Preface

The field of critical care has exploded since we last revised this textbook in 1998. In particular, the large number of high-quality clinical trials performed to elucidate mechanisms of critical illness and to guide clinical care has reverberated through ICUs around the world and generated tremendous excitement. A decade ago, intensivists managed patients based largely on an in-depth understanding of cardiopulmonary pathophysiology, coupled with a broad understanding of internal medicine, surgery, and a few related fields. The last decade has added to this a wealth of evidence revealing that there are better and worse ways to manage our patients. The modern intensivist must both master a complex science of pathophysiology and be intimately familiar with an increasingly specialized literature. No longer can critical care be considered the cobbling together of cardiology, nephrology, trauma surgery, gastroenterology, and other organ-based fields of medicine. In the 21st century, the specialty of critical care has truly come of age.

Why have a textbook at all in the modern era? Whether at home, in the office, or on the road, we can access electronically our patients’ vital signs, radiographs, and test results; at the click of a mouse we can peruse the literature of the world; consulting experts beyond our own institutions is facilitated through email, listserves, and web-based discussion groups. Do we still have time to read books?

We believe the answer is a resounding yes. Indeed, the torrent of complex–and, at times, conflicting–data can be overwhelming for even the most diligent intensivist. We have challenged our expert contributors to deal with controversy, yet provide explicit guidance to our readers. Experts can evaluate new information in the context of their reason and experience to develop balanced recommendations for the general intensivist who may have neither the time nor inclination to do it all himself.

A definitive text of critical care must achieve two goals: the explication of the complex pathophysiology common to all critically ill patients, and the in-depth discussion of procedures, diseases, and issues integral to the care of the critically ill. The exceptional response to the first two editions of Principles showed us that we succeeded in meeting these goals. In this third edition, we have made numerous changes in line with the tremendous evolution in our field. We have deleted the illustrative cases and their discussion to make room for exciting new chapters dealing with catastrophe-preparedness, therapeutic hypothermia, interpreting ventilator waveforms, adrenal dysfunction, telemedicine, biowarfare, intravascular devices, angioedema, massive hemoptysis, and evidence based prophylactic strategies, among others. The changing nature of our patients and increasing recognition of complications following critical illness by weeks, months and years spawned chapters on obesity in critical illness, chronic critical illness, long-term outcomes, delirium, and economics of critical care. We have completely revised many chapters to keep pace with changing concepts in nutrition, myocardial ischemia, airway management, ARDS, severe sepsis, cardiac rhythm disturbances, pericardial disease, status epilepticus, intracranial hypertension, blood transfusion, acute renal failure, acid-base disorders, electrolyte disturbances, gastrointestinal hemorrhage, fulminant hepatic failure, cirrhosis, mesenteric ischemia, gastrointestinal infections, coma, care of the organ donor, toxicology, dermatologic conditions, sickle cell disease, hypothermia, and hyperthermia. Finally, a former colleague, Dr. V. Theodore Barnett, an intensivist with extensive experience in the melting pot of Hawaii, has contributed an introduction that reminds all of us of the challenges and opportunities we face when dealing with our multicultural patients and their families.

We have collected up front many of the issues of organization which provide the foundation for excellent critical care as well as topics germane to almost any critically ill patient. The remainder of the text follows an organ system orientation for in-depth, up-to-date descriptions of the unique presentation, differential diagnosis, and management of specific critical illnesses. While we have made many changes, we have preserved the strengths of the first two editions: a solid grounding in pathophysiology, appropriate skepticism based in scholarly review of the literature, and user-friendly chapters beginning with “Key Points.”

We attempted to preserve our vision and approach in the third edition of Principles of Critical Care by contributing approximately one fourth of the total chapters ourselves and recruiting associate editors and colleagues who share our vision concerning academic critical care. In general, we are convinced that clinical scholarship in critical care is conferred by balanced involvement in both management and investigation of critical illness, so we invited two associate editors who actively deliver intensive care and publish about it. Our selection of associate editors having a shared spirit was considerably aided by our having practiced, researched, published, or taught with both.

