion transport and the generation of electrical potentials is considered in detail. Furthermore, data on the properties and selectivity of different types of mechanosensitive ion channels, as well as results of morphological experiments on characteristics of the mechanosensitive membrane, and the changes during the activation of primary and secondary mechanoreceptors are discussed. This comprehensive overview is of interest to molecularbiologists, neuroscientists and biophysists.

Essential Pain Pharmacology: The Prescriber's Guide expertly reviews the most important medications used to relieve pain, now considered by many physicians as the fifth vital sign. The catalogue of analgesics has expanded rapidly, and this text presents the most up-to-date, comprehensive array of agents available for prescribing. Each clear and concise drug entry covers the range of indications, advantages and disadvantages, and tips for appropriate dosing and avoiding adverse effects. A separate section covers nutraceuticals, a class of drug increasingly used to manage chronic pain, yet little discussed in medical literature. The detailed description of each medication enables the user to make quick and informed decisions, confident that they are best serving the needs of their patients. Practical 'pearls' for each entry provide a quick go-to reference for the key information to consider before prescribing. This concise user-friendly reference is a must-have on the shelf of every physician.

This book records the presentations given at a workshop held in Bonn in May 1994. The aim of the meeting was to bring together scientists from various disciplines and clinicians to discuss within a group of experts the theoretical, medical, engineering, and regulatory aspects of automated control of therapeutic interventions in. anaesthesiology. The meeting was considered a continuation of a preceding work shop on "Quantitation, Modelling and Control in Anaesthesia" 1], which was held also in Bonn 10 years ago in May 1984. That workshop dealt with problems of how to quantitate concepts like anaesthetic depth, how to model anaesthetic drug disposition, how to link phar macokinetics and pharmacodynamics, and how to use such concepts for the control of anaesthetic drug delivery. With respect to these topics the current proceedings have simultaneously both a broadened and a narrowed perspective. It is broadened in so far as the topics of the workshop did not focus exclusively on anaesthetic drugs and the control of their delivery, but did also discuss anaesthesia machine monitoring and patients therapeutic monitoring as well as control of blood pressure and artificial ventilation. The proceedings have nar rowed the perspective insofar as they do not intensively discuss the processes of quantitation and modelling but presuppose them and give more room to control, especially automated control. During the past 10 years informatics has tremendously expanded its knowledge and methods applicable to control problems."

This supplement of Acta Neurochirurgica contains the proceedings of the Ninth Convention of the Academia Eurasiana Neurochirurgica held in Chateau St. Gerlach, Houthem, The Netherlands, 29 July - 1 August 1998. During this convention a three-day symposium on Neurosurgery and Medical Ethics was held. In this time of tremendous technical advancement in medicine in general and neurosurgery in particular, we are liable to lose sight of the sick patient as a human being, and the odds are that he will be the object rather than the subject of our action in the near future. It is a purpose and a task of the Academia Eurasiana Neurochirurgica to recognize this thread and to pay attention to tradition, morality and ethics in neurological surgery. The theme of this convention and the subject of the symposium met this purpose as no other. In the scientific sessions during the first day, the moral backgrounds of medical ethics in the most important cultures and religions in east and west were elucidated by invited experts in this field. A mutual respectful understanding of each other's conception of and belief in ethical principles is a growing necessity in our multicultural societies in both continents. On the second day, the ethical aspects of different fields of neurological surgery were discussed by members of the Academia. In this context, also the internationally much-discussed and much-criticized regulations on euthanasia in The Netherlands were explained.

C. Manni The focusing of general interest and of many disciplines on disaster medicine is an interesting and recent phenomenon in our society. Disasters have by now left the his torical and philosophical sphere and finally entered the operational arena. Modern man, in other words, no longer accepts disasters in a passive and fatalistic manner, but claims to be able to control them like so many other forces of nature. The new approach is aimed at preventing, containing, and remedying the invariably tragic consequences of these events. The role of medicine in this context is of fundamental importance and is charac terized by two main aspects: application of techniques of intervention appropriately and effectively, and collaboration with the general organization, assuming responsi bility for the protection of health and the treatment of injuries. Following a period of more or less chaotic growth, during which sectionalism and empirical interests prevailed, and localized aspects of this new discipline underwent considerable development, a need is now felt to propose and realize a more com prehensive scientific approach. It has become necessary to identify and to rationally analyze the individual components of this branch of medicine. As in any analysis, the recognition of the "object" of the research is of fundamental importance: hence the title of this first round table: "Types and Events of Disaster."

