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.

Successful pain management is key to patient quality of life and outcomes across many fields of medicine. The Handbook of Pain Management provides an insightful and comprehensive summary, authored by a noted expert.

Concise and insightful review of an important and complicated area of medicine

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.

Dieser Band gibt die Referate des 4. Internationalen An{sthesie-Symposiums, 15.-17. Juni 1989 wieder. Amerikanische und europ{ische Spezialisten der unter- schiedlichsten Fachgebiete diskutieren neueste Entwicklungen der Labor- und klinischen Forschung.

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 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.

Every specialist, at present, is confronted with the fact that it is continually becoming more difficult to remain 'up to date'. The areas in which he must read are expanding while the individual publications are becoming greater in number, larger in content and appear more frequently. The choice of the subject was not easy. This time we have selected the pharmacological aspects of anaesthesiology as our main topic, as a continu ation of the Boerhaave course in 1971. Although we know that a drug works, the mechanism behind this action is of great importance. The pharmacokinetics and side effects of the drugs we administer affect not only our patients, but also ourselves, our children, and the personnel under our care. In a special section we draw attention to this subject. We fervently hope that this symposium will further enrich your knowledge of anaesthesia and that through this enrichment you will derive more pleasure from the profession you have chosen and that in the end this will lead to even better care and treatment of the patients entrusted to us. We wish to express our thanks to Prof. C. M. Conway, Dr. D. T. Popescu, and Prof. D. M. E. Vermeulen-Cranch for their assistance in the editing of some of the chapters in this book."

Pain is unfortunately not an early symptom in neoplastic diseases. When it occurs, however, as it so often does in the advanced stages of the disease, then it can be particularly severe. Many physicians are not able to treat such pain efficiently with the standard methods familiar to them. Even in the oncological clinic, it is common for cancer patients not to receive adequate treatment of their pain; the therapeutic efforts are directed principally at the cancer, the pain often being neglected. This book fills a gap in the literature and should enhance the awareness of pain of all those who deal with cancer patients. For the patient, the symptoms of the disease are usually the direct cause of suffering, and pain is often the most severe symptom. The pain may be potentiated by knowledge of the threat posed by the cancer, or may itself considerably increase the patients existing anxiety. Thus there is a vicious circle of pain and psychological factors which will reduce the patient to a state of despair and distress. It is, therefore, obvious that efficient pain therapy is of utmost signi ficance to the patient, who will judge the doctor's ability to provide medical assistance according to the degree of pain relief achieved. The patient's quality of life will also depend critically on the relief obtained."

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.

Psychopharmacology: A Concise Overview, 3rd Edition is an evidence-based overview of the major classes of psychiatric medications and their use in clinical practice. Clinical considerations as to when, why, and how to use each individual medication are discussed in depth, as are relevant clinical controversies and treatment caveats. Each chapter also features an updated table of individual medications and their generic and brand names, dosing information, pertinent clinical comments, black box warnings, and Food and Drug Administration indications. This overview will equip readers with an essential framework of the concepts of psychopharmacology in an accessible length and style ideal for use as either a primer or refresher text. Medical students, residents, practicing physicians, nurse practitioners and other prescribers, as well as non-prescribing mental health clinicians who need to have a functional familiarity with available pharmacotherapies, will benefit from reading this concise book.

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 20 years two groups of investigators have concerned themselves with the problem of acid-base regulation at various body temperatures. Each group, in professional isolation, pursued a separate path. Surgeons and anesthe tists developed techniques and tools for hypothermic cardio-pulmonary by-pass operations and based their rationale for acid-base management on in vitro models of blood behavior. Physiologists and biochemists, on the other hand, endeavored to understand acid-base regulation in living organisms naturally subjected to changes in body temperature. Only in the last decade has there been an increasing awareness that each group could benefit from the other's experiences. With this goal in mind members of both groups were invited to present their views and observations in the hope of arriving at a better understanding of acid-base management during hypothermia and gaining a greater insight into the factors which control acid-base regulation during normothermia. This led to the presen tation of the present volume with the aim of providing the clinician with a survey of present theories and the resulting strategies for management of the hypother mic patient. Acknowledgment The editors express their great appreciation to Miss Augusta Dustan for her dedicated effort in the preparation and editing of the manuscripts. Contributors Heinz Becker, M. D. Department of Surgery, University of California Medical Center, Los An geles, Los Angeles, CA 90024, U. S. A. Gerald D. Buckberg, M. D. Department of Surgery, University of California Medical Center, Los An geles, CA 90024, U. S. A."

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."

Throughout the course of history it has always been noted that any ideas about brain function depended upon the highest technological model of the day. Hence, in the Greek or Roman era the ventricular system was singled out because of the devel opment of hydraulics. Early in this century we drew the analo gy between telephone circuits and the brain. Now it is popular to characterize neural function as that of a sophisticated com puter. Indeed, in many ways it may be. But, as yet, the pre pared human brain will likely prevail in the sorting out of information necessary for a proper diagnosis. In this manual, POECK has provided the ground work for such prepara Dr. tion. We all admire the clever diagnostician, and usually ascribe the skill to great intuition. Not so It is the clinician who has seen many patients, and has compiled a menu of choices. Dr. POECK is such a clinician, and he has provided us with his menu of choices. Use of these lists will likely aid the student or resident physician in coming to a proper diagnosis but, more importantly, will help train his or her mind to think in a logical and systematic way. ROBERT J. JOYNT, M.D., Ph.D."

