Intensive Care Practitioners Research Articles

Accuracy of ChatGPT responses on tracheotomy for patient education.

To investigate the accuracy of information provided by ChatGPT-4o to patients about tracheotomy. Twenty common questions of patients about tracheotomy were presented to ChatGPT-4o twice (7-day intervals). The accuracy, clarity, relevance, completeness, referencing, and usefulness of responses were assessed by a board-certified otolaryngologist and a board-certified intensive care unit practitioner with the Quality Analysis of Medical Artificial Intelligence (QAMAI) tool. The interrater reliability and the stability of the ChatGPT-4o responses were evaluated with intraclass correlation coefficient (ICC) and Pearson correlation analysis. The total scores of QAMAI were 22.85 ± 4.75 for the intensive care practitioner and 21.45 ± 3.95 for the otolaryngologist, which consists of moderate-to-high accuracy. The otolaryngologist and the ICU practitioner reported high ICC (0.807; 95%CI: 0.655-0.911). The highest QAMAI scores have been found for clarity and completeness of explanations. The QAMAI scores for the accuracy of the information and the referencing were the lowest. The information related to the post-laryngectomy tracheostomy remains incomplete or erroneous. ChatGPT-4o did not provide references for their responses. The stability analysis reported high stability in regenerated questions. The accuracy of ChatGPT-4o is moderate-to-high in providing information related to the tracheotomy. However, patients using ChatGPT-4o need to be cautious about the information related to tracheotomy care, steps, and the differences between temporary and permanent tracheotomies.

Point of care ultrasound for triage of critically ill patients in the emergency department

Point of care ultrasound (POCUS) has been a constantly evolving and growing tool utilized by emergency medicine and intensive care practitioners. Ultrasound use for the assessment and management of critically ill patients has been available for several decades with the focused assessment with sonography in trauma (FAST) exam being one of the first widely adopted POCUS protocols. This along with other established protocols has made an impact on the care delivered to critically ill patients. This narrative review will cover some of the history of POCUS in the emergency department, brief considerations for machines and infrastructure, and current uses including in trauma, shock/hypotension, cardiac arrest, dyspnea, abdomen, vascular, and procedural guidance. Furthermore, it will provide a review of the evidence supporting its efficacy in managing critically ill patients and future directions.

Beyond the incubator: applying a "one health" approach in the NICU.

A "one health" approach recognises that human health, animal health and planetary health are closely interlinked and that a transdisciplinary approach is required to fully understand and maintain global health. While, by necessity, Neonatal Intensive Care has traditionally focused on the acutely unwell newborn, the avoidance of long-term harm is core to many management decisions. The COVID 19 pandemic and climate crisis have brought into sharp relief the importance of a "one health" approach as part of long-term health promotion in the holistic care of neonates, who may survive to experience the burden of future environmental crises. This narrative review seeks to integrate what we know about "one health" issues in the neonatal intensive care unit, notably antimicrobial resistance and climate change, and suggest "everyday changes" which can be utilised by practitioners to minimise the impact of neonatal intensive care on these global health issues. Many of the changes suggested not only represent important improvements for planetary health but are also core to good neonatal practice. IMPACT: Neonatal patients are likely to bear the burden of future environmental crises including pandemics and climate related disasters. While the focus of intensive care practitioners is acute illness, awareness of "one health" problems are important for our smallest patients as part of preventing long-term harm. High quality neonatal care can benefit both the planet and our patients.

Development and Validation of a Nomogram Prediction Model for Multidrug-Resistant Organisms Infection in a Neurosurgical Intensive Care Unit.

To develop a predictive model for assessing the risk of multidrug-resistant organisms (MDROs) infection and validate its effectiveness. Logistic regression analysis revealed that sex, hospitalization time, febrile time, invasive operations, postoperative prophylactic use of antibiotics, mechanical ventilator time, central venous catheter indwelling time, urethral catheter indwelling time, ALB, PLT, WBC, and L% were independent predictors of MDROs infection in the NICU. The area under the ROC curve for the training set and validation set were 0.880 (95% CI: 0.857-0.904) and 0.831 (95% CI: 0.786-0.876), respectively. The model's prediction curve closely matched the ideal curve, indicating excellent predictive performance. The prediction model developed in this study demonstrates good accuracy in assessing the risk of MDROs infection. It serves as a valuable tool for neurosurgical intensive care practitioners, providing an objective means to effectively evaluate and target the risk of MDROs infection.

