Topics in Anaesthesia and Critical Care – serie

The critically ill patient in intensive care often has to face significant metabolic alterations caused directly by the illness or secondary by complications (i.e.infections, organ failure or sepsis). Situations of rapidly evolving altered metabolism are maintained by or can trigger complex hormonal reactions which in turn promote further metabolic derangements. Surgery or trauma patients and those afflicted by septic complications can present significant nitrogen loss with consequent altered protein, carbohydrate or lipid metabolism. Further knowledge regarding the pathophysiology of metabolism and how abnormal stimulation of pyhsiological mechanisms can alter the consumption of principal energy substrates is necessary for optimal care of patients with altered metabolic functions.

The anesthesia and intensive care in infants and children have assumed positions of primary importance in contemporary medicine. In these delicate sectors of medicine, clinical research activities must be continually supported by interdisciplinary collaborations. Neonatal and pediatric intensive care requires that all involved physicians, including the surgeon and anesthesiologist, be willing to work together as a team. However, coordination of the various pathophysiological and clinical aspects of neonatal and pediatric critical medicine is highly complex. A complete and current review of the anaethesia and intensive care of infants and children must include discussions of morbidity rates, so as to guide the clincians in choosing the diagnostic approach, as well as of monotoring techniques appropriate to support the therapeutic decision. Recent progress in intensive care medicine for infants and children has been significant.

Local regional anaesthesia and pain therapy represent two areas of common interest for all physicians. This is a study in functional anatomy and general pharmacology, including familiarity with local anaesthetics and analgesics. It provides knowledge of the mechanisms of action, efficacies and side effects of the relevant drugs, and an appreciation of possible drug interactions to evaluate eventual toxic effects. Local regional anaesthesia and pain management are being used increasingly in diverse medical specialities, including those requiring manual dexterity. In contemporary medicine correct evaluation of the medical outcome becomes essential, especially in relation to the cost-benefit balance, not only in terms of the resources consumed, also and more importantly for the quality of life of the patient.

Trauma has assumed a prominent role in contemporary medicine as an event that can significantly influence clinical variables such as morbidity, functional deficits and consequential disability, and mortality. Trauma is the principal cause of death in the population below 40 years of age in industrialized countries. Therefore, there is great interest in studying traumatic events from both the clinical and epidemiological viewpoints. The importance of trauma is exemplified by the fact that in many countries, the trauma patient is first treated in specialized trauma centers in which the diagnostic and treatment processes are facilitated by the 24 hour presence of personnel having interdisciplinary competences.

Management of the intensive care patient afflicted by respiratory insufficiency requires knowledge of the pathophysiological basis for altered functions. The etiology and therapy of pulmonary diseases, such as acute respiratory distress syndrome (ARDS) and chronic obstructive pulmonary disease (COPD) are highly complex. While physiologists and pathophysiologists work prevalently with theoretical modes, clinicians employ sophisticated ventilation support technologies in the attempt to understand the pathophysiological mechanisms of the pulmonary diseases which can present with varying grades of severity. Despite the availability of advanced technologies it is common to personalize the treatment protocol according to the patient's physiologic structure.Given the complexity and difficulties of treating respiratory disease, a strong collaboration between clinicians and physiologists is of fundamtental importance.

Dedicated to Camillo Golgi, a neuroscience pioneer, the volume deals with the process of diagnosis and the strategies of treatment of pain. The most recent data on the biochemical basis of neurotransmission are reported, and the results of updated researches in pain processing, either concerning the brainstem, the thalamus and the limbic system are analysed. The importance of the ethical aspect in decision-making during the treatment of terminally ill patients is underlined.

Infections contracted by patients constitute an important factor in the manage- ment of any hospital unit. For patients with weakened resistance due to trauma, after surgery and in intensive care, infection-related complications have a nega- tive impact on care quality indicators, specifically in terms of protracted hospi- talisation time, increased costs from complications and extended hospitalisation, and increased mortality rate. Effective strategies to prevent and treat infections are a priority in optimising the cost-effectiveness of care. Infection control, diag- nostics and targeted antibiotic therapy require an integrated epidemiological, microbiological and clinical approach. This is indispensable for critically ill patients, especially when the processes of infection and sepsis are supported by micro-organisms which are multidrug-resistant and difficult to root out. The importance of this subject has been demonstrated by a European obser- vational study on the prevalence of hospital infections in patients under intensive care.In this study, the prevalence of infections contracted in a "high-risk" envi- ronment was 21 %, while other studies have observed that the incidence of pneu- monia in patients undergoing artificial ventilation varied between 8% and 54%, with a median of 24%. These figures alone are enough to show the clinical impor- tance of the infective process and the need for continuous interdisciplinary updating and exchanges of experience.

In this book are discussed topics of particular importance to critical care cardiovascular diagnosis and management in the perioperative period. Chapter topics are the causes for heart failure; the pathophysiology of heart failure; coronary heart disease and ischemic preconditioning; hypertensive urgencies and emergencies; diagnosis of heart failure; preoperative cardiac risk assessment; hemodynamic monitoring in patients with heart failure; electrocardiography of heart failure - features and arrhythmias; pharmacologic management for patients with heart failure; devices for management of heart failure; pacemaker and internal cardioverter-defibrillator therapies; management of cardiopulmonary arrest; circulatory shock - anaphylactic, cardiogenic, haemorrhagic, septic; prevention and management of cardiac dysfunction during and after cardiac surgery; vasodilator therapy - systemic and pulmonary; and, thromboembolism and anticoagulation. This work represents an important update for anaesthesiologists, cardiologists, cardiac surgeons, emergency care physicians and intensivists caring for patients with acute, life-threatening cardiovascular afflictions.