This major reference work is the most comprehensive resource on oncologic critical care. The text reviews all significant aspects of oncologic ICU practices, with a particular focus on challenges encountered in the diagnosis and management of the critically ill cancer patient population. Comprised of over 140 chapters, the text explores such topics as the organization and management of an oncologic ICU, diseases and complications encountered in the oncologic ICU, multidisciplinary care, surgical care, transfusion medicine, special patient populations, critical care procedures, ethics, pain management, and palliative care. Written by worldwide experts in the field, Oncologic Critical Care is a valuable resource for intensivists, advance practice providers, nurses, and other healthcare providers, that will help close significant knowledge and educational gaps within the realm of medical care for critically ill cancer patients.

Das 4. Heidelberger Symposium uber "Hamostase in der Anasthesiologie" hat es sich zum Ziel gesetzt, fachubergreifend die noch ungelosten Fragen in der Hamostaseologie offenzulegen und auf der Basis einer kritischen Wertung der bekannten Studien klare Handlungsanweisungen fur den praktisch tatigen Arzt zu geben. Die angesprochenen Themen sind haufig in der Klinik auftretende Probleme wie die perioperative Einstellung von Hamophilen, die Betreuung von Patienten mit Massivtransfusion, Protein Z-Mangel, Lungenembolie, Katheterthrombose und Probleme der Gerinnungsanalyse und die Sicherheit von Praparaten mit Gerinnungsfaktoren. Das vorliegende Buch hat es sich zum Ziel gesetzt, den Leser uber die neuen Entwicklungen zu informieren und Anleitungen zum praktischen klinischen Handeln zu geben.

Ein vertieftes pathophysiologisches Verstandnis der respiratorischen Insuffizienz und die technischen Entwicklungen der letzten Jahre haben die Beatmung, uber die reine Substitution bei Atmungsausfall durch zentrale oder periphere Atemlahmung hinaus, zu einer Therapie der respiratorischen Insuffizienz und pulmonaler Erkrankungen werden lassen. Es gibt heute ein breites Indikationsspektrum fur vielerlei Beatmungsverfahren, die von einfachen Atemhilfen bis hin zu komplexen, computergesteuerten Beatmungsmustern und zur Lungenersatztherapie reichen. Dieses Buch enthalt neben den pathophysiologischen Grundlagen eine systematische Darstellung der Verfahren und Gerate und gibt Anasthesisten und Intensivmedizinern wertvolle Hinweise fur indikationsgerechte Entscheidungen.

High quality critical care medicine is a crucial component of advanced health care. Completely revised and updated, Key Topics in Critical Care, Second Edition provides a broad knowledge base in the major areas of critical care, enabling readers to rapidly acquire an understanding of the principles and practice of this area of modern clinical medicine. Expanded to include the latest hot topics, the new edition puts an increased emphasis on recent reviews and contains added references to key landmark papers. Using the trademark Key Topics style, each topic has been written by an expert in the field and includes a succinct overview of the subject with references to current publications for further reading. The book provides a framework for candidates of postgraduate medical examinations such as FRCS, MRCP, and FRCA and a reference that can be consulted in emergency situations. New topics include: Critical illness polyneuromyopathy End of life care Inotropes and vasopressors Medical emergency team (outreach critical care) Status epilepticus Venous thromboembolism

This title introduces and examines a number of current debates in the UK in the accident and emergency speciality. It allows the practitioner to consider modern accident and emergency nursing and its implications for the practitioner and society.;This book should be of interest to qualified accident and emergency nurses, and to student nurses on Accident and Emergency.

A comprehensive survey of recent advances is given in this Update. The wide spectrum of experimental and clinical investigations include the pathophysiologic, diagnostic and therapeutic aspects.

Critical Care Clinicians can use general drug references (Micomedex, Lexicomp) for data on dosing of high-alert medications in special patient populations but these references are not available to all healthcare clinicians, they are expensive and they are not specific to high-alert medications or critically ill patients. Doctors, nurses and pharmacists in the hospital setting will benefit from having one resource with all of this information. The purpose of this reference manual would be to guide critical care clinicians on dosing of high-alert medications in special patient populations. The most important feature of the book will be a summary of primary literature using tables when possible. This will be useful to readers because currently a reference book does not exist that guides clinicians in these difficult dosing decisions.

