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.

Despite the progress that has been made in intensive care medicine, sepsis and septic shock are still accompanied by a high mortality rate. In recent years, new therapeutic approaches have been developed on the basis of a better understanding of this complex condition. This monograph contains contributions by well-known scientists and clinicians in the fields of hygienics, microbiology, infectious diseases, physiology, surgery and intensive care medicine. It provides an up-to-date overview of the etiology, pathophysiology, prevention, and therapy of sepsis and its complications.

The increased complexity of spinal surgical procedures in recent years has required more sophisticated anesthetic management of patients undergoing these procedures. Spine surgery anesthesia is now recognized as a distinct sub-specialty, increasingly undertaken by general anesthesiologists as well as neuroanesthesiologists. Anesthesia for Spine Surgery describes the anesthetic management and surgical procedures at every vertebral level in both adult and pediatric patients. The most important related considerations are covered, including: * Postoperative pain management * One lung ventilation during anterior thoracic spine surgery * Intraoperative neuromonitoring * Fluid management Additional chapters review the radiological features of normal and abnormal spines, common complications of spine surgery and ASA closed claims relating to spine surgery anesthesia. Written by highly experienced neuroanesthesiologists and spine surgeons, Anesthesia for Spine Surgery is essential reading for trainee and practising anesthesiologists, neuroanesthesiologists and spine surgeons.

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 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."

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 ."

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."

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.

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.

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.

Increased intra abdominal pressure as used in laparoscopic surgery produces various changes in the human organism. This book provides surgeons and anesthesiologists with a complete overview on these changes and the consequences for the patient in the perioperative and postoperative period. Special emphasis is laid on the management of pneumoperitoneum related complications.

This book reflects the proceedings of the Boerhaave Course, "Developments in drugs used in Anaesthesia", held on r'lay 7th and 8th 1981 at Leiden University. The goal of the organizers of the course was to obtain a better under standing of the pharmacological and clinical applications of the drugs used in the field of Anaesthesiology. In my opinion, there is a constant need for post-graduate teaching not only on a clinical basis, but also in the so-called "basic sciences". This especially applies to anaesthetists. I would like to express my thanks to the speakers, who were all so kind as to send their manuscripts in time for publishing, and to thank the co-editors of this book, as well as rtr. B.P. Ccmnandeur, from r'lar tinus Nijhoff Publishers for their fruitful co-operation. Last but not least, I would like to thank the secretarial staff of my depar~ent for all the work they did arranging for manuscripts to be in the right places at the right times. Joh. Spierdijk THE USE OF H2 BLOCKERS T.H. STANLEY In the last decade a new important histamine receptor, H2 receptor, has been discovered which has major importance in gastric acid production. In addition, a new drug Cimetidine (Tagamet) which blocks the H2 receptor has been synthesized. The object of this presentation will be to discuss the possible role of this interesting drug (Cimetidine) before and during operation and possible postoperatively as well.

Anesthesiology and the Cardiovascular Patient contains the edited presentations of the 41st Annual Postgraduate Course in Anesthesiology, February 1996. The chapters reflect new data and concepts within the general framework of the pathophysiology and management of surgical candidates with cardiovascular disease. The textbook will serve as a vehicle to bring many of the latest concepts in anesthesiology to those who did not attend the conference. Each chapter is a brief but sharply focused glimpse of the current interest in anesthesia. This volume, as well as past and future volumes, reflects the rapid and continuing evolution of anesthesiology in the late twentieth century.

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."

The manuscripts in this book were generated from a conference occurring at the University of Heidelberg in September 1996. These manuscripts have been reviewed and updated by the designated authors in late 1997 for publication in early 1998. Conferences occur for a variety of reasons. These include the need to exchange information where complex activities are undergoing reassessment or change. For the emergency and critical care man agement of stroke this is certainly the situation. Today, both the pri mary care and the neurologic physician must provide medical care in an environment where daily change in the knowledge base of: brain function, disease mechanism(s), therapeutic efficacy, and cost control are all occurring. In addition, patient advocacy has become increasingly complex because government, employers, insurers, health care providers as well as families all desire a voice in the phy sician relationship with the patient. Our conference subject was the organization of rapid care delivery and the development of a ration al basis for treatment of a previously untreatable disorder acute stroke. Thus, the obvious need for multiple open and free discus sions about priority setting and modification of current treatment plans. Clearly, the face to face opportunities provided by this first conference on Emergency Management And Critical Care Of Stroke (EMACCOS) are required when patient care issues are as complex as these. Neuroscience is new to the experience of active therapeutic inter vention.