Dr. Jameel Ali is a Canadian trauma surgeon actively involved in providing and teaching ATLS and critical care in North America. His wide range of publications on critical care topics addresses mechanisms in basic science journals such as the Journal of Applied Physiology and clinical investigations in the best surgical and medical journals. From this base in surgical critical care and its considerable overlap with anesthesiology and medicine, Dr. Ali coordinated most of the chapters aimed at essential surgical aspects of critical care and those related to the gastrointestinal system, while authoring (or co-authoring) four chapters himself. Dr. Keith Walley is another Canadian intensivist who combines basic and clinical investigation with his practice and teaching of critical care. He helped organize the sections covering general management and cardiovascular diseases and contributed two chapters himself.

We have encouraged our contributors to state cautiously and with experimental support their diagnostic and therapeutic approaches to critical illness, and to acknowledge that each approach has adverse effects, in order to define the least intervention required to achieve its stated therapeutic goal. With the help of our associate editors, our review process was closer to that enforced by excellent peer-reviewed journals than that encountered by most contributors of invited book chapters. We hope the attendant frustrations and revisions of the authors provide a better learning experience for the readers.

Our approach to patient care, teaching, and investigation of critical care is energized fundamentally by our clinical practice. In turn, our practice is informed, animated, and balanced by the information and environment arising around learning and research. Clinical excellence is founded in careful history taking, physical examination, and laboratory testing. These data serve to raise questions concerning the mechanisms for the patient’s disease, upon which a complete, prioritized differential diagnosis is formulated and treatment plan initiated. The reality, complexity, and limitations apparent in the ICU drive our search for better understanding of the pathophysiology of critical care and new, effective therapies.

We enjoy teaching principles of critical care! We came to our affection for teaching the diagnosis and treatment of critical illness through internal medicine, albeit by different tracks. Two of us (JH, GS) were educated at the University of Chicago’s Pritzker School of Medicine and Internal Medicine Residency before serving as chief medical residents in 1981 and 1985, respectively. The other (LW) graduated in medicine from the University of Manitoba in Winnipeg, Canada, completed a PhD program at McGill University in Montreal in the course of his internal medicine residency, then joined the critical care faculty in Winnipeg in 1975. There, critical care had a long tradition of effective collaboration among anesthesiologists, internists, and surgeons in the ICU and in the research laboratories. When we three began to work together at the University of Chicago in 1982, our experience in programs emphasizing clinical excellence combined with our questioning, mechanistic approach to patients’ problems to help establish a robust and active clinical critical care service with prominent teaching and research activities. Our teaching program was built upon the components of: 1) an understanding of underlying pathophysiology; 2) a state-of-the-art knowledge of current diagnosis and management of problems in the ICU; 3) a familiarity and experience with the tools and results of basic and clinical investigation in critical care; and 4) an appreciation of the issues and methods of ICU organization and management. We have attempted to make this text incorporate just these components in its explication of the principles of critical care, and hope that the text continues to be a well-received and valued extension of our teaching methodology beyond the confines of the University of Chicago.

In addition to our associate editors and individual authors, others too numerous to mention facilitated the completion of this book. We are especially indebted to our own students of critical care at the University of Chicago who motivate our teaching – our critical care fellows; residents in anesthesia, medicine, neurology, obstetrics and gynecology, pediatrics, and surgery; and the medical students at the Pritzker School of Medicine. Our colleagues in providing critical care within the section, Edward Naureckas, John Kress, Brian Gehlbach, John McConville, Imre Noth, and Kyle Hogarth, combine with others in our institution such as Michael O’Connor, Avery Tung, Axel Rosengart, Jeffrey Frank, Michael Woo, Patrick Murray, and Lawrence Gottlieb, to make our practice of interdisciplinary critical care at the University of Chicago interesting and exciting.

Even with all this help, we could not have completed the organization and editing of this book without the combined efforts of many at McGraw-Hill. Our editors have guided this group of academic physicians through the world of publishing to bring our skills and ideas to a wide audience, and we are thankful for their collaboration.

Finally, the revision of a book such as this one is a major adventure that could not succeed simply through the efforts of its senior authors, nor the considerable contributions of our many colleagues, nor the meticulous work of its publisher. This book would never have seen the light of day without the untiring support of Cora D. Taylor, our editorial assistant, a remarkable colleague who guided all of our efforts through the day-to-day difficulties of writing this text. To this task she brought organization, persistence, and a sense of humor that delighted and aided all who were fortunate enough to work with her. We especially acknowledge her contributions, without which we would not likely have overcome the innumerable impediments during the three years of revising this book.