Intensive Care Section Research Articles

Child and maternal benefits and risks of caseload midwifery – a systematic review and meta-analysis

BackgroundIt has been reported that caseload midwifery, which implies continuity of midwifery care during pregnancy, childbirth, and the postnatal period, improves the outcomes for the mother and child. The aim of this study was to review benefits and risks of caseload midwifery, compared with standard care comparable to the Swedish setting where the same midwife usually provides antenatal care and the checkup postnatally, but does not assist during birth and the first week postpartum.MethodsMedline, Embase, Cinahl, and the Cochrane Library were searched (Nov 4th, 2021) for randomized controlled trials (RCTs). Retrieved articles were assessed and pooled risk ratios calculated when possible, using random-effects meta-analyses. Certainty of evidence was assessed according to GRADE.ResultsIn all, 7,594 patients in eight RCTs were included, whereof five RCTs without major risk of bias, including 5,583 patients, formed the basis for the conclusions. There was moderate certainty of evidence for little or no difference regarding the risk of Apgar ≤ 7 at 5 min, instrumental birth, and preterm birth. There was low certainty of evidence for little or no difference regarding the risk of perinatal mortality, neonatal intensive care, perineal tear, bleeding, and acute caesarean section. Caseload midwifery may reduce the overall risk of caesarean section. Regarding breastfeeding after hospital discharge, maternal mortality, maternal morbidity, health-related quality of life, postpartum depression, health care experience/satisfaction and confidence, available studies did not allow conclusions (very low certainty of evidence). For severe child morbidity and Apgar ≤ 4 at 5 min, there was no literature available.ConclusionsWhen caseload midwifery was compared with models of care that resembles the Swedish one, little or no difference was found for several critical and important child and maternal outcomes with low-moderate certainty of evidence, but the risk of caesarean section may be reduced. For several outcomes, including critical and important ones, studies were lacking, or the certainty of evidence was very low. RCTs in relevant settings are therefore required.

OP019 [Comfort Management » Sedation]: A NATIONAL SURVEY OF SEDATION PRACTICE AND CLINICIANS’ ATTITUDES REGARDING SEDATION-RELATED RESEARCH IN UK PAEDIATRIC INTENSIVE CARE UNITS

1Paediatric Intensive Care Unit, Imperial College Healthcare NHS Trust, London United Kingdom. 2School of Health & Society, University of Salford, Salford, UK. 3Anaesthetics, Pain Medicine and Intensive Care Section, Imperial College London

Covid-19 in Pregnancy: Cases of Women Managed in the City of Douala-Cameroon

Introduction: The SARS-COV-2 virus has been responsible for a health crisis in pregnancy, causing severe acute respiratory distress syndrome. Materno-foetal complications can be observed. Taking into account the materno-foetal risks associated with COVID-19 infection in pregnant women and the low sample size of the first publication in Cameroon, we considered it necessary to conduct an in-depth study on the maternal and foetal prognosis of this condition in pregnant women in three hospitals in Douala. Materials and Methods: We conducted a cross-sectional survey with retrospective data collection in the three state tertiary and reference hospitals in Douala (DGOPH, DGH and DLH) from November 1, 2021 to April 30 2022 after obtaining ethical and administrative clearances. All records of COVID-19 pregnant women confirmed by reverse transcription polymerase chain reaction (RT PCR) or COVID-19 rapid diagnostic test (COVID RDT) were included. The survey form contained socio-demographic data, clinical and para-clinical characteristics, management and materno-foetal outcome. SPSS.26 and Microsoft Excel 2016 software were used to analyze the data, and a logistic regression model was used to look for associations between the variables. Results: We found in total 96 files that met our inclusion criteria. The most represented sector of activity was the unemployed (44.46%). Patients with a secondary level of education constituted the majority with 47% (45). The main comorbidity found was diabetes (27.2%). The most frequent symptom was fever, found in 87 patients (90.1%). In our series, a chest CT scan was performed in 50 patients. Caesarean section was the most common mode of delivery (58.3%). We recorded 15.6% of maternal deaths, mainly in patients admitted to intensive care. Factors associated with maternal death were: Maternal diabetes, high LDH and D-dimer levels, and 75% lung involvement on chest CT scan. Oxygen saturation > 94% on admission was a protective factor. Regarding fetal and neonatal outcomes, we registered 30.2% cases of prematurity, 32.3% cases of respiratory distress at birth and 24% neonatal deaths. Factors associated with neonatal death were temperature ≥ 38.5°C. Conclusion: At the end of the study, we can conclude that in pregnant women with COVID-19, fever is the main symptom, 1/3 are admitted to intensive care and caesarean section is the most common mode of delivery. The maternal death rate remains high, especially in diabetic patients admitted to intensive care with altered biological parameters. Fetal complications include prematurity and death.

