Improving standards of care is a real challenge in Intensive Care Medicine. Bettering clinical performance, patient safety, risk management and audit represents the cornerstone for raising the quality of care in ICU patients. Communication is the platform from where to start to reach a consensus in an extremely crowded area, a unique multidisciplinary and multiprofessional environment in which quality of care and, ultimately, patient survival need to be ameliorated.

In modern medicine the most functional methodologies are taking an increasing importance in spreading informations, rendering it credible while at the same time using reliable data to focus interaction between basic science and clinical medicine. Critical care medicine embraces these needs and more than any other discipline thrives and develops thanks to interdisciplinary contact.

APICE 2004 has been organised to provide precise answers to these issues. In particular, considerable emphasis has been given to the reviews regarding the most important aspects - or the most significant clinical developments - in the sectors involving variety of functions: neurological, respiratory and cardiovascular, gastrointestinal, metabolism and perfusion; trauma infections, sepsis and organ failure; perioperative medicine and life support techniques; information technology dedicated to clinical medicine, but also as a means of information and education. The contributing authors are all part of leading research groups at the international level in the various sectors presented in the volume.

by S. GUASCHINO Dean, Trieste University School of Medicine The society we live in is in continual development and has a number of priori ties for improving the standards of communication. The scientific sector in par ticular thrives on the exchange of information, which is the foundation of progress itself. The channels through which this interaction takes place are many and are aimed at optimising teaching methodology. Researchers and scholars, research centres and the places of higher learning themselves are increasingly aware of the growing importance of universities, which, thanks to their intrinsic ability to renew themselves, have taken on a vital central and propulsive role. Communication develops as a result of free exchange, debate of the materials available and the study of the various references and analysis sources. With the advent. of information systems, the teaching methodology has assumed a decisive role, both in terms of the quantity of data available and the quality of the information. Distance learning is a new and important opportu nity for the immediate future. The Anaesthesia and Critical Care School of Trieste has promoted this inter esting and highly relevant initiative by drawing together teaching material from the academic year 2003/2004. Numerous international lecturers have con tributed to this valuable achievement. In addition, a large part of the material is the fruit of a real consortium between the various Italian Schools of Anaesthesia."

Continuous update in critical care medicine is a real challenge due to the growing dimensions of its contents; these elements are the result of new research acquisitions, and of those clinical situations where the physician is able to intervene at a given moment, with the use of effective prevention techniques. They are also the result of new technologies able to define complex sub-clinical diagnostic aspects; lastly, they are the result of effective therapeutic techniques available, and of treatment strategies able to influence radically and positively the patient's clinical course. Critical care medicine is playing a key role in the most advanced environments, as it represents a cross-sectional field of action, involving several specialties, such as anesthesiology, general medicine, surgery, pediatrics.

Even if in the last years more information on sepsis and new treatments has become available, mortality rate is however high. In fact, the complexity of the several biohumoral factors involved in this process is difficult to understand. Another major problem is the consequent organ failure, which grows in a sequential way and in relation with the lesion gravity and the functional reserves of the patient. The volume presents the most recent results of research in this field.

The interest of researchers, clinicians, practitioners and surgeons in critical care medicine is growing. Clinical pharmacology and new technologies now allow more appropriate therapies, and the commitment of all those involved in this field is of fundamental importance for reaching high interventional standards, in both the prevention and treatment of critical conditions, but also for satisfying the concept of cost-effectiveness in critical care. In this volume advances in critical care medicine are described, including the application of new technologies in the clinical setting, the full integration of computers and informatics, and the continual training of physicians and technicians.

An experienced physician knows how to recognize a patient suffering from sepsis, but cannot accurately determine whether the patient will survive. Cardinal elements of the treatment for sepsis include specific antibiotic and vasoactive drugs, enteral and parenteral nutrition, artificial respiration, and optimization of the oxygen transport to tissues. Nonetheless, with a certain frequency, these techniques are insufficient to ensure the recovery of a critically ill patient, especially when it is necessary to overcome functional alterations subsequent to organ and vital-system overload. The key elements in the progression of the sepsis-MODS syndrome are tied to numerous factors. These include: the severity and location of the lesion; the patient's age; the remaining functional reserve; the presence of mediatory which may be stimulatory, inhibitory or both.