Right Care, Right Now: Bringing More Critical Care to Boarding Patients in the Emergency Department.

Right Care, Right Now: Bringing More Critical Care to Boarding Patients in the Emergency Department.

Intellectual ventilation modes in Russian Federation: a short questionnaire survey

INTRODUCTION: There are a lot of clinical trials about benefits of closed-loop ventilation modes, which are able to automatically adjust certain respiratory settings. These studies describe safety, reliability and advantages of intellectual modes over conventional ventilation modes. OBJECTIVE: To assess awareness of Russian intensive care practitioners about closed loop ventilation modes and availability of these modes in routine practice. The second aim was to explore difficulties and problems that arise for practitioners during work with these modes. MATERIALS AND METHODS: A short survey conducted with online and offline questionnaire. The survey consisted of nine questions regarding the application of closed-loop modes, some question has open answers. RESULTS: The response rate of the survey was 33 % (248 of 750). Most of respondents (85 %) have heard about closed-loop modes, and 52 % had access to these technologies in routine practice. But only 23 % of respondents use Adaptive Support Ventilation (ASV) and analogues as primary mode in their routine practice, 9 % point to Intellivent-ASV®, less than 1 % point to PAV + TM (Proportional Assist Ventilation) and nobody point to NAVA (Neurally Adjusted Ventilatory Assist) and Smart Care®. Over half of respondents (62 %) from clinicians who have access to this technology pointed to the lack of knowledge about closed loop modes; 60 % pointed to insufficient education and 40 % pointed to the lack of equipment. These facts demonstrate the necessity of additional educational programs for implementation of modern technologies in practice, need for organization of post customer service for respirators and provision of consumables in some hospitals. CONCLUSIONS: this questionnaire showed that 85 % of practitioners have heard about closed-loop ventilation modes, and half of them had access to these technologies in routine practice, but just 30 % regularly use one of these technologies.

An international survey of adherence to Surviving Sepsis Campaign Guidelines 2016 regarding fluid resuscitation and vasopressors in the initial management of septic shock.

Our survey aimed to evaluate adherence to Surviving Sepsis Campaign (SSC) Guidelines 2016 among intensive care practitioners and to identify issues that remain controversial or lack clarity. Members of the European Society of Intensive Care Medicine (ESICM) were surveyed using an anonymous web-based survey written by an international group of experts. The primary outcome measure was the rate of adherence to specific recommendations. Secondary outcomes were to describe areas of controversy and lack of data and to associate specific practices with clinician characteristics. Overall 820 questionnaires were completed. The SCC recommendations 2016 most adhered to were the choice of norepinephrine as first-line vasoactive drug (96.5%), vasopressor prescription based on therapeutic goal rather than dose (83.4%), targeting a specific mean arterial blood pressure during vasopressor use (77.9%), monitoring of blood pressure invasively (62.8%) and adding vasopressin or epinephrine as a second vasoactive agent (83.4%). We identified an internal conflict with regards to parallel versus sequential administration of fluids and vasoactive drugs and regional differences in practice that may be related to drug availabilities. The use of vasopressors and fluid use in septic shock is largely compliant with current guidelines but several controversies should be addressed in future guideline iterations.

The Different Challenges in Being an Adult Versus a Pediatric Intensivist.