Some data-analytic methods excel by their sheer elegance. Their basic principles seem to have a particular attraction, based on a intricate combination of simplicity, deliberation, and power. They usually balance on the verge of two disciplines, data-analysis and foundational measurement, or statistics and psychology. To me, unfolding has always been one of them. The theory and the original methodology were created by Clyde Coombs (1912-1988) to describe and analyze preferential choice data. The fundamental assumptions are truly psy chological; Unfolding is based on the notion of a single peaked preference function over a psychological similarity space, or, in an alternative but equivalent expression, on the assumption of implicit comparisons with an ideal alternative. Unfolding has proved to be a very constructive data-analytic principle, and a source of inspiration for many theories on choice behavior. Yet the number of applications has not lived up to the acclaim the theory has received among mathematical psychologists. One of the reasons is that it requires far more consistency in human choice behavior than can be expected. Several authors have tried to attenuate these requirements by turning the deterministic unfolding theory into a probabilistic one. Since Coombs first put forth a probabilistic version of his theory, a number of competing proposals have been presented in the literature over the past thirty years. This monograph contains a summary and a comparison of unfolding theories for paired comparisons data, and an evaluation strategy designed to assess the validity of these theories in empirical choice tasks."

This book presents a comprehensive survey in which internationally recognized experts discuss specific topics. The wide spectrum of experimental and clinical investigations include the pathophysiologic, diagnostic and therapeutic aspects. Update 1990 represents the series' continuous effort to combine the most recent developments in one reference source for all those involved in cardiology, internal medicine, pediatrics, anesthesia, intensive care and emergency medicine.

This book presents a comprehensive survey in which internationally recognized experts discuss specific topics. The wide spectrum of experimental and clinical investigations include the pathophysiologic, diagnostic and therapeutic aspects. Update 1989 represents the series' continuous effort to combine the most recent developments in one reference source for all those involved in cardiology, internal medicine, pediatrics, anesthesia, intensive care and emergency medicine.

In recent years, intensive care and emergency medicine have emerged as new medical specialties. Better understanding of acute illness and continuous advances in technology have fostered rapid development of new forms of therapy. This volume provides updates in this rapidly expanding field and includes various topics presented by recognized experts in the field.

Respiration is a unique topic among various subdisciplines of physiology. Physiolo gists and clinicians are now able to communicate quantitative functional properties of lung mechanics and gas exchange in the language of the engineer, physicist and mathematician. This is largely due to intensive and stimulating work during the last decades of brilliant minds in a handful of excellent schools in the international family of physiologists. Among these founders of respiratory physiology are a number of clinicians, and they have. taken significant ,part both in shaping the theoretical knowledge to clinical applicability and developing technical devices for diagnosis and therapy in pulmonology. However, the theory behind the evaluation of measure ments, and their interpretation in terms of clinical function tests, is so confusingly complex that the ordinary physician, not specifically trained in respiratory physiol ogy, finds himself unable to critically apply these techniques. We, therefore, need descriptions of respiratory physiology and of its clinical application presented in the language of the clinician. And that is what this book is meant to be. Written by an expert in electrical and biomedical engineering, and by an expert in intensive care medicine, this text constitutes an "operational manual" of clinical respiratory physiology. It does not intend to be another textbook of basic respiratory physiology or pathophysiology. This book not only addresses practical clinicians, particularly those of intensive care medicine, by describing the essentials of clinically relevant respiratory knowledge.