Sepsis and Innovative Treatment: The Odyssey R. C. Bone The Odyssey by Homer, dates back to the 8th century, B. C. [1]. It is a great epic adventure of Odysseus's dramatic journey from Troy back home to Ithaca. Odysseus survives the ordeals of this journey and returns with new powers and insights. The study of the pathogenesis and treatment of sepsis has also been an odys- sey. I feel we will return from this odyssey with new insights and treatments. However, as with Odysseus, this will occur only after considerable struggle. In the 1980s we had a rather simplistic view of sepsis. It was a highly lethal complication caused by infection and often charac- terized by shock and multi-organ failure. Our knowledge of the inflammatory responses associated with sepsis was embryonic compared to today. The inflammatory response was often treat- ment with mega-dose corticosteroids along with fluid resuscita- tion, vasopressors and antibiotics. Because of the paucity of mul- ti-center controlled trials documenting the risk/benefit ratio of the treatment of sepsis with corticosteroids, two large multi-cen- ter controlled trials were organized to evaluate the role of corti- costeroids in sepsis [2, 3]. Because animal models showed bene- fits of corticosteroids only with pre-treatment or early treatment, a definition of sepsis was used that did not require positive cul- ture documentation or septic shock to be included in the studied population.

This book concentrates on problems generated by acute care in severely traumatized patients during the first 24 hours after injury. During this hectic period, highly complicated problems have to be solved at the site of the accident, during transport to hospital, and in hospital. Multiple medical and paramedical disciplines are involved in providing care to the severely injured. This book endeavors to present a problem-oriented approach to the diagnostic, therapeutic, and organizational aspects that may be encountered.

The book is based on papers presented at the recently held international meeting on central-nervous-system monitoring in Hamburg, Germany. Experts inthe fields of neurophysiology, experimental and clincial anesthesia and intensive care discussed the state of the art in noninvasive central-nervous-system monitoring. Starting with the principles of CNS monitoring in humans, the topics covered include pharmacokinetic pharmacodynamic interactions, the usefulness of spontaneous and evoked brain electrical activity as an overall-control for afferent systems andfor the assessment of analgesic drug treatment, perioperative anesthesiological monitoring, and intraoperative awareness. Recently developed specific EEG and EP indices such as spectral edge frequency, median frequency, auditory and somatosensory evoked responses for the assessment of depth of anesthesia are evaluated for intraoperative monitoring. The surgical and anesthesiological perspective in intraoperativemonitoring during vascular surgery are presented, as is the state of theart in the monitoring of afferent central-nervous-system pathways by monitoring transcranial motor evoked potentials. Bispectral EEG analysis forthe assessment of anesthetic adequacy represents the future trend in intraoperative monitoring. In addition to neurophysiological methods, assessment of jugular bulb venous oxygen saturation and transcranial Doppler sonography may give additional information for the interpretation of brain fuction. In the field of intensive care, topics in multimodal long-term monitoring of brain function are presented. The application of an expert system supporting the diagnosis of brain death is also included.

Sepsis and infection are the major enemies of the intensive care patient in whom immunological defenses are severely impaired. This major problem is thefocus of attention in this book, based on the presentation of the First International Congress on the Immune Consequences of Trauma, Shock, and Sepsis, which is one of the first attempts to exchange ideas on the state-of-the-art in this area of immunology. Both basic and clinical research, including new centres of attention, are described. The growing role of immunology in medicine opens new avenues to the under- standing of trauma and sepsis and will allow the design of novel therapeutic approaches.