OBJECTIVES:There is little current research comparing stress, burnout, and resilience in pediatric and adult intensive care practitioners. This article analyzes data derived from a 2018 qualitative study of burnout and resilience among ICU providers to explore differences that may exist between the pediatric and adult domains of practice.DESIGN:This study represents a thematic subanalysis of textual data derived from a larger qualitative study of ICU provider burnout and resilience.SETTING:Six international critical care units (Australia, Israel, United States).SUBJECTS:Physicians working at the above sites who had been practicing as intensivists for a minimum period of 4 years.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:Data were collected using a semistructured interview process, and resulting transcripts were analyzed using postpositivist framework analysis. A secondary analysis was then performed separately on pediatric and adult datasets using the initial coding framework as a template. Three themes related to perceived differences were noted: differences in the patient characteristics within both cohorts, differences in the relationships between staff and family, and personal biases of individual intensivists. Pediatric and adult practitioners differed in their perceptions of the patient’s perceived responsibility for their illness. Emotional responses to the stressor of child abuse (particularly as they related to clinician-family relationships) also differed. The stress of dealing with family expectations of patient survival even in dire circumstances was unique to the pediatric environment. Both pediatric and adult practitioners commented on the perceived difficulty of assuming the opposite role. Differences in life expectancy and mortality rate were significant factors in this.CONCLUSIONS:Although similar stressors exist within each group, meaningful differences in how these are perceived and personally processed by individual clinicians exist. Better understanding of these differences will assist attempts to enhance the resilience and provide career guidance to aspiring intensive care clinicians.

Impact of Extracorporeal Membrane Oxygenation Service on Burnout Development in Eight Intensive Care Units. A National Cross-Sectional Study

This study aimed at investigating the effects of an extracorporeal membrane oxygenation (ECMO) service on Burnout syndrome (BOS) development in the intensive care unit (ICU). The authors conducted a cross-sectional descriptive study. Eight ICUs within 5 tertiary hospitals in 1 country. Intensive care practitioners (nurses, physicians, and respiratory therapists). Using an online questionnaire, the Maslach Burnout Inventory Human Services Survey for Medical Personnel. In addition, demographic variables, workload, salary satisfaction, and caring for COVID-19 patients were assessed. Participants were divided based on working in an ICU with ECMO (ECMO-ICU) and without (non-ECMO-ICU) ECMO service, and burnout status (burnout and no burnout). The response rate for completing the questionnaire was 36.4% (445/1,222). Male patients represented 53.7% of the participants. The overall prevalence of burnout was 64.5%. The overall burnout prevalence did not differ between ECMO- and non-ECMO-ICU groups (64.5% and 63.7, respectively). However, personal accomplishment (PA) score was significantly lower among ECMO-ICU personnel compared with those in a non-ECMO-ICU (42.7% v 52.6, p=0.043). Significant predictors of burnout included profession (nurse or physician), acquiring COVID-19 infection, knowing other practitioners who were infected with COVID-19, salary dissatisfaction, and extremes of workload. Burnout was equally prevalent among participants from ECMO- and non-ECMO-ICU, but PA was lower among participants in the ICU with an ECMO service. The reported high prevalence of burnout, and its predictors, requires special attention to try to reduce its occurrence.

RAND appropriateness panel to determine the applicability of UK guidelines on the management of acute respiratory distress syndrome (ARDS) and other strategies in the context of the COVID-19 pandemic

BackgroundCOVID-19 has become the most common cause of acute respiratory distress syndrome (ARDS) worldwide. Features of the pathophysiology and clinical presentation partially distinguish it from ‘classical’ ARDS. A Research and...

Target Temperature Control in Patients with Burns

Severe burns lead to a persistent hypermetabolic response of the organism with significantly increased resting energy turnover, multi-organ dysfunction, muscle breakdown and increased risk of infection. Elevated core and skin temperatures are characteristic. A further increase in the metabolic rate can be triggered by heat losses, for which these patients are particularly predisposed due to high heat dissipation via evaporation of moisture and impairment of the thermoregulatory and insulating properties of the burnt skin. This is especially true in all treatment situations with exposure to large, uncovered skin surfaces, such as primary care, dressing changes in the intensive care unit and surgery with extensive sterile operating field. It has been shown that hypothermia is associated with numerous risks for the burn patient. Consistent heat management with measurement of the core body temperature and application of external and internal heat protection measures is recommended. Traditionally, an increase in room temperature is used here. However, this effective measure is limited by the resilience of the intensive care practitioners and the surgeons. To avoid perioperative hypothermia, strict surgical planning with limitation of the duration of surgery and close intraoperative communication about the risk of hypothermia are of particular importance.The differentiation between accepted temperature increase and infectious fever is often only possible by the inclusion of further examination findings. The criterion for sepsis is a temperature above 39 °C or below 36.5 °C.