It has become increasingly difficult for the single clinician to cover the whole area of traumatology and particularly neurotraumatology. This is now a science with various specialized fields of research. The results are published in different and special journals, proceedings and books often not easily available to those responsible for the daily practical management of the patients with head injuries. Epidemiological investigations are necessary to evaluate the severity and frequency of accidents and injuries. Such studies will stress the importance of analysis of the causes and also the importance of prevention. They are useful for evaluation of the effects of injuries despite management. Moreover, the researchers of the different aspects may need some knowledge of other links in the chain of events at and after an impact. This is particularly evident with respect to the problems of accident and injury, their prevention, reduction, management and the presentation of the most important clinical features in each case for international comparisons. Therefore it is appropriate to let the different specialists briefly discuss and present their aspects of the subject. Moreover, it may facilitate and stimulate the clinicians in studying special fields of interest. This was the intention behind the "Scandinavian Symposium on Neurotraumatology" held in May 1985 in Gothenburg: - To accumulate wider knowledge for the neurosurgeon and better understanding between the researchers in various fields to the benefit of the coming and present patients. Sten Lindgren Contents Lindgren, S.: Introduction.

Discovery and Relative Importance of Continuous Arteriovenous HemofIltration Lee W. Henderson Continuous arteriovenous hemofiltration (CAVH) has seen a brisk upswing in popularity in Europe since its introduction by Dr. Kramer and colleagues from Gottingen, West Germany in 1977 [1]. In the United States, the technique re- ceived approval as a clinical tool from the Food and Drug Administration in April 1982. This approval flowed, in no small measure, from the extensive expe- rience reported from Europe and in particular West Germany [e. g. , 2, 3]. Reports of its clinical utility now have begun to appear in the United States [4]. Removal of excess total body water using synthetic membranes in an extracor- poreal circuit dates back to the work of Alwall and the artificial kidney that he designed which permitted utilization of a hydrostatic pressure gradient to moti- vate water flow across the membrane [5]. Kolffs original rotating drum with its unencased membrane required an osmotic driving force [6]. Hemofiltration, the use of the filtration process to remove uremic solutes with the artificial kidney, in analogy with the glomerulus, was reported in 1967 [7]. This was made possible by the availability of synthetic membranes with far higher hydraulic permeability (approximately 10 times higher) than conventionally used cellulosic hemodialysis membrane. Specific applications of these "high flux" membranes to the removal primarily of excess total body water followed shortly thereafter [8].

In spite of all the progress made by modern science and technology in penetrating the mysteries of nature and providing new possibilities for its transformation, we remain largely helpless in the face of such natural phenomena as earthquakes, tsunami, typhoons, floods, and droughts. Natural disasters occur suddenly, but with periodicity, and man has been confronted by their devastating consequences throughout history. The way people deal with these problems is primarily predetermined: by charac ter, by conditions, and by the social and economic development of society. Industri ous efforts to reconstruct nature, and exploitation of her resources, have brought about additional damage, and there is the apparent danger that our interference with the atmosphere and other areas such as climate, soil, and hydrology has initiated devastating processes which may well be irreversible. As a result, the effects of natural disasters, and all the ensuing repercussions, become ever more aggravating. Their scope becomes global, and for the time being we have no effective countermeasures at our disposal with which to fight them. The contemporary world, then, faces the interconnected and interdependent phenomena of ecological crises and natural disasters: the problem of protecting man from the environment, and the concurrent problem of protecting the environment from man."

The anesthetist-computer interface tends to be a problem for the utilization of computer systems for anesthesia. Ergonomic interface design with an emphasis on the coherency of the interface's static and dynamic structure may improve this situation. To investigate this proposition we developed an Anesthesia Information System (AIS) with a touch-sensitive monitor as the hardware-user interface. Basic data input and system control techniques were defined and implemented. Record keeping is integrated into the user interface. Ventilator control from the same interface is an additional feature for laboratory simulations. The system is being evaluated using a technique that simulates live operations. References Anthony J (1982) BAS - A major change coming in delivery. IEEE EMB 1 (1): 36-42 Apple HP, Schneider AJL, Fadel J (1982) Design and evaluation of a semiautomatic anesthesia record system. Med lnstrum 16 (1): 69-71 Arnell WJ, Schultz DG (1983) Computers in anesthesiology - a look ahead. Med Instrum 17 (6): 393-395 Bender HJ, Osswald PM, Hartung HJ, Lutz H (1983) On line - Erfassung haemodynamischer und respiratorischer GraBen in der Anaesthesie. Anaesth Intensivther Notfallmed 18: 37-40 Cooper JB et al. (1982) A graphics-tablet for data entry in computer assisted recordkeeping Proc.