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.

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."

The 1973 Boerhaave Course in Leiden on Measurement in Anaesthesia was composed of the lectures included in this book, supplemented by the series of 'lecture demonstrations' organised by Dr. P. Cliffe and given by the members of the Departments of Clinical Measurement and the Magill Department of Anaesthetics, Westminster Hospital, London. The aim of the 1973 Boerhaave Course on Measurement in Anaesthesia was designed to arouse interest in this subject where it has not already occurred. The subjects discussed in the lectures and presented in this book were those that were considered topical and appropriate. The lectures were meant to give an idea of some basic and advanced possibilities of measurement. It was not intended to be an exhaustive review of all the measurements relevant to anaesthetic practice and research. In this time of monitoring one has to keep in mind that good measurement is the basis of good monitoring. A certain amount of repetition is unavoidable as each lecture was intended to be complete in itsel. However, editing has reduced this to a minimum. Department of Anaesthesiology Johan Spierdijk University Hospital, Leiden Department of Anaesthetics Stanley Feldman Westminster Hospital, London Julian Leigh CONTENTS Preface ... V Contributors VIII PART ONE INTRODUCTION The difference between measurement and monitoring. What is worth measuring? . . . . . . . . . . . . . . . . . . . .. . . . 3 . JOH. SPIERDUK and A. NANDORFF Problems of interference and electrical safety associated with the - cording of biological signals . . . . . . . . . . . . . .. . . . 13 J. P. BLACKBURN 22 The scope of measurements using radioactive isotopes .

This volume represents a review of recent work presented by eminent scientists at the Second International Symposium on 'Applied Physiology in Critical Care with Emphasis on Children' at Aruba, Netherlands Antilles, November 28 - 2 December, 1983. We are grateful to the keynote speakers who accepted our invitation and completed their chapters in time for the press. I must thank the Government of Aruba, the Tourist Office of Aruba, Mr Frank Croes and Mr Betico Croes for their support and generosity for organizing this symposium. My sincere thanks go to Mr Rory Arends, Lucy Arends, Simon Meij and Norma van Toornburg for their untiring efforts and cooperation. Omar Prakash, MD IX List of contributors Bryan, A.Ch., MB, BS, PhD, FRCP (C), The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, Canada M5G 1X8 Bryan, H., MD, Department of Pediatrics, Room 1241, Mount Sinai Hospital and The Hospital for Sick Children, University of Toronto, Ontario, Canada M5G 1X5 co-authors: A.L. Campbell, Y. Zarfin, M. Groenveld, P. Duffty Enhorning, G., MD, University of Toronto, Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario, Canada M5T 2S8 Gross, I., MD, Perinatal Medicine, Yale University School of Medicine, P.O.

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.

The peerless authority you trust...the portability you need! This practical handbook covers all of the most critical, clinically relevant topics from Stoelting's Anesthesia and Coexisting Disease, 5th Edition in a format suitable for a quick-reference guide you can carry in your coat pocket. The new edition presents the results of the latest clinical trials to help you make the most effective clinical decisions, while new illustrations aid in clarifying complex concepts. You'll have convenient access to dependable guidance on a full range of pre-existing conditions that may impact the perioperative management of surgical patients. Find the information you need easily with abundant tables throughout, a quick-reference outline format, and the same organization as Stoelting's Anesthesia and Co-Existing Disease. Confidently meet the needs of special patient populations such as pediatric and geriatric patients. Quickly access new guidelines on hot topics such as management of the morbidly obese patient. Make effective clinical decisions with access to current practice guidelines and results of the latest clinical trials.