Editor's Choice Articles for May.

I am very pleased to be presenting a new issue of Pediatric Critical Care Medicine (PCCM). Here are another three Editor’s Choice articles, but with a difference. If there is a theme, it is that these articles with their supporting content and editorial materials, together provide a wealth of new clinically relevant information. The first article is about hyperoxia during cardiopulmonary bypass and its association with greater odds of morbidity and mortality (1). The second article reports a framework for compassionate end-of-life endotracheal extubation at home (2). My third choice describes the feasibility of implementing a new tool for serial neurologic assessment in pediatrics (SNAP) in critically ill patients (3). All three articles (1–3) and related editorial material (4–7) will be freely available for the next two months. GIVEN RECENT INTEREST IN HYPEROXIA DURING CRITICAL ILLNESS, IS HYPEROXIA DURING CARDIOPULMONARY BYPASS SURGERY ASSOCIATED WITH OUTCOME? Beshish AG, Jahadi O, Mello A, et al: Hyperoxia During Cardiopulmonary Bypass is Associated With Mortality in Infants Undergoing Cardiac Surgery (1). This article describes a single center, retrospective study of 469 infants, half of whom had hyperoxia (arterial partial pressure of oxygen above 313 mm Hg) during cardiopulmonary bypass. The authors demonstrate an association between hyperoxia and various outcomes after controlling for covariables. In response to this information–and unique to PCCM this month–we have two items of editorial material to guide us as we read this report. Our editorialist discusses the research findings in the context of other literature, what they mean, and what readers should not do with this new information (4). The other readers’ supporting item is our first Statistical Note in the new section of PCCM Notes, Methods, and Statistics (5). Here, our editorialist uses this single center, retrospective study of hyperoxia as a vehicle to discuss confounding and causality in observational studies, and the criteria we should use to better understand the meaning of such research findings. It is definitely worth the time studying these three articles together. WHAT ARE THE INTRICACIES OF DECISION-MAKING AROUND END-OF-LIFE, COMPASSIONATE, EXTUBATION AT HOME? Woodruff AG, Bingham SB, Jarrah RJ, et al: A Framework for Pediatric Intensivists Providing Compassionate Extubation at Home (2). This article describes the framework in which to prepare, plan, and provide compassionate end-of-life extubation at home. The idea started with the authors’ response to a local need, followed by them developing an evidence-based framework for practice. Now, they share their work, clinical framework, and checklist so that other pediatric intensive care practitioners can adapt and use these materials for similar needs. Figures 1 and 2 in the article are a wonderful resource. Our editorialist provides us with an international perspective and a much-needed introduction to some of the legal, ethical, and cultural aspects of such end-of-life care (6). HOW FEASIBLE IS A STANDARDIZED, MODIFIED NEUROLOGIC EXAMINATION IN THE PICU? Kirschen MP, Smith KA, Snyder M, et al: Serial Neurologic Assessment in Pediatrics (SNAP): A New Tool for Bedside Neurological Assessment of Critically Ill Children (3). The third article describes the new beside SNAP tool, which can be used to summarize the neurology of critically ill patients with artificial airways, pharmacological sedation, or developmental disabilities. Our PCCM authors again give us unique materials: the three SNAP assessment scoring criteria panels are particularly useful (see Figures). The editorial places the SNAP tool feasibility study in the wider context of neurologic scoring systems (7). For example, over recent years we have seen the latest iteration of the Glasgow Coma Scale score (8) and other scores, but all for older pediatric or adult patients. Is SNAP the groundbreaking pediatric critical care standardized neurologic assessment tool that we have been waiting for? My three Editor’s Choice articles are not just good reads, but also have important materials to watch out for. The hyperoxia article (1) has a statistical note (4). The article about an aspect of end-of-life care has usefully illustrated a framework and checklist that can be adapted for local use (2). The article about the SNAP tool has highly practical information panels of age-related criteria (3).