Premature Birth is an Independent Risk Factor for Early Adiposity Rebound: Longitudinal Analysis of BMI Data from Birth to 7 Years.

Adiposity rebound (AR) refers to the second rise of the body mass index (BMI) curve that usually occurs physiologically between five and seven years of age. AR timing has a great impact on patients’ health, since early adiposity rebound (EAR) is associated with the development of metabolic syndrome later in life. We aimed to investigate the prevalence of EAR in a cohort of inborn preterm infants admitted to the Neonatal Intensive Care Section of the Policlinico University Hospital of Bari, Italy. Secondarily, we assessed whether some determinants such as (1) gender; (2) delivery mode; (3) birth weight and classification into small, normal, or large for gestational age; (4) type of feeding; (5) breastfeeding duration; (6) timing of introduction of solid food; (7) parental education; and (8) parental pre-pregnancy body mass index (BMI) influenced EAR in this cohort. The tertiary aim was to evaluate the prevalence of obesity or being overweight at seven years of age in children according to early versus timely AR. This is a prospective, population-based longitudinal study conducted at the Neonatal Intensive Care Section of the Policlinico University Hospital of Bari, Italy. Inborn preterm infants admitted to the neonatal ward between 2009 and 2011 were eligible. Enrolled preterm infants were evaluated at birth and at 1, 3, 6, 9, 12, 15, 18, and 24 months and 3, 4, 5, 6, and 7 years of age. Weight and height data were analyzed, and BMI was calculated. AR was assessed in the growth trajectory in a body mass index (BMI) plot. Of the 250 preterm newborns included, 100 completed the seven-year follow-up and entered the final analysis, 138 were lost during the seven-year follow-up, and in 12 cases parents withdrew over the course of the study. The prevalence of EAR in our cohort of preterm newborns was 54% at seven years of age. Early adiposity rebound was associated with being large for gestational age (LGA) at birth. No other factors were associated with EAR. Early adiposity rebounders had a significantly higher BMI at seven years compared to children with timely AR (17.2 ± 2.7 vs. 15.6 ± 2.05, p = 0.021). No significant differences were found in the prevalence of obesity or being overweight at seven years of age in children with early or timely AR (29% vs. 14%, p = 0.202). Ex-preterm infants have an increased risk of EAR. Since EAR may lead to long-term detrimental health effects with the onset of various chronic diseases (e.g., obesity, metabolic syndrome, etc.), healthcare providers should be prepared to counteract its occurrence, especially in delicate sub-populations of infants.

Structure of anaesthesia intensive care units: Recommendations of the Intensive Care Section of the Spanish Society of Anaesthesiology

Abstract Background and objective In this article, the Intensive Care Section of the Spanish Society of Anesthesiology (SCI-SEDAR) establishes new recommendations based on the standards published by the Ministry of Health, Consumer Affairs and Social Welfare and aligned with the principle international guidelines, and develops a tool to improve quality and efficiency. Materials and method Over a 12-month period (2018), 3 members of the SCI-SEDAR defined the methodology, developed the recommendations and selected the panel of experts. Due to the limited evidence available for many of the recommendations and the significant structural differences between existing anaesthesia intensive care units, we chose a modified Delphi approach to determine the degree of consensus. Results The panel consisted of 24 experts from 21 institutions. The group put forward 175 recommendations on 8 sections, including 129 with strong consensus and 46 with weak consensus. Conclusions The SCI-SEDAR has established a series of structural recommendations that should be used when renovating or creating new anaesthesia intensive care units.