The existence of a differential block is still part of the theory of regional anaesthesia. In 1980 it was described in detail by Cousins and Bridenbough in their standard work Neural Blockade. The theory of differential sensitivity of fibres in the peripheral nervous system essentially goes back to Gasser and Erlanger, who in 1929 established that when isolated peripheral nerves are electri- cally stimulated in the presence of increasing concentrations of co- caine, the compound action potentials of slow-conducting fibres are blocked before those of fast-conducting fibres show any measur- able changes. In man, regional anaesthesia begins subjectively with a feeling of warmth, objectively with a corresponding increase in skin tem- perature. There is then, in order of occurence, loss of sensation of cold, heat and pain, and pressure and touch, and fmally loss of voluntary motoricity. In recovery from anaesthesia, these return in the reverse order. The theory of differential block is by no means undisputed. In 1981, de Jong, commenting in Anesthesiology on the work pub- lished in that journal by Gissen et al. which showed a new sequence of differential sensitivity in the rabbit, wrote, "There remains plen- ty to be done yet before the book on differential nerve block can be closed".

The hemodynamic significance of the flow properties of blood was put into perspective only during the past decade. Advances in modern technologies today allow the quantitative analy- sis of the fluidity of blood and its components under conditions approximating the flow in vivo, particularly those in the microcirculation. The hematocrit is the most important of the determinants of blood fluidity (reciprocal value of blood viscosity); acute increases in the hematocrit exert deleterious effects on circulation and oxygen transport owing to impaired fluidity of blood. High viscosity of plasma due to hyper- or dysproteinemias initiates the microcirculatory dysfunctions in hyperviscosity syndromes. Furthermore, the fluidity or deformability of red cells might be critically diminished and therefore cause redistribution of blood elements and adversely affect the resistance to flow within the microvessels. In low- flow states blood fluidity most likely becomes the key determinant for microvessel perfu- sion, overriding the neural and local metabolic control mechanisms operative at physiological conditions to adjust blood supply to tissue demand. Microcirculatory disturbances are there- fore encountered whenever driving pressures are reduced, as in shock or hypotension, and distal to stenoses of macrovessels, but also in hemoconcentration due to plasma volume con- traction, polycythemia, leukemia, and dysproteinemia. Based on experimental studies exploring the possibilities and limitations, with regard to improving the fluidity of blood by reducing the hematocrit, the concept of intentional hemo- dilution has been introduced to clinical medicine.

In clinical anaesthesiology the inhalation anaesthetics halothane (fluothane), enflurane and - in recent times - forane got a renaissance in clinical application. The reasons are not only the ad vantages of volatile anaesthetics, but also the fact that the investi gations of pharmacodynamics and pharmacokinetics of Lv. narcot ics showed negative aspects. It was the aim of the organizers of the symposium to give a survey of the present state of knowledge on inhalation anaesthetics, which is as up-to-date, critical as well as detailed as possible. Furthermore it was the intention to evaluate the recent advances made in the field of basic research. The first section of the symposium in particular enters into the question of the toxicity of volatile anaesthetics as well as their mechanisms of action. In a second main part the influences on cardiovascular system and on microcirculation are discussed. Apart from the extensive discussion of the advances in knowledge in the field of cardiovascular pathophysiology, the focal point of the contribut ions is made up of those with anaesthesia in coronary heart disease and cardiac insufficieny as well as the contribution on interactions of inhalation anaesthetics with cardiovascular drugs. In the third and fourth section the influences of volatile anaesthetics on cerebral, hepatic, renal and pulmonary function are dealt with as well as questions concerning the clinical application. Particular attention is given to the important problems of indicat ion in patients belonging to the extreme age groups."