Physician Compensation in the United States – Through the Lens of the MS Neurologist

Purpose of review: To explore the elements that are typically considered when determining physician compensation in the United States and to examine if the compensation of neurologists with expertise in multiple sclerosis (MS) care is commensurate with that for other neurological specialists and medical specialists that also employ complex therapies, e.g., oncology. Recent findings: The complexity in the diagnosis and management of MS requires increasing specialization. Additionally, changing models for the delivery of MS care has resulted in the MS neurologist generating significant contribution margins. In fact, the revenue to compensation ratio for the MS neurologist may be significantly higher than that of any other discipline in neuroscience service lines. However, while the contribution margin is often a key justification of compensation of interventional and intensive care practitioners in neuroscience service lines, it is generally not considered in the MS neurologist's compensation. Compensation models for MS neurologists typically depend heavily on the absolute number of relative value units associated with evaluation and management (E&M) codes making other fields of neurology financially more attractive to trainees. Summary: In considering the shortage of MS specialists, the demands of their discipline, and the revenue to compensation ratios, the MS neurologist is significantly undercompensated relative to other neurological specialists and to physicians in other disciplines. Compensating the MS neurologist appropriately and supporting the necessary infrastructure for MS care will likely attract more trainees to this discipline and help reverse the current scarcity of MS neurologists in the United States.

Ventilator Mode Finder: An Android application to find equivalent of a mode on different ventilators.

There are hundreds of ventilator modes on different ventilators. Despite different names, many are similar in functions and options. Educational institutions only teach a limited collection of ventilator modes of a few numbers of models; therefore, graduates may have substantial difficulties encountering new ventilator models with unfamiliar mode names on them. In this article, an Android application for finding similar modes on different ventilators is presented. The aim is to help an intensive care practitioner to easily find a familiar mode on a new ventilator.

Multimodal brain monitoring following traumatic brain injury: A primer for intensive care practitioners.

Traumatic brain injury (TBI) is common and potentially devastating. Traditional examination-based patient monitoring following TBI may be inadequate for frontline clinicians to reduce secondary brain injury through individualized therapy. Multimodal neurologic monitoring (MMM) offers great potential for detecting early injury and improving outcomes. By assessing cerebral oxygenation, autoregulation and metabolism, clinicians may be able to understand neurophysiology during acute brain injury, and offer therapies better suited to each patient and each stage of injury. Hence, we offer this primer on brain tissue oxygen monitoring, pressure reactivity index monitoring and cerebral microdialysis. This narrative review serves as an introductory guide to the latest clinically-relevant evidence regarding key neuromonitoring techniques.

Enteral Nutrition In 6 Malaysian Intensive Care Units: A Point Prevalence Study of Prescription Practices

INTRODUCTION: Enteral nutrition (EN) is the first line of nutrition therapy for critically ill patients with an intact gastrointestinal tract. Even though intensive care units (ICUs) generally have established feeding protocols, prescribing practices to achieve nutrition goal is still widely variable among intensive care practitioners. The aim of this study was mainly to investigate commonly prescribed types and energy concentration in EN formulations including protein prescription. MATERIALS AND METHODS: This was an observational, point prevalence study, involving six level 3 ICUs in Malaysia. All patients aged type of EN formulation and protein prescription recorded. RESULTS: A total of 109 patients were included in the analysis out of which 78% of them were mechanically ventilated. At the point of the study, more than 16 years of age in the participating ICUs on the 11th of October 2016 were enrolled in this study and 71.5% (78/109) received EN. Among the EN group, 68% (53/78) received standard formulation feeds (1kcal/ml) while the rest received energy dense formulation (>1kcal/ml). Fluid restriction was the main indication for energy dense formulation prescription, occurring in almost all (24/25) of the patients. There was no report of feeding intolerance. Only 2/109 received parenteral nutrition (PN) giving the EN to PN ratio of 30:1. The mean protein prescription was 0.9g/kg (SD± 0.4). CONCLUSION: Prescription of EN was 30 times more frequent than PN in these ICUs. In those receiving EN, standard formulation feed was 3 times more commonly prescribed than energy dense feeds with fluid restriction being the main indication of the latter. Protein prescription was less than the guideline recommendation.

Approaching COVID-19-Bedside strategies for intensive care.

