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.

This book is a complete guide to the use of ultrasound in critical care. Beginning with an overview of ultrasound and its applications, the next chapters discuss basic physics of ultrasound, modes of ultrasonography, and Doppler imaging. The following sections cover the use of ultrasound in different critical care situations including for vascular access, in acute respiratory distress syndrome, for cardiac evaluation, in neurocritical care, in the ICU, and more. The book concludes with clinical case scenarios and guidance on infection control and legal issues in ICU sonography. The comprehensive text is further enhanced by more than 300 ultrasound images, figures and tables to assist learning. Key points Comprehensive guide to the use of ultrasound in critical care Includes discussion on basic physics and modes of ultrasound Provides clinical case scenarios and guidance on infection control Features more than 300 ultrasound images, figures and tables

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.

During the last decade a multitude of studies concerning the dynamic changes in cerebral blood flow (CBF), cerebral metabolic rate of oxygen (CMRO2), and intracranial pressure (ICP) in the acute phase after head injury have been published. These studies have been supplemented with studies of cerebral autoregulation, CO2 reactivity and barbiturate reactivity. Other investigations include studies of cerebrospinal fluid pH, bicarbonate, lactate and pyruvate. In this book experimental and clinical studies of the dynamic changes in CBF, CMRO2, CO2 reactivity and barbiturate reactivity are reviewed. The author's own clinical studies of the dynamic changes in CBF and cerebral metabolism are summarized and discussed, and the therapeutical implication as regards the use of artificial hyperventilation, sedation with barbiturate and mannitol treatment are discussed.

"A Quick Reference Text" Easy to read and practical in design, Neurocritical Care is the book specialists will turn to for quick reference. It concentrates on management problems, from diagnostic procedures to therapeutic strategies. Exact descriptions are given for treatment procedures, and it is easy to find the appropriate treatment for a given patient. "International Expertise" More than 100 authors from North America have contributed to the book. The different strategies used on either side of the Atlantic have been described, the sections on neuroimaging have been reviewed by a neuroradiologist. "Comprehensive in Scope" Both frequent and rare neurological diseases that may require critical care treatment and subjects of more general interest such as monitoring strategies, ethical problems, brain death and neurological disorders in internal medicine have been covered. Pathophysiology is also discussed, insomuch as it is important for understanding the treatment strategies.

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 first international symposium on brain edema was held in Vienna/ Austria in 1965 followed by altogether eight meetings since. The most recent was organized in Y okohama by the Department of Neurosurgery of the Musashino Red Cross Hospital, Tokyo. The continuing interest of both, clinicians and experimental scientists alike may be attributable to the fact that brain edema is a common denominator of many cerebral disorders, which under acute conditions threatens life and weIl-being of afflicted patients. Although progress in understanding as weIl as treatment can be recognized since 1965 many problems remain, particularly concerning the control of brain edema under acute conditions, as in trauma or ischemia. A quantum leap was the distinction of the cytotoxic and vasogenic brain edema prototypes as advanced by Igor Klatzo, providing for transition from a morphological to functional understanding now. The recent brain edema meetings were certainly benefiting from developments of both, molecular neurobiology on the one hand side and functional brain imaging at an ever-increasing resolution on the other, such as magnetic resonance imaging orpositron emission tomography. The international symposium in San Diego 1996 may witness further breakthroughs, hopefully also of effective treatment modalities. The symposium in Y okohama was dedicated to the "Legacy of 28 Years of Brain Edema Research" as a reminder of accomplishments as weIl as remaining challenges.

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.

Therapeutic Hypothermia will provide a review of the subject, in particular, resuscitative hypothermia and include known mechanisms of action and results from both mechanistic and outcome laboratory studies and clinical trials. Cooling methods and potential side effects of hypothermia will be addressed as well as recommendations for future laboratory and clinical research.

This volume will be of interest to both the researcher interested in therapeutic hypothermia as well as the clinician interested in the potential use of therapeutic hypothermia in their patient population.

From the viewpoint of a health economist, the intensive care unit (leU) is a particularly fascinating phenomenon. It is the epitome of "high-tech" medicine and frequently portrayed as the place where life-saving miracles are routinely wrought. But the popular imagina tion is also caught up in the darker side, when agonizing decisions have to be made to avoid futile and inhuman continuation of expen sive treatments. My analytical interests led me to approach these issues by asking what the evidence tells us about which leu activities are very bene ficial in relationship to their costs and which are not. This quickly translates into a slightly different question, namely, which patients are most appropriately treated in an leu and which not. Unfor tunately, it is very hard to answer these questions because it has pro ved very difficult to investigate these issues in the manner which is now regarded as the "gold standard: ' namely by conducting rando mized clinical trials or alternative courses of action. I think this is a pity, and I am not at all convinced that it would be unethical to do so in many cases, because there is wide variation in practice and ge nuine doubt as to which practices are best -the two conditions that need to be fulfilled before such a trial is justifiable."