The recent development of the use of spinal opiates as a rational therapy for pain rests on clear and certain experimental data. We have long known the spinal cord to be a highly complex structure. Anatomical studies of the substantia gelatinosa have repeatedly demonstrated signs of massive synaptic interaction between primary afferents, descending pathways and intrinsic neurons. Yet, to date that knowledge, insofar as clinical therapy is concerned, has permitted us only to destroy certain connections within the spinal cord in the hopes that the substrate mediating pain could be anatomically differentiated from those which mediate other function. Though cordotomies are clearly effective under certain circumstances, they suffer from the fact the spinal cord is not organized in such an anatomically discrete fashion as is often times drawn in basic medical text. Rather, functions intertwine exquisitely and specific physical interventions are no more likely to produce a specific effect than smashing of the fmgertip with a hammer will produce just a loss of the fingernail. The development of specific therapies of the spinal cord has come about by our growing aware ness of the intricate organization of the pharmacological substrates associated with specific neural function."

bei cardio-chirurgischen EingrifIen U. Brenken, G. Karliczek und H. Oldenziel Einleitung 1 2 Seit einigen Jahren werden an unserer Klinik Etomidate und Piritramid aufgrund der gUn* stigen Mitteilungen in der Literatur [3-9, 12, 13, 15, 17] routinemae,ig zur Narkoseeinlei- tung fill Koronar- und Klappenersatzoperationen eingesetzt. In dieser Untersuchung sollte gezeigt werden, inwieweit auch bei schwerstkranken Herzpatienten Narkosen ohne wesent- liche Veriinderungen der Haemodynamik eingeleitet werden konnen. Entsprechende Unter- suchungen haben sich bisher auf den Vorgang der Schlafinduktion beschrankt. In Wirklich- keit umfae,t die Narkoseeinleitung Muskelerschlaffung, endotracheale Intubation und den Ubergang zur kontrollierten Beatmung mit meist Lachgas-Sauerstoff. Diesen Sachverhalt ha- ben wir in unserer Untersuchung mitberiicksichtigt Methoden Die Messungen erfolgten an 12 Patienten mit ernster Koronarsklerose und an 12 weiteren Patienten mit Herzklappenfehlern im klinischen Stadium III, III bis IV und IV der NYHA- Klassifikation. Die verwendeten Mee,methoden wurden an anderer Stelle eingehend be- schrieben [10]. Praemedikation: 10-15 mg Valium, kein Atropin. Unter Lokalanaesthesie wurde ein 7-F-Swan-Ganz-Katheter (KMA) eingebracht. Nach Messung der Basiswerte: Herzfrequenz, arterieller Blutdruck (Riva-Rocci), zentralvenoser Druck, Pulmonalarteriendmck und Cardiac Output (Thermodilution) wurde die Anaesthesie durch langsame Injektion von Etomidate 0,2-0,3 mg/kg in 30 Sekunden und Piritramid 0,3-0,5 mg/kg eingeleitet. Bis zur Intuba- tion unter Pancuroniumbromid (pavulon) 0,1 mg/kg in der 5. Minute wurden die Patienten tiber eine Maske mit 100% Sauerstoff beatmet. Nach der Intubation erfolgte die Beatmung mit dem Servo-Ventilator mit einem Lachgas/Sauerstoffgemisch (Fi0 = 0,5). Es wurde eine 2 endexpiratorische CO -Konzentration von 5% angestrebt.