The spread of novel coronavirus disease (COVID‐19) urged a never‐seen coordinated global response to prepare the health system, including primary care, hospital facilities and intensive care units (ICUs). Lessons have been learned from countries who suffered the pandemic at the beginning, helping the ones which are on different phases of the spreading curve. Currently, optimizing intensive care resources is mandatory as admittance to the ICUs remains rising exponentially. While public and private health system struggle for changing the slope of the curve, intensivists prepare the facilities for a tsunami of respiratory failure patients with COVID‐19.1

The Critical Care Society of Southern Africa Consensus Guideline on ICU Triage and Rationing (ConICTri).

In South Africa (SA), administrators and intensive care practitioners are faced with the challenge of resource scarcity as well as an increasing demand for intensive care unit (ICU) services. ICU services are expensive, and practitioners in low- to middle-income countries experience the consequences of limited resources daily. Critically limited resources necessitate that rationing and triage (prioritisation) decisions are routinely necessary in SA, particularly in the publicly funded health sector. The purpose of this guideline is to utilise the relevant recommendations of the associated consensus meeting document and other internationally accepted principles to develop a guideline to inform frontline triage policy and ensure the best utilisation of adult intensive care in SA, while maintaining the fair distribution of available resources. An overall conceptual framework for the triage process was developed. The components of the framework were developed on the basis that patients should be admitted preferentially when the likely incremental medical benefit derived from ICU admission justifies admission. An estimate of likely resource use should also form part of the triage decision, with those patients requiring relatively less resources to achieve substantial benefit receiving priority for admission. Thus, the triage system should maximise the benefits obtained from ICU resources available for the community. Where possible, practical examples of what the consensus group agreed would be considered appropriate practice under specified South African circumstances were provided, to assist clinicians with practical decision-making. It must be stressed that this guideline is not intended to be prescriptive for individual hospital or regional practice, and hospitals and regions are encouraged to develop specified local guidelines with locally relevant examples. The guideline should be reviewed and revised if appropriate within 5 years. In recognition of the absolute need to limit patient access to ICU because of the lack of sufficient intensive care resources in public hospitals, this guideline has been developed to guide policy-making and assist frontline triage decision-making in SA. This document is not a complete plan for quality practice, but rather a template to support frontline clinicians, guide administrators and inform the public regarding appropriate triage decision-making.

The Critical Care Society of Southern Africa Consensus Statement on ICU Triage and Rationing (ConICTri)

Background. In South Africa (SA), administrators and intensive care practitioners are faced with the challenge of resource scarcity as well as an increasing demand for intensive care unit (ICU) services. ICU services are expensive, and practitioners in low- to middle-income countries experience the consequences of limited resources daily. Critically limited resources necessitate that rationing and triage (prioritisation) decisions are routinely necessary in SA, particularly in the publicly funded health sector. Purpose . The purpose of this guideline is to utilise the relevant recommendations of the associated consensus meeting document and other internationally accepted principles to develop a guideline to inform frontline triage policy and ensure the best utilisation of adult intensive care in SA, while maintaining the fair distribution of available resources. Recommendations . An overall conceptual framework for the triage process was developed. The components of the framework were developed on the basis that patients should be admitted preferentially when the likely incremental medical benefit derived from ICU admission justifies admission. An estimate of likely resource use should also form part of the triage decision, with those patients requiring relatively less resources to achieve substantial benefit receiving priority for admission. Thus, the triage system should maximise the benefits obtained from ICU resources available for the community. Where possible, practical examples of what the consensus group agreed would be considered appropriate practice under specified South African circumstances were provided, to assist clinicians with practical decision-making. It must be stressed that this guideline is not intended to be prescriptive for individual hospital or regional practice, and hospitals and regions are encouraged to develop specified local guidelines with locally relevant examples. The guideline should be reviewed and revised if appropriate within 5 years. Conclusion . In recognition of the absolute need to limit patient access to ICU because of the lack of sufficient intensive care resources in public hospitals, this guideline has been developed to guide policy-making and assist frontline triage decision-making in SA. This document is not a complete plan for quality practice, but rather a template to support frontline clinicians, guide administrators and inform the public regarding appropriate triage decision-making.