Estructura de las unidades de cuidados intensivos de anestesia: recomendaciones de la Sección de Cuidados Intensivos de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR)

Background and objectiveIn this article, the Intensive Care Section of the Spanish Society of Anesthesiology (SCI-SEDAR) establishes new recommendations based on the standards published by the Ministry of Health, Consumer Affairs and Social Welfare and aligned with the principle international guidelines, and develops a tool to improve quality and efficiency. Materials and methodOver a 12-month period (2018), 3 members of the SCI-SEDAR defined the methodology, developed the recommendations and selected the panel of experts.Due to the limited evidence available for many of the recommendations and the significant structural differences between existing anesthesia intensive care units, we chose a modified Delphi approach to determine the degree of consensus. ResultsThe panel consisted of 24 experts from 21 institutions. The group put forward 175 recommendations on 8 sections, including 129 with strong consensus and 46 with weak consensus. ConclusionsThe SCI-SEDAR has established a series of structural recommendations that should be used when renovating or creating new anesthesia intensive care units.

Patient work load and doctor hours in a Norwegian university hospital department

Background: Although clinical hospital departments are 24/7 operations, doctor staffing is mainly concentrated during day-time on weekdays, while the rest of the week is covered by on-call systems to secure a minimum of patient care throughout the week. Few studies have investigated how this affects the relation between units of service (UOS) and available doctor hours.Methods: The study was carried out in a paediatric department with a neonatal intensive care section at a university hospital. Sixty per cent of the admissions were emergency cases. The organization of the 24/7 operation of the department is considered to be representative for most university hospital departments in Norway. OUS were calculated from the average number of in-hospital patients, out-patient consultations, the number of admissions and discharges during three defined time-periods: daytime, evening and night, assuming that all these doctor-patient contacts had the same impact on time use. Gross and net doctor hours on day-time during weekdays, on evenings, nights and weekends were calculated from work schedules, corrected for approved absence and long time sick leave. UOS per hour was calculated as the ratio between UOS and available gross and net doctor hours.Results: Both available doctor hours as well as UOS per hour varied considerably throughout the week. Eighty-three per cent of doctor hours were concentrated on day-time during weekdays, representing only 24% of week hours. Evenings and nights representing 76% of weekly hours, were covered with only 17% of doctor hours, and all nights through the week and weekend evenings, representing 55% of weekly hours, were covered with only 7% of total doctor hours available. Gross and net OUS per hour was increased six-fold and three-fold respectively at day-time on weekends compared to day-time during weekends. Evenings and nights had an even higher UOS per hour.Conclusion: The distribution of doctor hours through the week does not match UOS per hour. The high work load during weekends, evenings and nights are probably negative for the quality in patient treatment as well as for doctors work conditions. The department is probably understaffed during these time periods. It can also be asked if the department is overstaffed during day-time on weekdays. A more even and balanced staffing of hospital departments in relation to patient work load seems necessary in relation to quality in patient treatment, doctors' working conditions and productivity.

