Transmediastinal gunshot injuries present the risk of immediately life threatening injuries. Stable patients have been evaluated by a combination of esophageal swallow and endoscopy, aortography and bronchoscopy. There is an increasing trend favoring CT scan. Unstable patients require immediate exploration, being prepared to enter both hemi-thoraces. Selected References: * Bergsland J, Karamanoukian HL, Soltoski PR, Salerno TA. Single suture forcircumflex exposure in coronary artery bypass grafting. Ann Thorac Surg.1999;68: 1428-1430. * Fedalen PA, Bard MR, Piacentino V, et al. Intraluminal shunt placement and off- pump coronary revascularization for coronary artery stab wound. J Trauma 200 1;50: 133-135 * Hanpeter DE, Demetriades D, Asensio JA, Berne TV, Velmahos G, Murraygunshot wounds. J Trauma 2000;49(4):689-695. * MacPherson D. Bullet Penetration: Modeling the dynamics and the incapacitation resulting from wound trauma. Ballistics Publications, EI Segundo, CA, 1994 * Wall MJ, Soltero E. Damage control for thoracic injuries, Surg Clin North AmI997;77(4):863-878. * Rozycki GS, Feliciano DV, Oschner MG, Knudson MM, Hoyt DB, Davis F, Hammerman D, Figueredo V, Harviel JD, Han DC, Schmidt JA. The role ofUltrasound in patients with possible penetrating cardiac wounds: aProspective multicenter study. J Trauma 1999; 46(4):543-552. * Roussseau H, Soula P, Bui B, D'Othee BJ, Massabuau P, Meites G, Concina P,Mazzerolles M, Joffre F, Otal P. Delayed treatment of traumatic ruptureof the thoracic aorta with endoluminal covered stent. Circulation 1999 Feb2; 99(4): 498-504.

Over the last two decades, the increasing use of noninvasive ventilation (NIV) has reduced the need for endotracheal ventilation, thus decreasing the rate of ventilation-induced complications. Thus, NIV has decreased both intubation rates and mortality rates in specific subsets of patients with acute respiratory failure (for example, patients with hypercapnia, cardiogenic pulmonary edema, immune deficiencies, or post-transplantation acute respiratory failure). Despite the increased use of NIV in clinical practice, there is still a need for more educational tools to improve clinicians knowledge of the indications and contraindications for NIV, the factors that predict failure or success, and also what should be considered when starting NIV. This book has the dual function of being a "classical" text where the major findings in the literature are discussed and highlighted, as well as a practical manual on the tricks and pitfalls to consider in NIV application by both beginners and experts. For example, setting the ventilatory parameters; choosing the interfaces, circuits, and humidification systems; monitoring; and the "right" environment for the "right" patient will be discussed to help clinicians in their choices."

This is an introduction to the patient monitoring technologies that are used in today's acute care environments, including the operating room, recovery room, emergency department, intensive care unit, and telemetry floor. To a significant extent, day-to-day medical decision-making relies on the information provided by these technologies, yet how they actually work is not always addressed during education and training. The editors and contributors are world-renowned experts who specialize in developing, refining, and testing the technology that makes modern-day clinical monitoring possible. Their aim in creating the book is to bridge the gap between clinical training and clinical practice with an easy to use and up-to-date guide. * How monitoring works in a variety of acute care settings * For any healthcare professional working in an acute care environment * How to apply theoretical knowledge to real patient situations * Hemodynamic, respiratory, neuro-, metabolic, and other forms of monitoring * Information technologies in the acute care setting * New and future technologies

th It is a great pleasure for me to open the jubilee 25 International Symposium on Blood Transfusion here in Groningen. This symposium is co-sponsored by the World Health Organization and is being held under the auspices of the ISBT and the Secretary General of the Council of Europe, Mr Walter Schwimmer. The patronage was granted with great pleasure for several reasons. First of all, Dutch experts are very active in our Committees and have largely contributed in developing the Council of Europe principles in the blood area. Secondly, the Council of Europe is active today in the area of blood transfusion due to a tragic event, which occurred in 1953 in the Netherlands; following a flooding many of the blood products given for assistance' could not be used due to incompatibilities and differences in labelling. Some words to present the Council of Europe since the organisation is sometimes confused with institutions ofthe European Union: The organisation has been founded in 1949 to establish the principles of democracy and rule of law all over Europe. Since 1989, the year of the fall of the Berlin wall and the opening up of the iron curtain, these principles could be extended to the countries of Central and Eastern Europe. Today this makes the Council of Europe the only pan-European organisation with 41 Member States thus representing more than 750 million people.

