James C. Eisenach, M.D., Editor.

Critical Care Medicine: Perioperative Management. By M. J. Murray, D. B. Cousins, R. G. Pearl, and D. S. Prough. Philadelphia, Lippincott-Raven Publishers, 1997. Pages: 424. Price:$125.00.

Critical Care Medicine: Perioperative Management is a textbook of 62 chapters divided in three major sections written by a multi-author team comprised largely of anesthesiologists. This newly written textbook offers an original and interesting approach to critical care medicine because of its main focus on perioperative treatment of critically ill patients. Anesthesiology has greatly evolved during the past decade, changing from a specialty consisting of taking care of patients in the operating room to a specialty that requires expertise in all aspects of perioperative medicine. Today, the anesthesiologist-perioperative medicine specialist should be able to perform an expeditious preoperative assessment of sometimes critically ill patients, to conduct careful intraoperative treatment of these patients, and to treat them during the immediate postsurgical period. In addition, the anesthesiologist-perioperative medicine specialist also provides care outside the operating room, including anesthesia services for diagnostic procedures, consultation for airway management, pain management, intravenous line placement, and acute treatment of “floor” and critically ill patients. To fulfill this job description, the modern anesthesiologist-perioperative medicine specialist not only has to be competent in all technical aspects of anesthesia but also must have deep knowledge of general medicine because all forms of disease are represented in the surgical patient.

The present textbook responds to some of the important questions the anesthesiologist-perioperative medicine specialist may have to answer while taking care of critically ill patients. It is divided in three major sections. The first section not only covers traditional topics such as basic intensive care unit organization, risk assessment and reduction in the preoperative period, and preanesthetic evaluation, but also includes novel and interesting chapters on quality management in the intensive care unit and on ethical and end-of-life issues. These innovative chapters are of particular importance for the young physician who is expanding his or her training in critical care medicine. This text also provides some new information for the established anesthesiologist-perioperative medicine specialist. For example, these chapters include a detailed analysis of the shift from the traditional quality-assurance activities to quality improvement as a new approach to evaluate patient care activities. This change in the approach to quality management is of particular interest because it will help to provide the most appropriate and cost-effective delivery of care to critically ill patients. The chapter on ethics and end-of-life issues provides a comprehensive discussion about the difficult ethical problems frequently encountered in critically ill patients. This excellent chapter also proposes some useful decision-making processes to include approaches to the very controversial and delicate question of physician-assisted suicide and active euthanasia.

A second and longer section is dedicated to organ-specific diseases in the perioperative period. This section discusses most of the problems the anesthesiologist-perioperative medicine specialist will face while treating critically ill patients during the perioperative period. The information provided to the reader is often up-to-date, including recent publications on sometimes scientifically controversial subjects. For example, the chapter on principles of cerebral protection provides not only information about the classical principles of physiology and pathophysiology of the cerebrovascular function, but also offers a comprehensive analysis of the newer potential pharmacologic and nonpharmacologic treatments for patients with acute head injury. Similar comments can be made for the chapter on thermoregulation control, a common but often underestimated problem in critically ill patients. Also, the chapter on evaluation of fever in the intensive care unit, a common but sometimes very difficult clinical problem, proposes a series of excellent and innovative workups to the anesthesiologist-perioperative medicine specialist. In contrast, some chapters of this section are somewhat disappointing. For example, the chapter on vascular access and cannulation consists of a lengthy text with few figures to describe the different techniques of arterial and venous cannulation. In addition, one of the figures describes the Allen's test performed before placement of a radial artery catheter. As stated by the authors themselves, this test is neither sensitive nor specific and therefore does not deserve such an emphasis in a textbook on perioperative medicine. A shorter text and more figures would have been significantly more useful to explain and demonstrate these cannulation techniques to the readers. Also, it would have been helpful to include a table describing the advantages and disadvantages of the different types of catheters available on the market. Similarly, in the chapter discussing the pathophysiology and management of cardiogenic shock, it is surprising that the description of the management of this clinical entity does not include a discussion about the several newer vasoactive agents. Rather, it only refers to classical drugs that have long been available (summarized in table 3).

Finally, the third section covers subspecialty critical care and specialized problems encountered in critical care medicine. This section consists of excellent chapters covering various topics, including endocrine emergencies, specific problems related to the critically ill obstetric and pediatric patients, and chapters on multiple trauma, burns, and poisoning.

The presentation of the topics is similar for all chapters of the textbook. Each chapter starts with a very useful list of key words and ends with a summary of key points. This approach gives some unity to a textbook written by many different authors and allows the reader to rapidly access to the essential information contained in the text of the chapter. The quality of figures and tables is good and consistent through the different chapters of the textbook. In addition, each chapter finishes with a paragraph entitled “Eye to the Future.” This is an interesting attempt to provide to the reader some insight into the current research on the particular subject discussed in the chapter or into new trends for the management of clinical problems. It is, however, unfortunate that the authors of several chapters have included only one or two sentences in their final paragraph (for example, chapters 23 and 61). In general, the citations of literature appear to be up-to-date and comprehensive despite the usual constraints to strictly limit their number in a textbook. The subject index is well organized and easy to use. Finally, the cost of this textbook is reasonable for the effort and information provided by the authors and editors, although its price ($125) may appear high to young physicians with limited financial resources.

Overall, this textbook consists of a number of superb and innovative chapters covering all area of perioperative medicine. This textbook will not only be useful to young physicians in training to become anesthesiologist-perioperative medicine specialists, but can also be strongly recommended to trained anesthesiologists as a general reference on specific perioperative medical problems concerning critically ill patients.

Jean-Francois Pittet, M.D.

Department of Anesthesia; Room 3C-38; San Francisco General Hospital; 1001 Potrero Avenue; San Francisco, California 94110