ПРОБЛЕМА ОРГАНИЗАЦИИ БЕЗОПАСНОЙ ЭВАКУАЦИИ ПАЦИЕНТОВ ЛЕЧЕБНЫХ УЧРЕЖДЕНИЙ ПРИ ПОЖАРЕ

Foreword. The article considers a very urgent and complex issue: ensuring fire safety of patients during their evacuation from multi-field healthcare institutions. According to official data, there are about 13 million disabled people and 40 million low-mobile people in our country, and no one knows how many such people will be in healthcare institutions in a certain period of time. However, even without understanding of composition of the flow in healthcare institutions, it is evident that filling of healthcare institutions by people of reduced mobility will be many times more than in any other buildings. Analytical part. Apatient differentiation has been developed for classification of patients, as well as a personnel differentiation. The patient differentiation is carried out for various degrees of mobility limitations. The category of people who cannot move without special medical equipment and medical personnel is considered for the first time. All possible spatial planning structures in healthcare institution buildings are brought to one solution — a corridor system, and a huge number of functional directions in the medicine can be brought to three sections of buildings. The oldest healthcare institution Vladimirskiy GBUZ MO MONIKI is considered as an object of research. All buildings of different medical nomenclatures are consolidated in this healthcare organization, and the main building sections are outpatient-polyclinic, stationary-surgical, stationary-therapeutic, and laboratory sections. Composition of the main functional contingent and the main types of rooms are determined for each section. Creating of the base of the composition of the main functional contingent in rooms was started, depending on their transportability, including the intensive care section, taking into account long-term statistics. Conclusion. After getting acquainted with specifics of the problem, it becomes obvious that without timely and effective means of fire protection are required. Besides, it is clear that such vulnerable population groups cannot be evacuated without means of transportation, therefore, safety zones shall be designed for patients to wait for arrival of fire units, since using of lifts as evacuation means is strictly forbidden in our country.

Genesis of the College of Intensive Care Medicine of Australia and New Zealand

Background: In 2008, the College of Intensive Care Medicine (CICM) of Australian and New Zealand was inaugurated in Melbourne, Australia. This College now regulates the education, training and accreditation for specialist intensivists for Australia and New Zealand. CICM origins started in 1975 with the formation of the Intensive Care Section of the Faculty of Anaesthetists, Royal Australasian College of Surgeons (RACS), which moved through intermediary stages as the Faculty of Intensive Care, Australian and New Zealand College of Anaesthetists (ANZCA) when that College was formed from the former Faculty of Anaesthetists RACS, and then the Joint Faculty of Intensive Care Medicine (ANZCA and the Royal Australasian College of Physicians), until becoming completely independent as CICM in 2010.

Unanticipated difficult airway management in children - the consensus statement of the Paediatric Anaesthesiology and Intensive Care Section and the Airway Management Section of the Polish Society of Anaesthesiology and Intensive Therapy and the Polish So.

Tracheal intubation may be defined as an artificial airway established in order to provide mechanical ventilation of the lungs during surgical procedures under general anaesthesia, treatment in an intensive care unit, as well as in emergency situations. Difficulties encountered during intubation may cause hypoxia, hypoxic brain injury and, in extreme situations, may result in the patient's death. There may be unanticipated and anticipated difficult airway. Children form a specific group of patients as there are significant differences in both anatomy and physiology. There are some limitations in equipment used for the airway management in children. There are only few paediatric difficult airway guidelines available, some of which have significant limitations. The presented algorithm was created by a group of specialists who represent the Polish Society of Anaesthesiology and Intensive Therapy, as well as the Polish Neonatology Society. This algorithm is intended for the unanticipated difficult airway in children and can be used in all age groups. It covers both elective intubation, as well as rescue techniques. A guide forms an integral part of the algorithm. It describes in detail all stages of the algorithm considering some modifications in a specific age group, e.g. neonates. The main aim of Stage I is to optimise conditions for face mask ventilation, laryngoscopy and intubation. Stage IIA focuses on maximising the chances of successful intubation when face mask ventilation is possible. Stage IIB outlines actions aimed at improving face mask ventilation. Stage IIIA describes the use of a SAD (Supraglottic Airway Device) during effective face mask ventilation or in a CICV (Cannot Intubate, Cannot Ventilate) situation. Stage IIIB outlines intubation through a SAD. Stage IV describes rescue techniques and outlines possible options of either proceeding with surgery or postponing it, depending on clinical situation.

Intensive Care of Anaesthesia: Recommendations of the Intensive Care Section of the Spanish Society of Anaesthesiology

Intensive Care of Anaesthesia: Recommendations of the Intensive Care Section of the Spanish Society of Anaesthesiology

Neurological examination of critically ill patients: a pragmatic approach. Report of an ESICM expert panel