Infection Control in the ICU Environment provides the details of the most common infection control problems facing intensive care units. Authors include noted scientists, intensivists and epidemiologists from the United States and Europe as well as infection control experts from the Centers for Disease Control and Prevention. Acinetobacter, methicillin resistant staphylococcus aureus and vancomycin resistant enterococci are examined in detail. This volume also includes cutting edge information regarding the potential for prophylactic and pre-emptive therapy of fungal infections in intensive care units. Innovations in vascular catheter care and prevention of bloodstream infections are discussed in this volume as well as the newest information in mathematical modeling to understand the epidemiology and control of infections in intensive care units.

Brain resuscitation is the therapeutic intervention for critically ill patients with severe brain damage, particularly the types caused by ischemia and hypoxia. The The objective of the International Symposium on Brain Resuscitation held in Ube, Yamaguchi Japan October 31 to November 2 1988, and sponsored by Yamaguchi University and the Japanese Ministry of Education, was to review our recent progress in brain resuscitation and to discuss controversies both basic and clinical. To my knowledge, this symposium was the first held in Japan. Our understanding of neuronal dysfunction due to ischemic/hypoxic insults at organ, cellular, and molecular levels has advanced significantly in the last two decades. We had therefore intended that this international symposium should broadly cover the topics which are of interest to both basic researchers and clinicians. Three hundred and twenty-five attendants, including twenty scientists from eight different countries, actively participated in discussion and exchange of new ideas and thoughts concerning brain resuscitation. This book comprises the re ports presented during the symposium which consisted of two main parts: basic and clinical. Although one single meeting can never be expected to solve any problems, meetings often highlight areas of ignorance and problems which are ripe for solving. It has been hard to review all the papers because of the multi plicity of the discussed topics, but the overview on brain resuscitation by Profes sor Bo K. Siesjo and the summary by Professor J."

This aim of this book is to focus on a very common situation seen in medical practice, the acute catabolic state. This pathophysiological sit uation is rarely discussed as a separate entity, possibly because it is seen in all specialties of medicine and results from a great diversity of agents, insults, and diseases. It thus seemed to be high time to gather the most important and up-to-date knowledge on this entity, and the primary aim of the book is to offer a collection of updated information on the acute catabolic state. Another objective of the book is to make clear that, apart from the general response of the whole organism during the acute catabolic state, a series of organ-specific responses will also take place, which must also be considered during treatment. It has become very clear of these organ-spe from working on this book that current knowledge cific responses is very sparse and in some areas almost nonexistent; this book thus also focuses on the responses and changes which take place in different organs during the acute catabolic state and the inter action between these organs and their responses.

In spite of today's increasing body of knowledge in regard to central nervous func tion and/or the mode of action of centrally active compounds, little is done to monitor those patients which are at risk of cerebral lesions either in the OR or in the ICU. Due to the inconsistency of reports regarding the application and the benefits computerized EEG and/or evoked potential monitoring will bring to the clinician, physicians still are reluctant to get involved with a technique, which they think, will have little or no effect on the outcome of a patients well being. However, due to the development in computer technology, data acquisition and comprehension, it now is possible to monitor such a viable organ as the Central Nervous System (CNS) on a routine base without being a specialist in neurology or electroencephalography. Thus, the book is intended to guide the clinician to use BEG and evoked potential monitoring in a day to day situation, without going too deep into technical details. As an improvement of cerebral care is needed, various representative cases underline the interpretation of EEG power spectra and evoked potential changes in regard to the underlying clinical situation. It is hoped that this book will serve as a guide to anyone who considers cerebral monitoring a necessity in today's patient care. This may be the anesthesiologist, the intensive care therapist, the nurse anesthetist as well as the medical personnel in the lCU setting."

In recent years much enthusiasm and energy has been directed toward the development of human gene therapies, especially for inherited conditions and cancers. However, current gene transfer technology is limited in its transduction efficiency and ability to permanently and safely correct genomic defects. Thus the promise of gene therapy for these conditions is as yet unrealized. The progression of gene transfer technology will eventually surmount these limitations. Gene Therapy for Acute and Acquired Diseases includes selected examples of ongoing studies in molecular genetics that have the potential to evolve into human therapies for acute illnesses. These chapters are intended to highlight lesser known applications of gene therapy for acquired disorders. It is expected that human gene therapy trials for these conditions will be forthcoming in the near future, leading to previously unimaginable therapies. Thus, this first-ever book about gene therapy for acute and acquired diseases is intended to serve as a glimpse into the future.