This volume is a compilation of papers presented at the Tenth International Symposium on Brain Edema held on October 20-23, 1996, in San Diego, California. This follows the sequence of meetings that was initiated 31 years ago in the First International Symposium held in Vienna. Subsequent symposiums were held in Mainz, Montreal, Berlin, Groningen, Tokyo, Baltimore, Bern, and Tokyo CY okohama). A considerable number of papers was chosen from over 100 papers that were received. The organizers wish to thank the Advisory Committee for the excellent work done in selection of the papers. We also wish to thank all the persons who contributed to the success of the Tenth International Symposium, especially the staff who worked behind the scenes. These papers were reviewed, edited, approved or disapproved by the Editorial Board. Those manuscripts that were felt not pertinent to this publication were not accepted by the Editorial Board. Therefore, the excellent quality of those that are in the book are a reflection of the authors' dedication and work and that of those of the Editorial Board in their review process. For the reader's convenience, the papers are structured according to the various disease processes which are associated with the primary topic: hypertension, hydrocephalus, infection, ischemia, tumor, etc. We do hope that the reader will enjoy the articles and that they will provide an impetus and insight for future work.

Painful disorders following injury ofperipheral nerves; bones and othersoft tissueshaveoccurredfrom theearliesttimesofhuman existence. Ambroise ParewascalledupontotreatthepersistentpainexperiencedbyKing Charles IXwhich wascausedbyalancetwound. Thepainwaspersistent,diffuseand associatedwithcontractureofmuscles. Thekingcouldneitherflexnorextend hisarmforamonth untilthepainfmally disappeared WeirMitchell, G.R.Moorehouse,andW.W.Keeneproducedamonumental treatisein 1864titled"GunshotWoundsandOtherInjuriesofNerves,"which containedan account ofsymptoms and signs ofperipheral nerve injuries as observed in Unionist Soldiers. After 1864, however, little mention ofthis condition wasmade during peacetimeuntil a spateofarticlesappearedagain afterWorldWarOneandTwo. With the formation ofsocieties such as International Association for the Study of Pain, renewed interest has been shown in understanding the mechanismsandmanagementofpainsyndromes. Paincausedbysympathetic disordershasalwayscaughtthefancyofclinicians, andyetconfusionexistsas tothe etiologyandpropertreatmentofreflexsympathetic dystrophy. Many new names have been proposed for these syndromes; recent ones include sympatheticallyornonsympatheticallymaintained pain. Taxonomy ofThe International Association for the Study ofPain lists causalgia and reflex sympathetic syndromes as two distinct entities. All clinicians seem to feel that pain relieved by a diagnostic sympathetic block should be labeled as causalgia or reflex sympathetic dystrophy. Similarly, numerous therapeuticmodalitieshavebeenproposed. Theyallcenteraround sympathetic denervation of some sort, pharmacologically, chemically, or surgically. Inspiteofagreatadvanceinourunderstandingofpainmechanism in the last quarter century, we are no closer to improving the outcome of patientswithsevere reflexsympatheticdystrophy. Etiologyand incidenceis xvi Serieseditorforeword still unclear. Diagnosis is made late and treatment is not standardized Clinicians whotreatcausalgiaandreflexsympatheticdystrophyhavedifferent treatmentsbasedupon their background and experience,ratherthan on the mechanism ofthesyndrome itself. ThetimeisopportunenowtogathersomeunbiasedthoughtsonRSDand clem- the air. Our editors, in particular Michael Stanton-Hicks, needto be congratulatedfor organizing a timely symposium onthesubject and inviting international expertsto discuss the pathophysiology and treatmentofRSD. Whatfollowsinthismonograph isaclear,concisepresentationanddiscussion ofnomenclature, etiology, incidence, mechanism, treatment, and outcome of RSD.

After a long period of neglect, the gastrointestinal tract is increasingly being recog nized as an important target of anesthetics and anesthesia-related processes, as well as of conditions and treatments related to peri- and postoperative period and inten sive care. Drugs used in anesthesia and intensive care and physiological or pathologi cal changes in the perioperative period affect the digestive system in its function from the pharynx to the colon. Prolonged postoperative ileus or stasis of propulsive peri stalsis in the critically ill or multiply injured patient may impair enteral nutrition and give rise to complications such as sepsis or multiple organ failure. In view of this new understanding of the clinical relevance of gut function, we felt that a book on problems of the gastrointestinal tract in anesthesia, the perioperative period, and intensive care was badly needed. The present volume is the product of an international symposium which brought together physiologists, pharmacologists, experimental and clinical anesthetists, gastroenterologists, surgeons, and intensive care physicians to discuss all major contemporary aspects of bowel function in health and under the influence of anesthesia, surgery, and intensive care."