Many patients admitted to the intensive care unit (ICU) have pre-existing or acquired neurological disorders which significantly affect their short-term and long-term outcomes. The ESICM Neuro Intensive Care Section convened an expert panel to establish a pragmatic approach to neurological examination (NE) of the critically ill patient. The group conducted a comprehensive review of published studies on the NE of patients with coma, delirium, seizures and neuromuscular weakness in critically ill patients. Quality of data was rated as high, moderate, low, or very low, and final recommendations as strong, weak, or best practice. The group made the following recommendations: (1) NE should be performed in all patients admitted to ICUs; (2) NE should include an assessment of consciousness and cognition, brainstem function, and motor function; (3) sedation should be managed to maximize the clinical detection of neurological dysfunction, except inpatients with reduced intracranial compliance in whom withdrawal of sedation may be deleterious; (4) the need for additional tests, including neurophysiological and neuroradiological investigations, should be guided by the NE; (5) selected features of the NE have prognostic value which should be considered in well-defined patient populations.

CHOC ANAPHYLACTIQUE APRÈS PONCTION D’UN KYSTE HYDATIQUE DU FOIE

Introduction: the hepatic hydatidosis, which is a real health problem in Morocco, is known as begnin; however, it may turn to be serious because of its inescapable complications. A crack dominate ini the biliary canals or in the peritoneum, and can take anaphylactic appearances due to antigens of the echinococcus granulosus. These reactions can enamel the spontaneous evolution of the hydatid cyst, as they can occur after a traumatism, or during surgical manoeuvres. Observation: it is about a 21-year-old patient who presented an anaphylactic choc after a percutaneous puncture of a hydatid liver cyst. The immediate treatment of the choc was efficacious and the intervention was performed without any incidents after laparotomy. After some time at the intensive care section, the rehabilitation of the patient was satisfactory and the post surgical effects were normal. Discussion and conclusion: The analysis of this observation and other data of the literature make admit the scarcity and seriousness of this fearsome incident. The association of an abdominal chart and a collapsus with allergic signs should attract attention. Given the endemic character of this pathology in our country, the best treatment starts with prevention.

Comparison of video laryngoscopes with direct laryngoscopy for tracheal intubation

Editor, The recent meta-analysis of Su et al.1 comparing video laryngoscopes with direct laryngoscopy for tracheal intubation was of great interest to us. Although their findings are consistent with the current literature, we believe that many questions remain on this issue. First, it is surprising that no study evaluating the Airtraq has been included in the meta-analysis. The authors declared they had searched PubMed and EMBASE up to 24 September 2010. They considered only randomised clinical trials with at least two independent groups comparing video laryngoscopes with direct laryngoscopy. With these criteria, they included only 11 reports in the meta-analysis and in none of these were the Airtraq studied. However, with the same criteria, we identified at least two more articles that should have been included in the analysis. In the study of Maharaj et al.,2 the Airtraq was compared with the Macintosh laryngoscope in patients deemed at low risk for difficult intubation in a randomised controlled trial. In this study, the Airtraq provided comparable or superior intubating conditions in the normal airway and did reduce intubation difficulty as evaluated with the intubation difficulty scale (IDS).3 The same authors compared the Airtraq with the Macintosh laryngoscope in patients at increased risk for difficult tracheal intubation.4 The Airtraq reduced the duration of intubation attempts, the need for additional manoeuvres and the IDS score. It should also be mentioned that, recently, Lu et al.5 carried out a systematic review and meta-analysis on Airtraq, concluding that it facilitates a more rapid and accurate intubation, especially when used by novices. Su et al. stated that this is the first meta-analysis of randomised trials evaluating the video laryngoscope with direct laryngoscopy. This is not completely true, as Mihai et al.6 recently performed a quantitative review and meta-analysis including other devices such as Bonfils and failed to provide strong evidence that video laryngoscopes should supersede the Macintosh laryngoscope. To omit some studies may lead to misleading results in meta-analysis.7 In our opinion, focusing meta-analysis on single devices is more useful and should help us to evaluate the performance of each tool. We agree with the authors about the limitations of the study that are related to the nature of the subjects. There is little doubt that randomised trials and their meta-analyses constitute very persuasive evidence. However, randomised trials are not the only source of evidence and it has gradually become apparent that perfectly pragmatic decisions could also be based on ‘lower’ levels of evidence. It is time for a new approach in this area of research, or the questions will never find a definitive answer. Acknowledgements Assistance with the study: none declared. Sources of funding: There was no contribution from any other person and the authors did not receive any financial support. This work was supported by the Department of Emergency, Anaesthesia and Intensive Care Section ‘G.B. Morgagni-Pierantoni’ Hospital, Forli, Italy. Conflicts of interest: None of the authors declares any conflict of interest.