A large number of cardiovascular diseases are accompanied by inflammation. This volume on the molecular basis of microcirculatory disorders gives a comprehensive summary of key steps in the inflammatory cascade. Leading investigators present a state-of-the-art analysis of the molecular determinants of leukocyte-endothelial cell adhesion, mechanotransduction in endothelial and inflammatory cells, mechanisms of cell activation, microvascular apoptosis with applications to ischemia-reperfusion in the brain, the heart and in venous disease, diabetes and hypertension. The book provides the latest thinking in these important cardiovascular problems, with the most contemporary literature and a look at the increasingly complex events during inflammation. Molecular biology tools, microvascular and modern bioengineering analysis are seamlessly integrated into the analysis of clinical problems. The book helps not only newcomers to gain entry into the interesting problems associated with microvascular disorders, but lays the foundation for the design of new therapeutic interventions.

Until recently, monitoring of cerebral blood flow and metabolism was an unattained goal. Determination of cerebral blood flow was limited to intermittent measurements and particularly difficult to perform in critically ill patients. Meanwhile there are techniques available, however, to monitor cerebral blood flow and cerebral oxygenation, both globally and regionally. Therefore we thought it worthwhile to discuss these new continuous techniques and to compare them with well-known techniques which discontinuously measure CBF. For that purpose, an international workshop with some leading experts in the field was held in October 1992 in Berlin. The workshop consisted of about 20 lectures, either reviews on a special topic, or latest results. These contributions were given by invitation and were extensively discussed. Unfortunately it is impossible to reproduce the discussions. On the other hand, all speakers delivered a manuscript promptly after the meeting so that we were able to edit them within a short time. Since monitoring of cerebral blood flow in intensive care is a rapidly growing and changing topic, the written contributions should be quickly available. Authors, editors and publishers have tried to come close to this ideal. As editors we would like to thank the authors and the publishers who enabled us to come out with this volume of the proceedings as early as possible.

In recent years much progress has been made in the field of neurochemical monitoring for the acutelly injured brain. The development of safe continuous microdialysis techniques coupled with microanalytical methodology can generate semi-continuous time profiles of the changes in numerous brain analytes such as lactate, glucose, pyruvate, excitatory amino acids, structural amino acids, indicators of free radical generation, cytokines, adenosine, and neuroprotective drugs. Descriptive studies have shown profound, prolonged, and severe abnormalities in many of the analytes measured and the next phase is to determine the effects of therapeutic interventions upon these parameters. This field of research has contributed tremendously to our understanding of pathomechanisms in acute human brain damage.

Pre- and post-operative care of transplant patients is an aspect of Critical Care Medicine in which most ICU physicians and nurses have received little or no formal training and are left to cope with this complex population with only incomplete 'on-the-job experience' as a guide. In response to this clinical knowledge gap, ICU Care of Abdominal Organ Transplant Patients provides a concise bedside resource fo intensivists, surgeons, and nurses caring for abdominal organ transplant patients before and after surgery. In a concise, practical style, the authors offer concrete solutions to questions and situations confronted by ICU clinicians. Chapters address general principles of immunosuppression, infectious complications, management, and nursing considerations, plus indications, approach to anesthesia, transplant procedure, and post-operative care for liver, kidney, pancreas, islet cell, and small bowel and multivisceral transplantation.

This volume contains contributions by well-known scientists and clinicians in the fields of microbiology, infectious diseases, physiology, internal medicine, surgery, anaesthesiology, and intensive care medicine. It provides an up-to-date overview of the mediators and pathophysology of sepsis and septic shock as well as the latest therapeutic approaches.

During the past twelve years, a course on critical care medicine has been sponsored by the Post Graduate Division of the University of Southern California School of Medicine in association with its Center for the Criti cally Ill. The content of each of the symposia has paralleled the evolution of critical care medicine as a recognized service specialty. The annual program was planned as a teaching session for physicians and allied medical personnel who sought to advance their involvement in this rapidly advancing field. A panel of highly regarded authorities on sub jects bearing on critical care medicine, faculty members of the USC School of Medicine, and staff members of our own Center for the Critically 111 at the Hollywood Presbyterian Medical Center serve as faculty of these symposia. Although the primary commitment of the organizers to maintain this as a teaching and demonstration session was not abandoned, the number of annual registrants progressively increased from fewer than 100 to more than 1200, gradually outstripping local hotel facilities in central Los Angeles. The symposium for the past two years has been held in the large and at tractive Anaheim Convention Center adjacent to Disneyland."