The interrelated syndromes of shock and the adult respiratory distress to attract the attention of both clinical and syndrome (ARDS) continue laboratory scientists. This reflects both the size of the problem and its unresponsiveness to current lines of treatment. Doubtless, a greater appreciation of the underlying pathophysiological disturbances during the past two decades has led to appropriate action and increased survival in the early stages but once established these syndromes have remained remarkably immune to a wide spectrum of therapeutic modalities. This observation stresses the importance of prevention but also indicates the need for continued research into the nature of the established syndromes and the means whereby they may be reversed. Drs Kox and Bihari are to be congratulated on bringing together within the covers of this volume many of the acknowledged European experts in these two fields of investigation. Each author has provided an up-to-date account of his current experimental and clinical research, and their com bined contributions makes fascinating reading. Undoubtedly, these are exciting times in the development of understanding of shock and ARDS. Inevitably, more questions are raised than answers provided, but the accumulated knowledge presented here adds significantly to our under standing of this complex biological jigsaw. From this corporate endeavour will come the clinically useful developments of the future and with them the ultimate hope that the term 'refractory' shock may be finally removed from our vocabulary.

A state-of-the-art presentation of intraoperative neuro- physiologic monitoring by specialists from well-known international medical centers.

The spinal cord has a characteristic structure and functions that are distinct from those of the brain. Its functions are tremendously important since it modulates the peripheral sensory inputs to the dorsal horn, and it gives rise to the ascending pathways transmitting peripheral afferent inputs to the brain, and conveys the descending pathways from the brain both to the lower motor neurons, the final common pathway, and to dorsal horn sensory neurons. In spite of these vital functions, the spinal cord constitutes only a small percent age of the mass of the human central nervous system and is located far from the skin surface, which has obstructed the recording of its electrical activity. Recently, however, important advances have been made in several recording techniques, including epidural recording or averaging methods, allowing both sensory and motor evoked spinal cord potentials in man to be recorded. This volume is based on the papers presented at the Fourth International Symposium on Spinal Cord Monitoring and Electrodiagnosis. Each of these international symposia has brought together many of the specialists involved in this research, with an important increase in the number of participants since the first symposium was held in Toyko in 1981. At the past symposia several attempts were made to standardize data, techniques, and clinical applications and to integrate the new findings into patient care."

Echocardiography has been one of the most significant advances in cardiology in the past two decades. It can provide anatomic, functional hemodynamic, and blood flow information. Conventional transtho- racic echocardiography has limitations, particularly in certain patients such as those with obesity, chronic lung disease, or chest wall defor- mity, or in those where a transthoracic approach is difficult for reasons including trauma, life support apparat uses, and surgical dressings. There are also certain disease states or conditions in which transtho- racic echocardiography expectedly gives incomplete or inadequate in- formation. Transesophageal echo cardiography has opened a unique "new window to the heart." The immediate proximity of the esophagus and the posterior heart permits exceptionally high resolution images, par- ticularly of the left atrium, mitral valve, and intraatrial septum. Addi- tionally, from the stomach (trans gastric views), the ventricles can be dependably imaged. Transesophageal echo cardiography presently is utilized in two environments: intraoperatively and for outpatient examinations. Intraoperatively, TEE is utilized to monitor cardiac function and de- tect intracardiac air or debris, to diagnose or quantitate cardiac path- ology, and to access operative results.

Theodore H. Stanley. M. D. W. Clayton Petty. M. D. Anesthesia. the Heart and the Vascular System contains the Refresher Course manuscripts of the presentations of the 32nd Annual Postgraduate Course in Anesthesiology which took place at the Westin Hotel Utah Convention Center in Salt Lake City. Utah. February 20-24. 1987. The chapters reflect new data and concepts within the general framework of "risk. preoperative evaluation and monitoring. " "cerebral. pulmonary and peripheral vascular disease. " "new agents. their advantages and their problems" and "pediatric. cardiac and non-cardiac surgery. " The purposes of the textbook are to 1) act as a reference for the anesthesiologists attending the meeting. and 2) serve as a vehicle to bring many of the latest concepts in anesthesiology to others within a short time of the formal presentation. Each chapter is a brief but sharply focused glimpse of the interests in anesthesia expressed at the conference. This book and its chapters should not be considered complete treatises on the sub jects addressed but rather attempts to summarize the most salient points. This textbook is the fifth in a continuing series documenting the pro ceedings of the Postgraduate Course in Salt Lake City. We hope that this and the past and future volumes reflect the rapid and continuing evolution of anesthesiology in the late twentieth century. YO TABLE OF CONTENTS Diabetes: Preoperative Evaluation and Intraoperative Management Simon de Lange, M. D., Ph. D."