A multidisciplinary approach to intensive care medicine

A multidisciplinary approach to intensive care medicine

Survey of pharmacologic thromboprophylaxis in critically ill children*

There is lack of evidence to guide thromboprophylaxis in the pediatric intensive care unit. We aimed to assess current prescribing practice for pharmacologic thromboprophylaxis in critically ill children. Pediatric intensive care units in the United States and Canada with at least ten beds. Cross-sectional self-administered survey of pediatric intensivists using adolescent, child, and infant scenarios. Pediatric intensive care unit clinical directors or section heads. None. Physician leaders from 97 of 151 (64.2%) pediatric intensive care units or their designees responded to the survey. In mechanically ventilated children, 42.3% of the respondents would usually or always prescribe thromboprophylaxis for the adolescent but only 1.0% would prescribe it for the child and 1.1% for the infant. Considering all pediatric intensive care unit patients, 3.1%, 32.0%, and 44.2% of respondents would never prescribe thromboprophylaxis for the adolescent, child, and infant scenarios, respectively. These findings were significant (p < .001 for the adolescent vs. child and infant; p = .002 for child vs. infant). Other patient factors that increased the likelihood of prescribing prophylaxis to a critically ill child for all three scenarios were the presence of hypercoagulability, prior deep venous thrombosis, or a cavopulmonary anastomosis. Prophylaxis was less likely to be prescribed to patients with major bleeding or an anticipated invasive intervention. Low-molecular-weight heparin was the most commonly prescribed drug. In these scenarios, physician leaders in pediatric intensive care units were more likely to prescribe thromboprophylaxis to adolescents compared with children or infants, but they prescribed it less often in adolescents than is recommended by evidence-based guidelines for adults. The heterogeneity in practice we documented underscores the need for rigorous randomized trials to determine the need for thromboprophylaxis in critically ill adolescents and children.

International Anesthesiology Clinics. Critical Care: Current Challenges and Future Directions.

International Anesthesiology Clinics. Critical Care: Current Challenges and Future Directions.

Errors and omissions in hospital prescriptions: a survey of prescription writing in a hospital

BackgroundThe frequency of drug prescription errors is high. Excluding errors in decision making, the remaining are mainly due to order ambiguity, non standard nomenclature and writing illegibility. The aim of this study is to analyse, as a part of a continuous quality improvement program, the quality of prescriptions writing for antibiotics, in an Italian University Hospital as a risk factor for prescription errors.MethodsThe point prevalence survey, carried out in May 26–30 2008, involved 41 inpatient Units. Every parenteral or oral antibiotic prescription was analysed for legibility (generic or brand drug name, dose, frequency of administration) and completeness (generic or brand name, dose, frequency of administration, route of administration, date of prescription and signature of the prescriber). Eight doctors (residents in Hygiene and Preventive Medicine) and two pharmacists performed the survey by reviewing the clinical records of medical, surgical or intensive care section inpatients. The antibiotics drug category was chosen because its use is widespread in the setting considered.ResultsOut of 756 inpatients included in the study, 408 antibiotic prescriptions were found in 298 patients (mean prescriptions per patient 1.4; SD ± 0.6). Overall 92.7% (38/41) of the Units had at least one patient with antibiotic prescription. Legibility was in compliance with 78.9% of generic or brand names, 69.4% of doses, 80.1% of frequency of administration, whereas completeness was fulfilled for 95.6% of generic or brand names, 76.7% of doses, 83.6% of frequency of administration, 87% of routes of administration, 43.9% of dates of prescription and 33.3% of physician's signature. Overall 23.9% of prescriptions were illegible and 29.9% of prescriptions were incomplete. Legibility and completeness are higher in unusual drugs prescriptions.ConclusionThe Intensive Care Section performed best as far as quality of prescription writing was concerned when compared with the Medical and Surgical Sections.Nevertheless the overall illegibility and incompleteness (above 20%) are unacceptably high. Values need to be improved by enhancing the safety culture and in particular the awareness of the professionals on the consequences that a bad prescription writing can produce.