Postoperative Critical Care for Adult Cardiac Surgical Patients

Cardiac operations represent one of the most common categories of surgery in developed countries with an annual cost in excess of $20 billion in the United States alone. Cardiac surgery is continuously evolving and modern practice has come to include minimally invasive, hybrid, and transcatheter techniques with the patient managed by “the heart team.” An increasing age and medical complexity of patients considered for cardiac surgical procedures mean that the critical care management needs to adapt to meet increasingly broad and elaborate needs. The second edition of Postoperative Critical Care for Adult Cardiac Surgical Patients remains edited by Dr Dabbagh, cardiac anesthetist, and Drs Esmailian and Aranki, both cardiac surgeons. Together they form an extensive body of professional expertise in all aspects of care of the adult cardiac surgical patient. They have supervised 26 chapter contributors representing anesthetic, critical care, and surgical departments mainly in Iran and the United States with a few Italian institutions represented as well. The book has an ambitious scope with the aim to cover all perioperative aspects of the cardiac surgical patient in 22 chapters totaling 670 pages with 60 tables and 97 illustrations, the majority in color. The format is conducive to a general discussion with a few aspects covered more in depth. All chapters are informative albeit some provide more guidance than others. The chapter of hemodynamic monitoring is detailed and includes an up-to-date overview of cardiac output monitors. A short final paragraph explains that transesophageal echocardiography is beyond the scope of this book and the reader is referred to other specialized resources. The chapter on postoperative coagulation and management of bleeding provides an excellent summary of point-of-care testing of coagulation in the intensive care unit with succinct presentations of both thromboelastography and rotational thromboelastometry. Interpretation and suggestions for actions based on results using both devices are presented and clearly summarized in table format. All relevant anticoagulants in current clinical practice and guidelines for their reversal are nicely presented. The chapter on “Postoperative Safety in Adult Cardiac Surgery Intensive Care Unit” includes a useful section on handoff protocols and also covers team huddles and team performance. In particular, the example multidisciplinary simulation scenario demonstrates the approach to building and improving teamwork along all facets of perioperative care, with a natural emphasis on postoperative complications. The chapter on cardiac anatomy is overly basic and lacking in terms of functional aspects and clinical implications. The chapter on cardiac physiology to some extent suffers from the same shortcomings and aspects of regulation of blood flow would seem to warrant a more comprehensive consideration. Some readers will surely be surprised that no references are made to the state-of-the-art research performed by Arthur Guyton. The pharmacology chapter provides a clinically orientated overview of most drugs likely to be encountered in a cardiac, or for that sake general, intensive care unit, while an approach of listing rather than categorizing by postoperative scenarios renders the text somewhat insipid. The chapter devoted to mechanical circulatory support includes rather extensive pharmacological and physiological considerations that are already covered in other chapters. This sidetracks the main theme of the text, in particular for the modality of venoarterial extracorporeal membrane oxygenation that has most relevance to cardiac intensive care practitioners. The chapter on renal complications focuses on basic principles, while renal replacement therapy is covered on less than 1 page. This appears cursory given the significance of dialysis-dependent renal failure on long-term clinical outcomes. Unfortunately, the presentation is at times distracted by a below-par English style and grammar that should have been addressed in a second revision. There is also a tendency for repetition and overlap between chapters, and a more effective use of cross-referencing would have been useful to the reader. An eBook edition is available but was not accessed for this review. The book navigates difficult waters between a preparatory text and a complete reference textbook. Those with some experience of general intensive care wanting to explore cardiac intensive care will likely find the book rewarding, while it is arguably a bit unwieldy to use as an introductory text. The fellow or specialist colleague with experience in a cardiac intensive care unit might find the text lacking in detail and depth compared to textbooks of cardiac surgery but still useful as a source for refreshing clinical knowledge. We recommend the advanced trainee or junior consultant looking for 1 manageable volume to cover the field to buy the book. Anders Aneman, MD, PhD, FCICMWilliam O’Regan, MD, FCICM, FANZCADepartment of Intensive CareLiverpool Hospital, South Western Sydney Local Health DistrictMacquarie University HospitalSydney, Australia[email protected]