W.F. List Unter einer praoperativen Ambulanz soll eine Organisationsform verstanden werden, die eine fruhzeitige praoperative Befunderhebung zur Feststellung der Anasthesiefahigkeit und des Anasthesierisikos durch Anasthesiologen ermoglicht. Chirurgische Patienten mit elektiven Eingriffen sollen entweder noch vor ihrer Spitalsaufnahme oder aber unmittelbar nachher in einer derartigen Ambulanz gesehen werden. Die Untersuchungen werden in eigenen Raum- lichkeiten der Anasthesieabteilung bzw. des Anasthesieinstitutes oder der Anasthesieklinik durchgefuhrt. Dadurch ist die Gewahr gegeben, dass der Anasthesiologe schon fruhzeitig mit dem chirurgischen Patienten in Kontakt kommt und alle notwendigen Befunde zur Feststel- lung der Anasthesiefahigkeit (Narkosetauglichkeit) und des Anasthesierisikos erheben kann. Zwischen 25 und 40 % unserer Patienten zeigen neben der chirurgischen Erkrankung noch medizinische Befunde, die beachtet werden mussen (Kyei Mensah et al. 1974). Das operative Risiko und die Operationsletalitat wird durch medizinische Begleiterkrankungen deutlich er- hoht (Goldman et al. 1977). Bisher war es doch so - jedenfalls in meiner Institution - dass praoperative Befunde vom chirurgischen Patienten selbst in mehreren Ambulanzen und Labors zusammengetragen werden mussten. Dann wurde sehr oft vom Chirurgen ein Internist angefordert, der die Ope- rationstauglichkeit meist bei "schonender Narkose" feststellt. Der Anasthesiologe sah die Pa- tienten erst am Vorabend der Operation. Eine oft sehr lange Liste von Patienten musste in kur- zester Zeit beurteilt und pramediziert werden. Nicht selten musste die Anasthesiefahigkeit auch noch mit unzureichenden Befunden abgeklart werden. Ein Absetzen der Operation fuhrte zu Schwierigkeiten mit dem Patienten, mit dem Operationsprogramm und dem Chirurgen.

Dieser Band ist die Fortsetzung von Beitragen internationaler Ex perten zur Physiologie und Pathophysiologie der ruckenmarksna hen Leitungsanaesthesien. Nachdem 1978 die Wirkung der Epiduralanaesthesie auf Kreis lauf und Atmung sowie auf die Stressreaktionen bei Operationen behandelt wurde, werden jetzt die Pharmakokinetik der Lokal anaesthetika, der Interaktion der Lokalanaesthetika mit Medika menten, die zusatzlich bei Regionalanaesthesien verabreicht werden und das Thromboembolierisiko bei Epiduralanaesthesie im Ver gleich zur Allgemeinnarkose angesprochen. Dabei wird insbesondere die klinisch wichtige Frage bespro chen, ob ruckenmarksnahe Leitungsanaesthesien bei Low-Dose Heparinisierung der Patienten durchgefiihrt werden durfen. AuEerdem wird der gegenwartige Stand der peripheren und ruckenmarksnahen Leitungsanaesthesien, vor aHem in den USA, aufgezeigt und mogliche neue Entwicklungen diskutiert. Diese Zusammenstellung soH dem Leser nicht das Lehrbuch ersetzen, sondern ihm einen raschen und umfassenden Dberblick uber den neuesten Stand der Entwicklung ermoglichen. Den Erfolg dieses Symposiums danken wir wiederum den in formativen und interessanten Beitragen der Referenten und Dis kussionsteilnehmer, sowie der groEzugigen Unterstutzung durch die Firma Astra Chemicals, Wedel/Holstein. Dusseldorf, im Oktober 1981 H.J. Wlist M. Zindler Inhaltsverzeichnis I. Pharmakokinetik der Lokalaniisthetika Vorsitz: B.G. Covino, Boston, USA und U. Borchard, DUsseldorf H. Stoeckel und P.M. Lauven Grundlagen der Pharmakokinetik . . . . . . . . . . . . . . . . . . . 3 Diskussion . . . . . . . . . . . . . . . . . . . . . . . .. . . . 11 . . . . . . B.G. Covino Pharmacokinetics of Local Anesthetics 12 Discussion . . . . . . . . . . . . . . . . . . . . . . . .. . . . 20 . . . . . . R. Dennhardt Pharmakokinetik und Metabolismus von Bupivacain ...... 21 Diskussion . . . . . . . . . . . . . . . . . . . . . . . .. . . . 30 . . . . . . L. Wiklund und A. Berlin-Wahlen The Influence of Liver Circulation of the Pharmacokinetics of Local Anaesthetics ... . . . . . . . . . . . . . . . . . .. . . 32 . . . . Discussion . . . . . . . . . . . . . . . . . . . . . . . .. . . . 41 . . . . . ."