Sepsis represents a life threatening condition to ICU patients. The evolution of sepsis to severe sepsis or septic shock may occur in an unpredictable way. In the coming millennium the prevention and management of sepsis and organ dysfunction will present a real challenge for researchers and clinicians.

Trauma has assumed a prominent role in contemporary medicine as an event that can significantly influence clinical variables such as morbidity, functional deficits and consequential disability, and mortality. Trauma is the principal cause of death in the population below 40 years of age in industrialized coun tries. Therefore, there is great interest in studying traumatic events from both the clinical and epidemiological viewpoints. The importance of trauma is exem plified by the fact that in many countries the trauma patient is first treated in specialized "trauma centers," in which the diagnostic and treatment processes are facilitated by the 24-hour presence of personnel having interdisciplinary competencies. Trauma in this context consists of any acute, often unexpected, condition. Many of the medical difficulties associated with trauma occur in a relatively brief period that spans from the first call for help to the initiation of first aid measures. A correct approach depends on the availability of experienced personnel. The first measures of aid must guarantee, above all, the patient's survival. The most critical, initial phases of care to trauma patients are represented by the triad: first aid, triage, and transport. Specific morbidity indices, whether anatomical, func tional or mixed, are indispensable elements for monitoring a patient's clinical evolution. The immediate availability of "essential" drugs is imperative to con front the clinical situations that often present in the acute post-traumatic phase."

Sepsis is a syndrome or sometimes it is a clinical condition evoked by uncontrolled endotoxin-reactions. These pathophysiological alterations can disturb the organism's homeostasis leading ultimately to a condition of severe organ dysfunction which in itself means a bad prognosis for patient survival. In the last decades researchers and clinicians have been involved in process directed to a better understanding of the basic mechanisms of sepsis and MODS. The best goal will be the achievement of preventive measures and optimization of management in patients suffering severe infections and critical conditions. This objective represents a true challenge at the dawn of the XXI century.

L'obiettivo principale di quest'opera A] quello di fornire gli elementi piA significativi di aspetti clinici e di problematiche inerenti la medicina perioperatoria, la terapia intensiva e l'emergenza, tutti elementi che costituiscono il nucleo centrale nell'ambito della Medicina per acuti. Il volume A] diviso in sette parti, ciascuna delle quali A] indipendente dalle altre sebbene un unico filo conduttore venga mantenuto; tale caratteristica A] il frutto della fattiva e crescente collaborazione tra diverse Scuole di Specializzazione in Anestesia e Rianimazione del nostro paese - anche attraverso la loro interazione con personale medico altamente specializzato proveniente da diverse strutture di riferimento - con l'intento di migliorare gli standard della formazione specialistica. Grande rilievo viene dato al monitoraggio della funzione respiratoria e alle nuove tecniche di ventilazione artificiale, con particolare riferimento all'uso originale della ventilazione percussiva ad alta frequenza (VPAF). Nella seconda parte del volume vengono tra l'altro offerti dagli Autori importanti aggiornamenti sull'importanza di un attento monitoraggio clinico e strumentale del paziente postoperatorio, nonchA(c) delle tecniche di trattamento del dolore postoperatorio. I capitoli finali sono dedicati all'epidemiologia delle infezioni, alla prevenzione e al trattamento delle stesse, e all'efficacia della decontaminazione selettiva del tratto digerente.

In this book are discussed topics of particular importance to critical care cardiovascular diagnosis and management in the perioperative period. Chapter topics are the causes for heart failure; the pathophysiology of heart failure; coronary heart disease and ischemic preconditioning; hypertensive urgencies and emergencies; diagnosis of heart failure; preoperative cardiac risk assessment; hemodynamic monitoring in patients with heart failure; electrocardiography of heart failure - features and arrhythmias; pharmacologic management for patients with heart failure; devices for management of heart failure; pacemaker and internal cardioverter-defibrillator therapies; management of cardiopulmonary arrest; circulatory shock - anaphylactic, cardiogenic, haemorrhagic, septic; prevention and management of cardiac dysfunction during and after cardiac surgery; vasodilator therapy - systemic and pulmonary; and, thromboembolism and anticoagulation. This work represents an important update for anaesthesiologists, cardiologists, cardiac surgeons, emergency care physicians and intensivists caring for patients with acute, life-threatening cardiovascular afflictions.

