Book Review

Surgical Critical Care

N Engl J Med 1995; 332:1039-1041April 13, 1995

Article

Surgical Critical Care
Edited by Joseph A. Moylan. 1040 pp., illustrated. St. Louis, Mosby, 1994. $125. ISBN: 1-55664-163-X

Not long ago, the clinician seeking to purchase a hardbound book dealing with critical care medicine had few choices. Now there are more than half a dozen texts on this topic. The newest entry is Surgical Critical Care, edited by Joseph A. Moylan.

Although this multiauthored book has features to recommend it, Surgical Critical Care is not one of the stronger sources of detailed, authoritative information on the care of critically ill surgical patients. For purposes of illustration, let me consider in detail one clinical problem, the adult respiratory distress syndrome (ARDS). This is a common syndrome characterized by arterial hypoxemia, pulmonary arterial hypertension, diminished pulmonary compliance, and noncardiogenic pulmonary edema. ARDS often complicates a number of conditions of interest to surgeons, including trauma, smoke inhalation, sepsis, and pancreatitis. And yet, despite the importance of ARDS, the chapter dealing with it is only 11 pages long. It has only 61 references, only 5 of which are from 1990 or later. A related chapter on mechanical ventilation is similarly short (14 pages and 47 references). The material presented in these chapters is accurate, but there are major gaps. For example, there is no mention of such important topics as the use of permissive hypercapnia to avoid high airway pressures, treatment of the fibroproliferative phase of ARDS with corticosteroids, techniques for measuring intrinsic positive end-expiratory pressure, the use of indicator dilution techniques to monitor extravascular lung water content (and titrate therapy to control it), or partial liquid ventilation using perfluorocarbon emulsions. A fascinating new therapy to lower pulmonary arterial pressure, inhaled nitric oxide, is covered very briefly in the chapter on congenital heart disease but not mentioned in the chapter on ARDS.

The chapter on monitoring is excellent as far as it goes, but it is similarly flawed by major omissions. Not mentioned, for example, is tonometric estimation of gastric mucosal pH (or carbon dioxide tension) as an index of splanchnic perfusion. This form of monitoring is hardly a standard of care in intensive care units in North America, but few would argue that it provides reliable prognostic information and that it is a “hot” area of investigation. Similarly lacking is a discussion of other methods of monitoring “organ-specific” perfusion (e.g., jugular-bulb oximetry and near-infrared spectroscopy).

The chapter on antibiotics is well written but omits a number of important topics, such as once-a-day dosing for aminoglycosides or the emerging problem of vancomycin-resistant enterococci. Nowhere in the book is there a discussion of selective digestive decontamination as prophylaxis against the development of infections acquired in the intensive care unit. Although the efficacy of this technique is controversial, the topic surely warrants at least a brief review in a textbook dealing with surgical critical care.

The major strengths of the book are its relative brevity and readability. This is a good book for medical students doing a clerkship in a surgical intensive care unit. Residents in surgery or the surgical subspecialties might also find it of value. However, for fellows in critical care medicine and practicing intensivists (of all stripes), there are better books available.

Mitchell P. Fink, M.D.
Beth Israel Hospital, Boston, MA 02215