Irwin and Rippe’s Intensive Care Medicine, Fourth Edition. By Irwin, Rippe, and Cerra. Philadelphia, Lippincott Williams & Wilkins, 1998. Pages: 2912. List Price: $225.00.

Intensive Care Medicine, in its fourth edition, remains one of the leading critical care textbooks and addresses both medical and surgical intensive care issues. This new edition comes as an attractive two-volume book. The binding seems more durable and of higher quality than its last edition. The pages are off-white, which is easier for the eye to read. It is also less bulky and heavy with nine fewer chapters and a reduction of 129 pages; however, the print is not  smaller and the pages are not  appreciably thinner. With this edition, new authors have been added as well as a few new chapters, while other chapters from the previous edition have been updated and several times two chapters have been consolidated into one chapter. For example, the section Pharmacology, Overdoses, and Poisonings is updated and condensed from 42 to 38 chapters. This has allowed the basic text to stay similar to the previous edition and yet remain a fresh, up-to-date, and comprehensive reference text.

The text begins with 30 chapters on various procedures and techniques used in the intensive care unit. Some of the chapters are almost identical to the previous edition. This is not a big deal, since really not much has changed in placement of central lines or arterial lines. However, the airway chapter could have been better updated. A huge picture of the optical stylet continues to be shown, which is unlikely to be used in the intensive care unit even by anesthesiologists, and no picture nor much discussion is given to the laryngeal mask airway, which should be a part of the nonanesthesiologist intensivist’s armamentarium. The intubating laryngeal mask airway can help in blind intubations. It facilitates placement of a larger endotracheal tube than the usual laryngeal mask airway, through which only a 6.0-mm endotracheal tube can be placed fiberoptically. The chest tube insertion and care chapter makes no mention of reexpansion pulmonary edema about which an intensivist should know. On the other hand, the chapters on methods of obtaining lower respiratory tract secretions in pneumonia is well written by a new author and completely updated. The chapters on tracheotomy, paracentesis and diagnostic peritoneal lavage, neurologic monitoring, and intracranial pressure monitoring have been significantly updated. The chapter on anesthesia for bedside procedures is likely to be welcomed by intensivists without an anesthesiology background. Overall, this section has consolidated the text and references, most of which have been updated to 1997. I find this section to be very useful for residents learning the various procedures. Next follow eight sections organized by organ systems.

Most of the chapters in the cardiovascular problems in the intensive care unit section are quite similar to the last edition; in fact, critical care of pericardial disease is identical whereas the chapter on syncope has been completely revamped and improved. The chapter on dissection of the aorta lacked any comment on the newer radiologic treatments such as endovascular stents. The section on coronary care is highly up-to-date in a rapidly changing field involving thrombolytics and interventional procedures. Likewise, the section on transplantation is well written, highly up-to-date, and includes the newest antirejection medications and latest survival statistics. A whole new chapter is dedicated to the liver transplant patient. The pulmonary problems in the intensive care unit section has been greatly updated and improved over the last edition and includes low-molecular weight heparin treatment for venous thromboembolism as well as other newer antithrombotic regimens. The acute respiratory failure chapter has added a segment on HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome that is important to know about, but is misplaced in this chapter. Although nosocomial pneumonia is briefly mentioned in the acute infectious pneumonia, ventilator-associated pneumonia is lacking mention and I look forward to an expansion in this area in the next edition. The extrapulmonary cause of respiratory failure remains one of my favorites. The renal section has been updated to include newer and ever changing anti-HIV drug dosing in the renal patient. The section on infections includes data on once daily dosing of aminoglycosides. Instead of a general review of patients with AIDS, there is a consolidated chapter addressing the critically ill patient with HIV and the problems most likely encountered in the intensive care unit. The section on nutrition has been thoroughly updated and consolidated. The multiple organ dysfunction syndrome has been appropriately placed under shock/trauma rather than nutrition even though gut mucosal barrier dysfunction likely plays a role in the development of multiple organ dysfunction syndrome.

In summary, the fourth edition of Intensive Care Medicine , which has been updated with newer references dating to 1997, is a multidisciplinary text edited by three well-known and experienced editors. It remains an excellent and comprehensive critical care textbook. It serves as a good reference for the physician involved in taking care of critically ill patients and provides a rather quick review of an issue not frequently dealt with. The editors have improved on an already excellent text, not an easy accomplishment. Although $225.00 seems pricey initially, it is worth it and is really only $0.07 per page.