A HISTORY OF MALIGNANT HYPERTHERMIA Malignant hyperthermia (MH) is a hereditary disorder of muscle. Undoubtedly, individuals have possessed this trait since time immemorial. However, because the trait is usually only unmasked in the presence of potent inhalational anaesthetic agents or non-depolarizing skeletal muscle relaxants, the existence of malignant hyperthermia was not suspected until we" after the dawn of the modern anaesthetic era. In the early years of ether and chloroform anaesthesia, monitoring was minimal. Body temperature was never measured. A finger on the pulse, and observation of respirations and skin colour were the most that could be expected. Death was not infrequent and usually unexplained (1). By the beginning of the twentieth century, reports of fulminant fever and tachycardia (rapid heart rate) during or immediately after anaesthesia often ending in death, were being described with increasing frequency in the medical literature (2-6). As a number of cases from New York had occurred during summer months, they were initially thought to be a form of heat stroke due to overly hot operating theatres (2-6). However, one enterprising anaesthetist (5: ' checked the weather reports for the days on which some of these so called "heat strokes" had occurred. He found that on the days i'n question the ambient 0 temperature had never been in excess of 72 F. Environmental heat, therefore, could not have been a cause of at least some of these reactions.

Assessing Chronic Pain offers a unique approach to the evaluation and assessment of treatment for chronic pain patients. Rather than adhering to the criteria of any one discipline's approach to treating chronic pain, whether that of anesthesia, physical therapy, psychiatry or psychology, the editors overview a range of disciplines, and focus on the integration of those approaches to achieve what they term a "handbook," rather than a textbook, for the assessment of chronic pain from a multidisciplinary perspective. Issues confronting clinicians have been compounded by procedural problems and assessment indecision, but in Assessing Chronic Pain, Drs. Camic and Brown create a framework to guide specialists in all fields in approaching the patient suffering from chronic, non-malignant pain.

Our present understanding of the psychosocial aspects of pain in children is reviewed in this monograph by leading scientists and practitioners. The contributions are integrated within a developmental perspective to provide an introduction to the conceptual and methodological tools necessary for comprehension of new work in the field. This volume offers a survey of major new developments in the area of pediatric pain and points out the directions in which clinical work and conceptualization are moving. Children in Pain argues consistently and persuasively that both models of pain assessment, intervention techniques, and research designs must demonstrate a sophisticated appreciation for developmental considerations. Topics explored include assessment of pediatric pain; coping and adaptation in children's pain; developmental issues among infants and toddlers and among preschool and school-age children, as well as among adolescents; recurrent abdominal pain; burn injury and treatment; chronic and recurrent pain in hemophilia, juvenile rheumatoid arthritis and sickle cell disease; developmental aspects of the biobehavioral treatment of migraine in childhood; and helping children cope with painful medical procedures.

The science of neuroanaesthesia and neurointensive care is fascinating, and the amounts of experimental and clinical studies are overwhelming. Surely, everyone can surf Medline and other database systems in order to get information. If you, however, ask for head injury, cerebral ischaemia or barbiturate, you will get hun dreds, may be thousands of titles and even the same number of abstracts. The aims of this book are to review important experimental and clinical data with emphasis on up-dated references. The text within each issue and sub-issue systematically covers experimental and clinical data separately, and details con cerning cerebral blood flow, cerebral metabolism, intracranial pressure etc. are reviewed accordingly. In our survey of the literature we did not use Medline or other database sys tems systematically. Rather, we used available medical journals which covered the topics of anaesthesia, neuroanaesthesia and neurointensive care. In this way we hope that relevant literature is presented. On the other hand, we cannot exclude that some important issues are omitted. The book covers 12 topics. In three chapters methodology of CBF measure ments, regulation of CBF, and intracranial pressure are described. In the next 6 chapters inhalation anaesthetics, hypnotic agents, analgesics, muscular relaxants, drugs used for control of blood pressure, and the sitting position are reviewed. The last three chapters cover head injury, subarachnoid haemorrhage and cere bral ischaemia."

Chronic and persistent pain, which is a problem for the individual who suffers and the society that has to deal with it, has become increasingly appreciated. Over the last three decades, several books and journals have been specifically devoted to the topic of pain, especially chronic and persistent pain. It has been increasingly recognized that chronic and persistent pain, unlike acute pain, involves significant psychosocial factors and requires treatment strategies that deal with these issues. All measurements and factors that affect improvement seem to be in the psychosocial area rather than the medical/ biological/physical areas. Psychosocial conveys the importance of the environmental and interpersonal factors of the patient's functioning. The writing of this book has brought together some of the leading researchers and clinicians in the area of managing the patient with chronic pain. The authors express their opinions based on experience and review of the literature available to date. Each of the chapters focuses on an important element of the assessment and/or treatment intervention utilized for the individual with chronic pain. The concluding chapter summarizes the status of the assessment and treatment strategies for those patients.