Monitoring of Cerebral and Spinal Haemodynamics During Neurosurgery is a comprehensive description of subdural monitoring of intracranial pressure (ICP) during neurosurgery. It offers thorough analysis of a comprehensive database consisting of measurements of ICP, cerebral perfusion pressure and other relevant physiological data from more than 1,800 patients subjected to intracranial surgery at Aarhus University Hospital. Features of anaesthesia, both inhalation and total intravenous, are discussed, and measures to reduce ICP are described. A majority of the patients had supratentorial tumours, but the database also includes patients with infratentorial tumours and patients with no intracranial space-occupying lesions. A chapter is reserved for discussion of the special features of children with cerebral tumours.

Modern critical care is characterized by the collection of large volumes of data and the making of urgent patient care decisions. The two do not necessarily go together easily. For many years the hope has been that ICU data management systems could play a meaningful role in ICU decision support. These hopes now have a basis in fact, and this book details the history, methodology, current status, and future prospects for critical care decision support systems. By focusing on real and operational systems, the book demonstrates the importance of integrating data from diverse clinical data sources; the keys to implementing clinically usable systems; the pitfalls to avoid in implementation; and the development of effective evaluation methods.

Mr. Chairman, ladies and gentlemen, with great pleasure I like to welcome you in the cityofGroningen and hope that you will have an enriching and enlighten ing discussion on the conference theme on risk management in blood trans fusion. The organisation of this symposium aims at scientific networking by discussing in an international forum the most important themes of current interest in relation to the state of the art in transfusion medicine. Dr. Cees Smit Sibinga took the initiative in 1976 to start organising the blood bank symposia as they were named in the beginning. Without doubt these symposia have contributed considerably to the development of transfusion medicine. To illustrate the fact that these symposia came to my attention I recollect that I have attended the symposium in 1978, chaired by Dr. Leo Vroman, in my capacity in those days of alderman deputy mayor of the city. So, it has been a long time since. After having been away from Groningen for 18 years I have been inaugurated last week as a mayor and it is a plcasure to be again in your midst. The scries of annual symposia on blood transfusion have contributed to mark the city of Groningen on the map of the international scientific world. A great number of prestigious institutes all over the world involved in the development of transfusion medicine have linked to Groningen and we are proud of that."

Die Infektion ist nach wie vor ein gravierendes Problem bei der Behandlung brandverletzter Patienten. Erkenntnisse uber die Pathophysiologie des Verbrennungstraumas und der Sepsis zeigen neue Therapieansatze auf und stellen konventionelle Behandlungsschemata teilweise in Frage. Die neuen Erkenntnisse uber Pathologie und Pathophysiologie septischer Komplikationen, die Aetiologie der Infektion, Infektionswege und Infektionskontrolle stellt dieses Buch dar. Es bietet allen, die Verbrennungen medizinisch behandeln, Hilfestellung bei der taglichen Arbeit.

Sepsis is still the leading cause of death in surgical and general intensive care units. Although our knowledge of this complex syndrome has increased in recent years, it is still far from com- plete. New therapeutic approaches have been developed. Some did not fullfill the high expectations for their use in clinical prac- tice; others are still under clinical evaluation. is the aim of this monograph to offer basic information on the It etiology, definition, pathophysiology, prevention and therapy of sepsis and septic shock to both the clinician and the scientist. We believe that it presents an extensive overview that may help the clinician to better understand and treat sepsis and septic shock. We also hope that this work will give some directions for future research both in the clinical field as well as the laboratory. Jena, Berlin, Jerusalem, K.Reinhart February 1994 K.Eyrich C.Sprung TableofContents I.Definition/Prognosis Sepsis and Septic Shock: Update on Definitions (Jo-L.Vincent) 0 0 0 0 0 0 0 0 0 0 0 0 ******** 3 Clinical Manifestations and Prognostic Indicators in Sepsis (R.C.Bone) ...0 * * * * * * * * * * * * * * * * * * * 16 What Determines Prognosis in Sepsis? Evidence for a Comprehensive Individual Patient Risk Assessment Approach to the Design and Analysis of Clinical Trials (W.A.Knaus, D.P.Wagner, F.E.Harrell, Jr.

This book fills the void to provide a comprehensive review of the theoretical knowledge and scope of opioid pharmacotherapy in pain medicine. While the information provided is obtainable in other major texts already in print, the present format style plus the illustrations will make easy reading and fast accessibility of information on opioids available. Information provided is based on clinical practice rather than pure experimental for use in daily practice.