A multidisciplinary overview of techniques for monitoring acute head trauma patients is given in this book. It includes neuroimaging procedures (TCD, MRI, SPECT) and multiple neurophysiological approaches: EEG, videomonitoring and integrated computer systems with clinical applications. Results that have been obtained by using new drugs to protect the brain as well as progress made in recovering techniques are emphasized. The long-term consequences of acute lesions are also discussed. The relationship between acute and long-term seizures is studied in posttraumatic epilepsy cases, and the relationship between neurophysiological and long-term clinical patterns, especially in posttraumatic epilepsy, is discussed. The socio-economic costs of traffic accidents are analysed - based on data from epidemiological studies - and then compared with reported data.

Great progress has been made in the understanding and prevention of secondary brain damage from acute cerebral disorders, such as trauma and ischemia. Advances may be concerned in particular with better organization and logistics of preclinical emergency care, including rapid arrival of well-trained medical staff on the scene of an accident and of transportation to a competent hospital. Nevertheless, it is a safe assumption that development of secondary brain damage from both intra- and extracranial causes still represents a major factor for the final outcome in severe head injury. Thus, exchanges of experiences and information between various disciplines involved with this important clinical problem - trauma still assumes the number one position as a cause of morbidity and mortality up to an age of 45 years - may provide a basis for in-depth analysis of remaining problems as well as of methods of their solution. This exactly is the purpose of the present publication on concepts and findings pertinent for the general subject of secondary brain damage from various experimental as well as clinical viewpoints. An internationally high-ranking group of experts has been contributing to this collection of reviews on cerebral trauma and ischemia and its adverse sequelae, including cerebral exploration by most modern technologies, such as NMR spectroscopy or PET scanning, among others.

Despite a worldwide reduction in its incidence, stroke remains one of the most common diseases generally and the most important cause of premature and persistent disability in the industrialized countries. The most frequent cause of stroke is a localized disturbance of cerebral circulation, i.e., cerebral ischemia. Less common are spon taneous intracerebral and subarachnoid hemorrhages and sinus ve nous thromboses. The introduction of new diagnostic procedures such as cranial computed tomography, magnetic resonance imaging, digi tal subtraction radiologic techniques, and various ultrasound tech niques has led to impressive advances in the diagnosis of stroke. Through the planned application of these techniques, it is even possible to identify the pathogenetic mechanisms underlying focal cerebral ischemia in humans. However, these diagnostic advances have made the gap between diagnostic accuracy and therapeutic implications even greater than before. This fact can be easily explained. In the past, therapeutic studies had to be based on the symptoms and temporal aspects of stroke; it was impossible for early investigations to consider the various pathogeneses of cerebral ischemia. Inevitably, stroke patients were treated as suffering from a uniform disease.

Over the last 10 years the syndrome of severe acute renal failure has progressively changed in its epidemiology. It is now most frequently seen in critically ill patients, typically in the context of sepsis and multiorgan failure. This epidemiologic change has meant that intensive care physicians and nephrologists must now work in close cooperation at all times and must take many com plex issues of prevention, pathogenesis, and management into account that they did not previously have to tackle. Simultaneously, the last 10 years have seen the development of major technical and conceptual changes in the field of renal replacement therapy. There are now previously unavailable therapeutic options that provide physicians with a flexible and rapidly evolving armamentarium. The nutrition of these patients, previously limited by the par tial efficacy of renal replacement therapies, has also become more aggressive and more in tune with the needs of critically ill patients. Increased understanding of the pathogenesis of the multi organ failure syndrome has focused on the role of many soluble "mediators of injury" (cytokines, leukotrienes, prostanoids etc.). These molecules are likely to participate in the pathogenesis of acute renal failure. Their generation and disposal is also affected by different techniques of artificial renal support."

This book reviews the most recent developments in the patho- physiology and therapy of ventilatory failure. It contains contributions by twenty-five internationally recognized aut- horities on respiratory muscle function and investigators actively contributing to our knowledge of the cause, diagno- sis and therapy of ventilatory failure. Of particular inter- estare the descriptions of new modalities of partial and complete ventilatory assistance as well as new knowledge re- garding ventilatory control and fatigue during stressful breathing. The reader will find here a state-of-the-art re- view of the latest research and practical applications in this most critical area of intensive care medicine.

The period that followed World War II has witnessed a dramatic change in neurology. From being a discipline in which its partici- pants were castigated for being interested solely in diagnosis, usually of disorders of unknown causation without effective therapy, neurology has evolved into a highly active treatment- orientated subject. This transition is clearly reflected in the ap- proach to diseases of the peripheral nervous system, and to the Guillain-Barre syndrome (GBS) in particular. In a state-of-the- art review made in 1952, Elkington (1952) observed that no less than 56% of neuropathies remained undiagnosed, and amongst those of unknown causation he listed GBS. With intensive in- vestigation and follow-up, the proportion of neuropathies seen at tertiary referral centres which elude diagnosis is now as little as 13% (McLeod et al. 1984). Overall, of course, the proportion is even less. This change is partly because of the introduction of new diagnostic techniques and partly because of the application of the great expansion in knowledge evident throughout medicine. In this book, Professor Richard Hughes has assembled current information on GBS and related disorders, including chronic in- flammatory demyelinating polyneuropathy (CIDP), the existence of which was not appreciated until Austin's perspicacious study published in 1958. In the Introduction, Professor Hughes gives an account of the way in which recognition of the GBS emerged and matured, and shows that it followed, pari passu, with the realisation that paral- ysis and sensory loss may result from peripheral nerve disorders.

Individualized dosing regimens specific to the patient, infection, bacteria, and antibiotic can optimize outcome. Integration of pharmacokinetic and pharmacodynamic data, called dual individualization, can be accomplished through the use of AUIe. AUIC dosing has been shown to predict bacteriological outcomes, hasten clinical outcomes, reduce the emergence of resistance, and be cost-effective. MPC dosing has been shown to predict the emergence of resistant submutants. AUIC and MPC information can provide guidance as to when low doses can be used, and when higher concentrations are required. This strategy can ensure efficacy, minimize toxicity, reduce the opportunity for resistance to occur, and save money. REFERENCES I. Paladino JA. Streamlining antibiotic therapy: clinical application of pharmacokinetic and pharmacodynamic principles. J Osteopath Med 1991; 5: 16-25. 2. Liss RH, Batchelor FR. Economic evaluations of antibiotic use and resistance - a perspective: report of task force 6. Rev Infect Dis 1987; 9 (suppI3): S297-312. 3. Holmberg SO, Solomon SL, Blake PA. Health and economic impacts of antimicrobial resistance. Rev Infect Dis 1987; 9: 1065-78. 4. Sanders cc. Mechanisms responsible for cross-resistance and dichotomous resistance among the quinolones. Clin Infect Dis 2001; 32(Suppl I ):S 1-8. 5. Ballow CH, Schentag 11. Trends in antibiotic utilization and bacterial resistance: report of the NNRSG. Diagn Microbiol Infect Dis. 1992; 15(suppl):37S-42S. 6. Rice LB, Eckstein EC, DeVente J, Shlaes OM. Ceftazidime-resistant Klebsiella pneumoniae isolates recovered at the Cleveland Department of Veterans Affairs Medical Center. Clin Infect Dis 1996; 23: 118-24.

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."

This monograph focuses on splanchnic function in health and disease. It represents a distillate of the communication that took place at the First International Symposium of Applied Physiol ogy of the Peripheral Circulation, "Splanchnic Circulation: No Longer a Silent Partner." The individual chapters roughly follow the individual presentations and display in durable form the con cepts and importance that this symposium achieved. The concept for this annual symposium was the child of An tonio Artigas, who not only recruited sponsorship but also Jean Francois Dhainaut and me to help with the organization and work. We chose the splanchnic circulation as the peripheral cir culatory system to be presented first for many important reasons. Much new information has become available which demon strates, as the title of the symposium implies, that splanchnic function has major influence on the overall expression of health and disease in humans. All aspects of splanchnic physiology, it seems, have been rediscovered to be dynamic, important, and complex in their interactions within individual tissues and among remote tissues and organs. It is hoped that after having reviewed this monograph the reader will agree that the splanchnic circula tion and its organ systems are emerging as important aspects of critical illness and host-defense homeostasis."