James C. Eisenach, M.D., Editor

The ICU Therapeutics Handbook. By Paul E. Marik. St. Louis, Mosby-Year Book, 1996. Pages: 434. Price:$35.95.

For anesthesiologists and other physicians who work in intensive care units (ICUs), quick and easy-to-use reference materials are nice companions to put in the pockets of a white laboratory coat. This is the purpose of The ICU Therapeutics Handbook, written by an internist-intensivist at St. Vincent Hospital in Worcester, Massachusetts. It is an easy-to-read text of 434 pages, including the index, and its 66 chapters are divided into 8 sections: respiratory, cardiovascular, metabolic and endocrine, gastrointestinal, neurology, infectious disease, miscellaneous, and a brief humor section. The majority of ICU practice is reasonably well covered, albeit in brief or absent detail. Because of the book's nature and purpose, references are rarely mentioned. I found this to be a major liability, and a few references that the author thought were important could have been included on the final page of each chapter.

This book has several positive aspects. Many of the chapters had good diagrams that outlined various courses of management. This reduced the size of the written text and allows a junior house officer to quickly visualize different therapeutic options, depending on the patient's status. As the old adage says, “A picture is worth a thousand words.” Unfortunately, patients often do not follow the courses shown in diagrams. Figure 4(2), “Mechanical ventilation flow diagram,” was cumbersome to follow, but many others were quite succinct and lucid.

Part 1 is composed of 12 chapters that review respiratory critical care. Chapter 3, although only two pages, contains a table that lists many values and equations pertinent to respiratory physiology. The house officer who knows these can avoid that embarrassing silence that often follows questioning from a malevolent attending physician.

Part 2, The Cardiovascular System, is of great value to the house officer and those clinicians who infrequently treat cardiac problems. The sections on acute myocardial infarction and the treatment of tachydysrhythmias were well done. Hopefully, those physicians who are Advanced Cardiac Life Support certified will notice that the author deviated from following Advanced Cardiac Life Support guidelines in the chapter on cardiopulmonary resuscitation. Part 3, Metabolic and Endocrine Problems in the ICU, was well presented and should satisfy the practical requirements for most general intensivists. Chapter 27 contains a well written, yet succinct, review of renal failure and its treatment, including the newer modalities of continuous renal replacement therapy. In Part 4, The Gastrointestinal Tract, the topic of chapter 33 was gastrointestinal prophylaxis. This consisted of only a one-page diagram, but should have had discussion of the pros and cons of sucralfate therapy, antacids, and H-2 blocking agents. Part 5 adequately discussed basic neurology as seen in the ICU, and Part 6 had a reasonably broad review of infectious complications and therapy. Part 7 contained 20 chapters of miscellaneous topics, such as brain death, burns, and obstetric complications.

The problem with any single-authored text is the lack of review by one's colleagues or coauthors, and this was evident in the text. Basilar skull fracture is, to a vast majority of anesthesiologists, a contraindication to nasotracheal intubation because of the concern for placing an endotracheal tube into intracranial contents. However, the author states “this complication is exceedingly rare and probably related to poor technique.” Even if the reader agrees that this statement possibly may be true, how many house officers have good technique? Also, this book does not discuss what constitutes good versus poor technique. Phenylephrine is mentioned for treating hypotension after intubation. However, the recommended dose of 0.5–1 mg is potentially dangerous and capable of producing profound and sustained hypertension. When discussing T-piece weaning trials, the author states that the trial should be terminated if any of five physiologic abnormalities occur. Three of the five are appropriate, but most intensivists would agree that such a trial should be halted long before an ICU patient experiences a heart rate of 140 beats per minute or a systolic blood pressure of 180 mmHg. Hopefully, junior house officers will know this also.

Metered-dose inhalers are an effective means to deliver B-2 agonists when treating asthma, but they are not mentioned. In at least two places, the author suggests avoiding pancuronium for muscle relaxation because of its histamine release (which it does not do) and its propensity for producing tachycardia. Most anesthesiologists/intensivists are comfortable using pancuronium in critically ill patients when necessary, knowing that profound tachycardias are rare. In the chapter in which myasthenia gravis is discussed, the author warns that methoxyflurane, decamethonium, gallamine, halothane, and curare increase muscle weakness. This may be true, but the first three drugs have seen little if any use for 15 years, and the last two drugs now see little use, at least in the United States. (But perhaps I should not be too critical, because The Washington Manual of Therapeutics [28th ed, 1995] continues to list ether as a problem drug in myasthenia gravis.)

In conclusion, the concept of providing a brief and succinct synopsis of critical care that fits into a laboratory coat pocket is a laudable undertaking. This book has much in its favor, but the user should be aware of its deficiencies.

Robert A. Strickland, M.D., Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota 55905.