During the past twenty years there has been a rapid evolution in anaesthesia, so much so, that we stand on the brink of a major change in the role of the anaesthetist in medicine. Anaesthesia has now emerged from being a craft speciality, obsessed with details of techniques, to become a science concerned with the maintenance of life. As a result of our better understanding of the physiological and pharmacological effects of anaesthesia and surgery, new opportunities have been created for anaesthetists to apply their particular knowledge, not only to provide better and safer conditions for surgery, but also in resuscitation, ventilatory and circulatory support and in the treatment of chronic pain. This has resulted in the recognition of the anaesthetist as a physician specialising in applied physiology and clinical pharmacology. The 1971 Boerhaave Course in Anaesthesia has deliberately tried to reflect this scientific basis of the speciality of anaesthesia by selecting for presenta tion in this book, subjects in which recent investigations have provoked new concepts and ideas. We are most grateful to our colleagues who presented a paper and to the secretary-staffs of our departments of anaesthesia in Leiden and London. Also thanks are extended to Mrs. Bongertman for the preparation of the proofs. Department of Anaesthesiology 10han Spierdijk University Hospital, Leiden Department of Anaesthetics Stanley Feldman Westminster Hospital, London v CONTENTS Preface . . . V Contributors . VIII PART ONE ANAESTHESIA AND THE HEART Alpha and beta blockers in anaesthesia . 3 H. LABORIT 18 Advantages and disadvantages of isoprenaline ."

During the last decade, the effects of anaesthetics on cerebral blood flow, cerebral metabolic rate of oxygen and intracranial pressure have been studied experimentally and clinically. In this review studies of CBF and CMRO2 during craniotomy have been performed with the classical technique described by Kety and Schmidt. In chapter 1 general considerations concerning the effects of anaesthetics on cerebral blood flow and metabolism are reviewed. In chapters 2 and 3 the effects of inhalation agents and hypnotics on flow and metabolism are considered. Chapters 4 and 5 cover the effects of central analgetics, and neuromuscular blocking agents. In chapter 6 the effects of other drugs in common use in neuroanaesthetic practice are summarized. Chapter 7 considers the effects of drugs used for controlled hypotension. In chapter 8 the application of Kety's method in studies of CBF and metabolism is reviewed, the studies of cerebral circulation and metabolism during nine different techniques of anaesthesia for craniotomy are presented, and other studies of cerebral circulation during neuroanaesthesia are reviewed. In chapter 9 considerations concerning central and cerebral hemodynamics during anaesthesia in the sitting position are considered. This review is primarily addressed to anaesthetists, but it will also be of interest to those working within neurosurgery, neuroradiology and clinical neurophysiology.

Theodore H. Stanley, M. D. Anesthesia and the Lung contains the Refresher Course manuscripts of the presentations of the 34th Annual Postgraduate Course in Anesthesiology which took place at The Cliff Conference Center in Snowbird, Utah, February 17-21, 1989. The chapters reflect recent advances in the diagnosis, pre-, intra-, and postoperative anesthetic management of patients with lung disease, presenting for pulmonary and non-pulmonary surgery. They also deal with ventilation-perfusion issues, the lung as a metabolic organ, the effects of anesthesia on pulmonary mechanics and pulmonary blood flow. In addition there are chapters that will focus around hypoxia; regional differences in the lung; pulmonary surfactant; recent advances in the understanding of pulmonary edema; high altitude disease; anesthesia and the control of breathing; recent developments in oximetry; instrumentation designed to measure pulmonary oxygen tension, P0 and PC0 trans 2 2 cutaneously; differential lung ventilation; reactive airways; septic shock; the adult respiratory distress syndrome and numerous aspects of ventilatory support. The purposes of the textbook are to 1) act as a reference for the anesthesiologists attending the meeting, and 2) serve as a vehicle to bring many of the latest concepts in anesthesiology to others within a short time of the formal presenta tion. Each chapter is a brief but sharply focused glimpse of the interests in anesthesia expressed at the conference."