James C. Eisenach, M.D., Editor

The Critically Ill Cardiac Patient: Multisystem Dysfunction and Management. Edited by Vladimir Kvetan and David R. Dantzker. Philadelphia, Lippincott-Raven, 1996. Pages: 432. Price:$139.00.

The editors of The Critically Ill Cardiac Patient: Multisystem Dysfunction and Management state that the book is directed toward cardiologists in training and in practice. The editors believe that cardiology fellowship training does not place enough emphasis on the multisystem dysfunction that exists in critically ill cardiac patients. This book is intended to offer a state-of-the-art collaborative view of critical care management. Among the 50 contributors are academic cardiologists, anesthesiologists, internists, surgeons, obstetricians, pulmonologists, and radiologists.

The 417-page book contains 22 chapters covering a range of topics. Chapter 1 provides a cursory overview of the pathophysiology of cardiac failure. Presumably those with extensive cardiology training would require little review of this subject. Chapter 2 addresses assessment of the high-risk cardiac patient for non-cardiac surgery. This complicated and well-researched topic is adequately reviewed, and an algorithm for preoperative risk assessment is presented. However, as an anesthesiologist who commonly addresses issues of risk assessment with cardiologists, I would like to have seen a more comprehensive review of this topic. In addition, the comment that, “It is generally accepted that the negative inotropic action of general anesthetics makes spinal anesthesia preferable (when possible) for patients with severe left ventricular dysfunction,” is a gross simplification of a complicated issue. Chapter 21 provides a nice overview of the various models used for risk stratification of cardiac surgical patients, and Chapter 22 does an excellent job of summarizing post-myocardial infarction risk stratification.

Chapter 3 provides a summary of ventilatory support in cardiac failure with specific emphasis on the effects of intrathoracic pressure changes on ventricular function and venous return. No mention of some of the more contemporary methods of ventilatory support such as pressure support, reverse I:E ratios, or high frequency ventilation are made.

Chapters 4 and 5 summarize the basics of oxygen transport and delivery and of regional blood flow in critically ill patients. Chapter 6, entitled Cardiac Metabolism and Nutrition Support, offers a nice summary of cardiac metabolism but makes no specific recommendations on providing nutritional support.

Chapters 7, 8, and 9 review renal, abdominal, and neurologic disorders in critically ill patients. The genesis, diagnosis, and treatment of renal failure is well covered. Included is a summary of the various methods of hemofiltration and dialysis. The chapter on abdominal crises is concise and well written. The chapter on neurologic disorders addresses cerebral emboli and cerebral hypoperfusion as well as concurrent cerebrovascular and coronary artery disease. It also includes a short explanation of alpha-stat and pH-stat blood gas management during hypothermia. Contrary to what is stated in the chapter, neurologic outcome studies comparing alpha-stat and pH-stat blood gas management during hypothermia CPB have now been conducted. Similarly, a superficial treatment of DHCA is offered.

Chapter 10 provides a thorough review of the pathophysiology of septic shock. Chapter 11 provides some basic information on the transport of critically ill patients from one institution to another. Chapter 12 is a comprehensive overview of pharmacologic cardiovascular support and is a well-developed chapter. Chapter 13 provides a broad overview of the hematologic and coagulation abnormalities likely to be encountered in the ICU. Chapter 14 is a concise summary of the diagnosis and treatment of cardiac trauma.

Chapter 15 provides a comprehensive overview of the short- and long-term management issues associated with heart, lung, kidney, liver, and intestinal transplantation patients. The section on preoperative cardiac assessment of liver transplantation candidates is particularly good. Chapter 16 covers obstetric emergencies and is one the best chapters in the textbook. The cardiorespiratory changes of pregnancy are well covered, as is the significance of various cardiac lesions. Eclampsia and preeclampsia, amniotic fluid embolus, hemorrhage, artificial valves, and anticoagulation are all well covered. Chapter 17 provides an excellent review of commonly encountered cardiac toxicities in the ICU.

Chapter 18 is a review of ICU-based cardiorespiratory monitoring and is divided into two sections. The first section is devoted entirely to TEE. This section provides a basic overview. The second section covers respiratory mechanics. This section provides the basics needed to understand more comprehensive respiratory mechanics. Chapter 19 deals with the cardiac complications of invasive procedures and provides a broad overview. Chapter 20 covers critical care radiology, with emphasis primarily on chest radiograph and CT findings.

The textbook is well indexed, and the references are fairly current. There are ample illustrations, tables, and charts. Despite the fact that there are many contributors, the style of the book is consistent from chapter to chapter, and there is little or no redundancy.

Overall, this textbook would be most useful to cardiologists and cardiology fellows with little previous exposure to the critical care environment. As such, this text would provide a nice introduction. Those individuals desiring a more comprehensive textbook or those more actively involved in critical care medicine will want to purchase one of the standard critical care textbooks.

James A. DiNardo, M.D., F.A.A.P.

Department of Anesthesiology; University of Arizona Health Sciences Center; Tucson, Arizona 85724