Civetta, Taylor, and Kirby's Critical Care, 4th Edition.  By Andrea Gabrielli, M.D., A. Joseph Layon, M.D., and Mihae Yu, M.D. Philadelphia, Lippincott Williams & Wilkins, 2009. Pages: 2,765. Price: $249.00.

Critical care medicine is a fascinating, ever-evolving discipline that requires a practitioner to make decisions based on rapidly changing information. Similar to all of medicine, it can be challenging to stay current as new research and information are being published almost daily. In the era of the Internet, acquisition and review of new information have become much easier. However, many clinicians and learners covet access to a comprehensive, hardcopy reference in addition to the web as an alternative source of learning.

Civetta, Taylor and Kirby's Critical Care  is a textbook that allows for both styles of learning. It is an impressive sight, measuring 3 in (6.6 cm) thick, weighing approximately 22 pounds (10.2 kg), and consisting of more than 2,700 pages! Unfortunately, it did not come with a gym membership!

This is the fourth edition and, consistent with the previous versions, both the editors and contributing authors represent significant national (>30 states) and (15 countries) international influences, with expertise in anesthesiology, general medicine, and surgery.

The size of the book is a preamble to its contents. The breadth of topics discussed is impressive with high clinical relevance. The book is divided into 20 general topic sections. It includes the core topics of general physiologic principles, monitoring, shock states, organ transplantation, cardiovascular disease/dysfunction, respiratory disorders, and infectious disease. Within each section, multiple chapters are presented to support the general topic. For example, infectious disease is supported by chapters on the approach to fever in the intensive care unit, and neurologic, catheter-related, and soft-tissue infections, as well as a discussion on treating the immunocompromised host.

Yet, there are topics that are not commonly discussed in other critical care texts. What I particularly found interesting was the inclusion of chapters on breaking bad news to patients and families, physician–nurse interactions, virtual intensive care units, and a succinct review of reading medical journals and understanding basic statistics. Another section is dedicated to the surgical patient. The chapters start with preoperative assessment and expand beyond the traditional topics of trauma-related critical care. There are chapters focused on the critical care of orthopedic, vascular, and thoracic surgical patients. Overall, the supporting chapters of each section are thorough and well written with good images and diagrams. All chapters provide robust lists of references.

There is an outstanding appendix that contain concise summaries of acid/base, common formulas, and a table outlining medication dosages based on renal function. There is also a brief discussion of medications (i.e. , paralytics, antihypertensives, and inotropes) that are commonly used in the intensive care unit. It summarizes the mechanism of action, indications, dosages, and most common concerns associated with administration. The final section focuses on typical antibiotics and describes the dosages and expected spectrum of coverage.

Besides the extensive topic list, an additional strength comes with the purchase of the book. An access code accompanies it allowing the user to access the entire contents via  the Internet. This is a very powerful and time-saving aspect, given its lack of portability and the increasing ubiquitous presence of the Internet.

Although a juggernaut in form and content, there are some weaknesses. Because of the mass of the book, I would suggest that future editions should be in at least two volumes. In addition, some of the photographs contained in the text would be greatly enhanced if provided in color. A color image of the purpuric rash seen in meningococcal sepsis would have a much better visual impact than black and white.

The Internet access feature is a major asset, but its search feature feels primitive. For example, if you type in “Xigris®,” it results in no hits. However, when you search “activated protein C” you get a number of hits, but the result list is not pleasing to the eye and slightly challenging to navigate. When comparing this with a search in the well-known Web site Up-To-Date®, the same search of “Xigris®” gives you multiple hits with many topics relevant to the search. Overall, the search engine is helpful, but not very intuitive. A period of familiarization is required to maximize its usefulness.

Overall, this is a great text that I believe would be a valuable reference to master clinicians, fellows, residents, and medical students with interest in critical care medicine. As a new intensivist, I found it a great resource, and over the review period, I used it as much as possible when addressing clinical questions. Its comprehensive topics with a searchable text feature and solid reference lists make it a great asset to any intensivist library. It offers to be a favorable resource that is suitable to a variety of learning styles.

Mayo Clinic, Rochester, Minnesota.