Perioperative Care in Cardiac Anesthesia and Surgery.

Associate Professor Department of AnesthesiologyWake Forest University School of MedicineWinston-Salem, North Carolina 27157dzvara@wfubmc.eduPerioperative Care in Cardiac Anesthesia and Surgery. By Davy C. H. Cheng, Tirone E. David.Austin, Lanes Bioscience, 1998. Pages: 247. Cost: $45.00.Perioperative Care in Cardiac Anesthesia and Surgery is a pocket-size spiral-bound manual. This book is the combined effort of 40 contributors, all of whom are from either the University of Toronto or the Toronto General Hospital, Toronto, Canada. The manual includes 40 chapters that are grouped into four major sections:“General Introduction into the Toronto General Hospital Cardiac Surgical Program and Fast Track Cardiac Surgical Procedures,”“Anesthesia for Cardiopulmonary Bypass Management,”“Surgical Technique and Postoperative Considerations,” and “Postoperative Cardiac Surgical Unit Management.” There is an extensive appendix and an adequate index.The authors summarize their subject in the introduction:“This handbook describes the perioperative management of adult patients who undergo cardiac surgery at our center.” The text is largely a compendium of practice management paradigms that involve patients who present for cardiac anesthesia and surgery at the contributors’ two institutions. The book thus represents “the Toronto way.” The introductory chapter outlines the authors’ institutions’ combined cardiac morbidity and mortality rates for 11,112 patients undergoing cardiovascular operations with use of cardiopulmonary bypass from 1993 to 1997. The overall operative mortality rate for the period was 3.4%. Data regarding mortality by surgical procedure and significant morbidities are outlined clearly in the first table. These data provide the foundation for the authors’ recommendations throughout the book. From their experience in a successful, busy cardiothoracic surgery practice, they describe techniques and make recommendations that practitioners everywhere can apply.The individual chapters are well-written and follow a basic outline format. Each chapter is approximately 2–10 pages, with an average length of 3 or 4 pages. There is heavy use of tables and lists, but surprisingly few diagrams. The tables and lists serve as quick references for specific problems clinicians may encounter. These are especially helpful in certain infrequent events. For example, Chapter 12 is a handy reference for clinicians who rarely, if ever, have an occasion to use nitric oxide. The majority of chapters discuss the material adequately; however, on occasion, the text is basic and general and is best suited for a resident or a fellow at the first stages of training in cardiothoracic anesthesia and surgery. Several of the chapters, however, provide excellent in-depth information. In particular, Chapter 17, “Intra-aortic Balloon Pumps,” and Chapter 20, “Valvular Heart Disease,” are particularly well-written.The book’s strength is its ability to present a large amount of information in a concise format. The appendices are particularly helpful, especially for managers in a cardiovascular intensive care unit and section heads of cardiothoracic surgery or cardiothoracic anesthesia programs who design and implement accelerated recovery programs. Each chapter ends with a short list of suggested readings. Although these supplement the reader’s research pool, the text itself does not have references. I consider this a troubling omission. On many occasions, a particular fact or figure is given for a disease condition, but these statements are not referenced, and, therefore, readers must further investigate or verify statements on their own. A second edition would be strengthened by an abbreviated reference list.Drs. Cheng and David have provided a well-written reference manual. Perioperative Care in Cardiac Anesthesia and Surgery is a comprehensive work, including the preoperative, intraoperative, and postoperative course of patients presenting for cardiothoracic surgery.

Diploma Case Study: Intensive Care

Sharon Chandler submitted this case study, which describes the management of pneumothorax in a dog, as part of the intensive care section in her case book for the Diploma in Advanced Veterinary Nursing (Surgical) which she gained in 1993. The appendices are relevant to all five cases that were submitted in the IC section and demonstrate a method of reducing repetitive text