Continuing medical education and specialty training procedures represent highly dynamical processes, with a continuously evolving content. The specific teaching methods available (micro-teaching, team teaching, mastery learning, simulation, and e-learning) are essential elements of this process to promote professional updating and teaching at the bedside, aimed at providing an excellent clinical practice. The didactic laboratory is the core of this process: teachers, students and the School must be able to integrate in order to encourage this trend, and following this trend, the Trieste School of Medicine has long recognised the importance of supporting educational aspects and teaching programmes that promote our discipline.

This volume is the result of the co-operation of the Trieste School of Medicine with experts at a national and international level who, in 2005, took part in seminars or micro-teaching sessions held at the Cattinara University Hospital.

Le condizioni di sepsi, sepsi grave e shock settico rappresentano i livelli gerarchici della risposta sistemica all'infezione normalmente causata da batteri in grado di determinare una condizione di disfunzione d'organo. Il quadro clinico e le citokine proinfiammatorie sono elementi importanti nella evoluzione della sepsi e l'elevato standard di cure rappresenta un elemento chiave per la sopravvivenza; in particolare il trattamento dell'infezione, la precoce stabilizzazione emodinamica e la terapia immunomodulatrice rappresentano alcuni dei punti cardine del trattamento della sepsi. Questo volume, frutto della collaborazione tra i maggiori esperti del settore, rappresenta il piu recente aggiornamento in materia."

The foundation of the World Federation of Societies of Anesthesiologists came to light in September 1955 after informal meetings had commenced in 1951 to explore the possibilities of a world body in anesthesia. The aim was and is: to make available the highest standards of anesthesia, pain treatment and resuscitation to all peoples of the world.

Appreciative that some of the founders were still around, able and willing, the WFSA Executive Committee (1998) agreed to commission this 50 years commemorative book to be published and presented to the national member societies on the occasion of the World Congress of Anesthesiologists 2004 in Paris, France, where the idea of the establishment of WFSA was germinated.

Sepsis evolution and organ dysfunction are still an enigmatic topic. Severe infection causes an important aggression of the whole body, and the so-called inflammation mediators play an important role in this evolution. It is however certain that the immune system is a key factor in sepsis progression. The volume focuses on some primary aspects such as the research of the rationale of the immune system activation during sepsis, on the molecular strategies available for ARDS treatment and on techniques of emofiltration and absorption of endotoxins through apheresis in the septic patient.

The end of the second millenium is distinguished for the increasing interest in the field of critical care medicine, not only among physicians and clinical scientists but also on the part of the mass media. This is an interdisciplinary area of medicine drawing upon the specialties of anesthesiology, internal medicine and surgery, and relying upon the essential contributions and support from basic research. Advances in critical care medicine depend on the application of new technologies to the clinic, the full integration of computers and informatics, the continual training of physicians and technicians, and the consideration of ethical issues in the clinical setting. Within this complex panorama of complementary approaches and viewpoints, it is apparent that critical care medicine is one of the best examples of evidence-based medicine.

Quest'opera vuole offrire ai cultori dell'anestesia un testo essenziale per approfondire l'importante tematica dell'anestesia e malattie concomitanti, privilegiando la trattazione degli aspetti legati alle patologie d'organo e sistemiche di piA frequente riscontro nella pratica clinica; l'attuale orientamento ha solide basi e mira a rafforzare la convergenza di vari specialisti in funzione del paziente. Lo scopo A] di valutare attentamente il rischio chirurgico e anestesiologico, ottimizzare gli standard di sicurezza e l'approccio clinico interdisciplinare.