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Reviews of Educational Material  |   May 2008
Irwin and Rippe's Intensive Care Medicine, 6th Edition.
Author Affiliations & Notes
  • Matthew J. Griffee, M.D.
    *
  • *Oregon Health and Science University, Portland, Oregon.
Article Information
Reviews of Educational Material / Critical Care
Reviews of Educational Material   |   May 2008
Irwin and Rippe's Intensive Care Medicine, 6th Edition.
Anesthesiology 5 2008, Vol.108, 968-969. doi:10.1097/ALN.0b013e31816bbdf4
Anesthesiology 5 2008, Vol.108, 968-969. doi:10.1097/ALN.0b013e31816bbdf4
Irwin and Rippe's Intensive Care Medicine, 6th Edition.  Edited by Richard S. Irwin, M.D., F.C.C.P., and James M. Rippe, M.D. Philadelphia, Lippincott Williams & Wilkins, 2007. Pages: 2,544. Price: $239.00.
Irwin and Rippe first published their eponymous Intensive Care Medicine  22 yr ago. In the preface to their latest edition, they state that their emphasis is on clinical management, and they reflect: “What was initially primarily a medical intensive care medicine textbook has evolved to focus an equal emphasis on medical, anesthesia, and surgical intensive care” (p. xL vii).
The book is arranged in 18 sections, comprising 211 chapters with more than 2,500 pages. There are 349 contributing authors, who hail from a panoply of specialties, including anesthesiology, surgery, pulmonary medicine, and cardiology. Because the book weighs 10 lb, the reader will welcome the password inside the front cover, which grants access to the on-line, searchable, complete electronic text.
The overall organization is encyclopedic, covering the expected core chapters arranged by organ system, but also including a section devoted to “Surgical Problems in the ICU” and an extensive discussion of “Overdoses and Poisonings.” The book's concluding section, “Contemporary Challenges in the ICU,” has been substantially expanded from the fifth edition and includes chapters on ethics, economics, and informatics in the critical care context.
Of particular interest to anesthesiologists is the outstanding, nuanced summary of the controversies surrounding the role of pulmonary artery catheters in critically ill patients (chapter 4), the chapter on cardiac surgery (152), and the chapter on preoperative medicine (153). In addition, there is a chapter on management of pain in critically ill patients (chapter 23), which includes a state-of-the-art overview of pain mechanisms and analgesic pharmacology.
Strengths
Several chapters provide succinct and practical tables summarizing pivotal recent literature on the topic of the section (e.g.  , “Summary of Advances in Managing Resuscitation,”“Selected Evidence-based Clinical Trials or Meta-analyses Relevant to Antithrombotic Therapy”). Moreover, in most cases, the evidence underlying clinical recommendations is described, and most chapters have references that are up-to-date (as recent as 2006) to the extent possible for a textbook.
In accord with the clinical focus, most sections concentrate on practical aspects of the various topics, and the interested reader is directed to reviews of corresponding basic science frontiers. A notable exception is the extensive coverage of the physiology of acute lung injury, from histology to molecular biology to epidemiology. This is easily forgiven because the writing and organization of the pulmonary section are outstanding. The overall clinical focus remains preeminent, and some creative approaches are used to translate scientific principles into clinical applications. For example, the chapter on acid–base disorders concludes with case scenarios illustrating application of quantitative rules of thumb to real-world diagnostic challenges.
The frequency of headings and subdivisions of chapters and the 75-page index makes it feasible to look up a topic and scan through a chapter for a particular paragraph or reference with reasonable efficiency.
Given the background of the editors (pulmonary/critical care medicine and cardiology), it is not surprising that the discussions of pulmonary and cardiac physiology applied to intensive care unit patients are insightful and effective introductions to their respective sections.
Weaknesses
Some important contemporary controversies are not presented. For example, the furor regarding the ethics of the manufacturer's marketing strategy for recombinant activated protein C, as well as the debate of the validity of the study design, is not mentioned in the sepsis chapter (chapter 163).1,2 
Curiously and conspicuously, there is no mention of the heated debate about the relative merits and risks of aprotinin for heart surgery, despite the dedication of an entire chapter (152) to “Management of the Postoperative Cardiac Surgical Patient.”3,4 This chapter's discussion of postoperative arrhythmias seems out-of-date to the reviewer, and in part is in contrast to current American College of Cardiology–American Heart Association guidelines.
The chapter on pulmonary hypertension is an excellent summary of the physiology of the right ventricle and the pulmonary circulation and provides a logical differential diagnosis of pulmonary hypertension. Unfortunately (and not characteristically), treatment discussion emphasizes long-term management of idiopathic pulmonary hypertension. What is frankly missing is an approach to the acute pulmonary hypertension crisis and suggestions for an algorithmic approach to rapid diagnosis and emergency treatment of life-threatening pulmonary hypertension (e.g.  , after heart transplantation).
The figures and illustrations are all black and white, which is regrettable especially when they are important in evoking a difficult concept to describe with words alone. The quality of some photographic reproductions reminds me of textbooks from years gone by.
Unfortunately, the recent publication of the updated guidelines for preoperative cardiac evaluation renders much of the preoperative medicine chapter dated; however, the book was already on the shelf when the latest guidelines were published.5 
There are some overlapping topics. For example, several chapters include redundant descriptions of the molecular biology (including cytokine profiles, endothelial activation, and the inflammatory response) underlying the development of systemic inflammatory response syndrome and multisystem organ failure. Considerable space could have been saved if this important information were condensed into a single chapter and repetitive discussions of this material were replaced by references to the dedicated chapter.
Assessment
As computers become ubiquitous, and electronic databases of medical literature become increasingly powerful and user-friendly, the textbook may seem less and less relevant as a resource for the front lines of clinical medicine. Nevertheless, the lengthy, multiauthored textbook presents the fundamental biology and the broad overview of clinical problems in more depth and breadth than is possible for the periodical literature. For those who are seeking to review the evidence basis for current critical care, in parallel with a lucid and methodical tutorial of the relevant physiology, the latest edition of Irwin and Rippe's Intensive Care Medicine  retains its place in the medical library.
*Oregon Health and Science University, Portland, Oregon.
References
Eichacker PQ, Natanson C, Danner RL: Surviving sepsis-practice guidelines, marketing campaigns, and Eli Lilly. N Engl J Med 2006; 355:1640Eichacker, PQ Natanson, C Danner, RL
Gardlund B: Activated protein C (Xigris) treatment in sepsis: A drug in trouble. Acta Anaesthesiol Scand 2006; 50:907–10Gardlund, B
Mangano DT, