Intensive care in childhood is a relatively new field of medicine. Due to major differences in physiology, many disciplines are involved in the care of the critically ill child. Apart from specific disease patterns, morbidity in direct relation to the stay in the ICU or the underlying disease mainly determine long term morbidity. Today we understand that the treatment of the critically ill child can have a great impact on the quality of life in adulthood. This book covers the whole spectrum of intensive care in childhood. It is based on the experience of leading specialists from the various fields involved in the treatment of these children.

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

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

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

The 1992 International Yearbook of Nephrology is the 4th in a successful series of yearly books updating practising nephrologists and nephrologists-in-training on rapidly changing areas of nephrology. We were encouraged to proceed in our editorial venture by reviews of the previous issues which have appeared in various Nephrology Journals. These reviews have pointed to the successful use of the International Editorial Board, the broad range of topics of current interest which have been covered and the comprehensive and practical nature of the reviews. The principal aim of the Yearbook remains to provide reviews which are more current than those which appear in Nephrology textbooks and which can be in the hands of the readers a few months after the authors have completed the manuscripts. The appointed authors are always experts in the field, who are asked to give an objective review of the topic, up-dating the readers on the world-wide literature and providing them with a complete, accurate and up-ta-date list of important recent references. We have decided to maintain the successful format of the first three issues. Thus, the volume will continue to be divided into sections; each section will continue to have a different primary focus every year, depending upon what is of greatest interest at the time.

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

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

The acute abdomen is one of the most frequent, most dangerous and most difficult problems that the diagnostic radiologist has to deal with. This comprehensive manual presents a clinico-radiologic approach to the use of diagnostic imaging techniques for acute abdominal conditions. Imaging techniques, radiologic symptoms and clinical conditions are treated separately. This lucid format, together with a detailed subject index, offer the reader a quick and reliable reference aid in daily practice. The text is clearly structured and concise in style, and provides helpful practical hints, including discussion of diagnostic pitfalls. It is supported by a wealth of illustrations covering native diagnosis, ultrasonography, computer tomography and angiography.

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

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

Nephrology, initially born as a small branch of medicine, has, in the last few decades, become an extraordinary large field of medicine. The recent development of renal medicine is mirrored by the numerous nephrological journals published, a natural consequence of the increasing number of basic and clinical research studies performed continuously all over the world. Undoubtedly the progress which has occurred in the different, specific fields of renal medicine has given rise to subspecialities which range from renal physiology and pathology to hemo- and peritoneal dialysis and renal transplantation. Even the diagnostic methodology in nephrology, very useful in the clinical practice, has become a speciality within the speciality. Thus, the problem for clinical nephrologists, as well as for internists, is to remain continuously up-dated in all fields of nephrology. Nephrology textbooks are published continuously and in great number. However, the time required for having authors appointed, chapters completed, manuscript edited, galley proofs corrected and the whole book printed makes many textbooks already out of date when they go on sale and their half lives are very short. On the other hand, nephrological journals are so many and the articles so numerous and detailed, that it is often impossible to rely on them for up-dating practicing clinicians.

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.

The simple reason for creating this book was my impression that the law is having an increasing impact on the practice of medicine. There is hardly a physician I know who has not been deeply troubled by legal problems professionally, economically, and most important of all, psychologically. The past decade has seen medical practice premiums steadily rising. Multimillion dollar verdicts have not been unusual. Having disregarded these vital issues for many years, physicians have suddenly become very aware of litigation-related problems. Having been interested for a long time in the logic ofthe law and the romance of legal research, I thought it would be useful to create a book that would result in the blending of great minds in law and medicine. It has been my long standing observation and belief that the approach of professors of medicine, and that of learned members of the bar and bench, when put together, produce unique results. Putting these views together has been the real challenge in editing this book."

Intracranial Pressure is a linking keyword, uniting various aspects of diagnostics and treatment of hydrocephalus, head injury, subarachnoid haemorrhage, and brain ischaemia. This volume contains selected papers presented at the XIth International Symposium on Intracranial Pressure and Brain Biochemical Monitoring, held in Cambridge, UK, in July 2000. Various clinical and experimental methodologies are discussed including multiparameter brain biochemical monitoring (including brain oxygenation, microdialysis and novel imaging techniques), assessment of cerebral autoregulation, measurement of brain compliance, etc. This state-of-the-art volume introduces neuroscientists into a world of new techniques, models, monitoring modalities but also theories and new concepts, which highlight directions for the further research and future clinical practice.

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 concise yet complete overview of the treatment of cardiovascular instability in the critically ill patient. The authors consider all aspects, ranging from basic physiology and pathophysiology to diagnostic tools and established and novel forms of therapy. The whole is rounded off with an integration of these principles into a series of clinically relevant scenarios.

There is a tendency of an increasing number of signals and derived variables to be incorporated in the monitoring of patients during anesthesia and in intensive care units. The addition of new signals hardly ever leads to thedeletion of other signals. This is probably based on a feeling of insecurity. We must realize that each new signal that is being monitored brings along its cost, in terms of risk to the patient, investment and time. It is therefore essential to assess the relative contribution of this new signal to the quality of the monitoring process; i. e. given the set of signals already in use, what is the improvement when a new signal is added? Beyond a certain point the addition of new information leads to new uncertainty and degrades the result (Ream, 1981) In the diagnostic process, it is possible to evaluate "result" in an objective, qualitative way. The changes in the sensitivity and specificity of the diagnosis as a result of the addition or deletion of a certain variable can be calculated on the basis of false negative, false positive, correct negative and false negative scores. Different methods for multiple regression analysis have been implemented on computers (Gelsema, 1981) which can support such decision processes. In monitoring, the situation is much more complex. Many definitions of monitoring have been given; the common denominator is that monitoring is a continuous diagnostic process based upon a (semi)continuous flow of information. This makes simple assessment methods useless.

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."

Serious disturbances of fluid and electrolyte balance are frequently encountered in acutely ill patients; somewhat less often in the chronically sick. There seems to be a trend for such cases to increase, due probably to an increase in major surgical procedures on older patients whose renal function is less than adequate. There are already many publications dealing with the physiology of the homeo stasis of fluid and electrolytes, and others dealing with the clinical aspects of the subject. It is often assumed that a knowledge of the basic principles of physiology will enable the doctor to prescribe suitable intravenous therapy. In practice this is often found not to be so and the evidence for this is the frequency of calls for help with electrolyte problems from well-qualified and experienced doctors who are undoubtedly equipped with adequate or even excellent knowledge of the basic It is not an unusual observation that knowledge of theory and principles involved. principles does not necessarily lead to successful practice in this or any other art or craft. Most doctors already possess knowledge of the physiology of the internal envi ronment, but some are aware of being unable to deal effectively with clinical problems related to fluid and electrolyte disturbances and seek guidance to translate theoretical knowledge into practice."

A comprehensive text of intensive care would readily fill the equivalent of the Shorter Oxford English Dictionary. This is because the diseases treated are both numerous and varied; thus the patient can be medical, surgical, trauma or obstetric. It follows that the sum total of knowledge which needs to be available is truly encyclopaedic. This compact volume represents only a fragment of such information. The contributors were chosen because of their experience and because their methods were well-tried. The text therefore summarizes the best of current therapy and includes the controversial. The contributors come from four countries, adding an international flavour. One topic - The Recovery Room - outside the confines of intensive care has been included for two reasons. The recovery room is an important but neglected aspect of care, and it also seems important to define its relationships with the intensive care unit. It is hoped that the book will help the nurses and doctors involved in intensive care and, therefore, the patient. ERIC SHERWOOD JONES Vll Contributors P. M. ASHWORTH K. CHATTERJEE Department of N . using * Medicine Cardiology Division University of Manchester University of California San Francisco Stop ford Building Cardiovascular Research Institute Oxford Road Manchester M 13 9PT, UK Moffitt Hospital Rm. 1186 San Francisco California 94143, USA S. T. ATHERTON Intensive Care Unit Whiston Hospital E. M. COOKE Prescot Department of Microbiology Merseyside, UK University of Leeds Leeds LS2 91Z, UK B. J. BAIN W. E.

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.

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 International Brain Hypothermia Symposium 2004was the second time I have had the honor of opening such a gathering on brain hypothermia treatment. It was a great pleasure to greet the participants in the hope that their valuablecontributions would make the Tokyo meeting memorable. Brainhypothermia has long been seen as a promising method that may overcome current limitations on brain resuscitation in patients with severe brain damage. However, although excellentresults have been obtained in experimental animal models, for some reason brain hypothermia has not alwaysbeen successful clinically, and resolving this problem has been a major challenge facing physicians specializing in brain therapies. The ICUmanagement of recent research has uncovered newmechanisms ofbrain damage not seen in animal models, including brain thermo-pooling at temperatures above 40 C in severe brain damage, masking neuronal hypoxia even with normal cerebral blood flow. Stress-related hyper glycemia with brain hypothermia was expected to generate useful results in patients with external injuries, cerebral occlusive stroke, and cardiac arrest. In recent clinical studies of brain hypothermia treatment, many excellent results began being reported on the manage ment of severe brain injury, ischemic stroke, and post-resuscitation after cardiac arrest. However, in clinical brain hypothermia treatment many questions remained about appro priate treatment targets, leu management technique, prevention of complications, control of brain tissue temperature, management of hypothermia insult, and mechanisms underly ing the onset of vegetative states."

Acute lung injury (ALI) impacts patient care in every ICU in the world. Our collective understanding of this condition has grown immensely over the past decade but morbidity and mortality remain unacceptably high. To enhance the understanding of clinicians and researchers, this book addresses the pathophysiology of acute lung injury from a molecular and cellular standpoint; includes animal models of acute lung injury and points to potential therapeutic advances based on scientific findings. It is a concise compendium of the multiple pathways, mechanisms and molecules involved in the pathophysiology of acute lung injury and is intended to help caregivers understand the process and thus care for patients more effectively.

Information is provided from the basic and clinical sciences on the mechanisms damaging the brain from trauma or ischemia. New aspects involve the endoplasmic reticulum, mitochondrial failure, pathobiology of axonal injury, molecular signals activating glial elements, or the emerging therapeutical role of neurotrophins. Experimental issues involve a better analysis of the ischemic penumbra, the salvagable tissue. Therapeutic contributions reach from the environmental influence to gene expression, including neuroprotection, such as hibernation - mother nature's experiment - or hypothermia which is reported to induce cell swelling. Treatment issues deal also with thrombolysis and combination therapies, or with the clearance of adverse blood components - LDL/fibrinogen - by a novel procedure using heparin. Other highlights are discussing the specificities of pediatric vs. adult brain trauma, or the evolving role of the Apolipoprotein-E e4 gene in severe head injury. An update is also provided on an online assessment of the patient management during the pre- and early hospital phase in Southern Bavaria. The empirical observation of neuroworsening is analyzed in further details, whether this is a specificity autonomously driving the posttraumatic course. Finally, the unsolved question why drug trials in severe head injury have failed so far in view of the promising evidence from the laboratory is subjected to an expert analysis.