This book is based on the proceedings of a conference held in Tubingen, West Germany, in 1981, at which anesthesiologists, neuro surgeons, pathologists and neurophysiologists met to consider the place of controlled hypotension in neurosurgery. In the first part of the book alternative methods of inducing hypotension are considered, and it is important to emphasize that the techniques which are suitable for neurosurgery may not be so for other types of surgery, and vice versa. In neurosurgery, and par ticularly in aneurysm surgery, the emphasis is on lowering intra luminal pressure and not mainly on reducing blood flow or limiting tissue oozing. Another special consideration in neurosurgery is the influence of drugs used to induce hypotension on intracranial pressure, with nitroprusside (NTP), and especially nitroglycerine, increasing ICP in the closed skull and increasing brain "bulk" when the skull is open. These and other points are extensively covered. The use of a non-essential technique like controlled hypotension demands that the procedure should carry minimal risk to the patient. Contributions in part IV consider the neuropathology associated with too severe a lowering of oxygen supply through hypotension. In the clinical avoidance of such ischemic changes in individual patients, monitoring of the brain electrical function is much the most import ant and practical approach and is discussed in part III. The Editors hope that the publication of these contributions to the Tubingen Symposium will help in the effective and safe appli cation of the technique of controlled hypotension in neurosurgery."

Theodore H. Stanley, M. D. Anesthesiology and the Heart contains the Refresher Course manuscripts of the presentations of the 35th Annual Postgraduate Course in Anesthesiology which took place at The Cliff Conference Center in Snowbird, Utah, February 16-20, 1990. The chapters reflect new data and concepts within the general framework of "evaluating myocardial function," "pharmacology and the cardiac patient," "anesthesia for patients with cardiac disease," and "stress, cardiopulmonary bypass, coagulation problems and related issues. " 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 subjects addressed but rather attempts to summarize the most salient points. This textbook is the eighth in a continuing series documenting the proceedings 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. vii LIST OF CoNTIUBUTDRS Bailey, P. L. Department of Anesthesiology, The University of Utah School of Medicine, Salt Lake City, UT 84132, U. S. A. Barash, P. Department of Anesthesiology, Yale University School of Medicine, New Haven, CT 06510, U. S. A. Covino, B. G.

Intensive Care Medicine has been continuously growing and expanding, culturally, technically and geographically. Monitoring and instrumentation are continuously improving and more and more hospitals are getting Intensive Care facilities. The costs have proportionally increased over the years, so that ICUs represent today a major cost for health structures. Since the available resources are limited, a real need is emerging to set the limits and indications of Intensive Care. It is understood that the problem not only involves medical considerations, but also ethical and economical aspects of the utmost importance. For the first time in Europe, this book edited by Reis Miranda and his colleagues tackles systematically the many structural aspects of the European Intensive Care. The organisation and financing of health care in the Old Continent is deeply different from the American one, and the results and consequent proposals obtained in the USA cannot simply be transferred to this side of the Atlantic Ocean. Weare extremely pleased to welcome this first European attempt to discuss the Intensive Care problem. It lays no claims to giving definite replies in a continuously developing field, but it will surely become the basis for future discussions and proposals. I am particularly happy that this work has mainly developed within the European Society of Intensive Care, whose final target is to ensure a common standard of therapy in our old Europe, beyond national differences. We warmly congratulate the authors, and I am sure that their work will find wide diffusion and consent.

The first two "Brain Heart Conferences" in Jerusalem in 1978 and 1983 were based upon the common interests of clinically orientated neurologists and cardiologists in the problems of centr'al autonomic control and autonomic disturbances of the cardiovascular system. The relatively slow scientific progress, at least clinically, in this area may be due to the fact that neither cardiologists nor neurologists felt competent in both topics. Furthermore, it has become increasingly difficult to have an overall view of the basic research and its clinical applications in this field. New research methods, based on a comtination of morphological, biochemical, and physiological techniques, have enabled the functional differentiation of various areas of the brain and subsequently also of the autonomic nervous system. The simple dualistic concept of an antagonistic sympathetic-parasympathetic regulation of the circulatory system is no longer valid. It is clear that numerous neurotransmitters, in particular the neuropeptides, are involved in a highly differentiated subdivision of the autonomic system. One of the aims of the IIIrd International Brain Heart Conference was therefore to supply a synopsis of the latest developments in basic research undertaken in this field by exceptionally competent scientists, to clinically orientated neurologists and cardiologists, and thus to provide new impulses for clinical research.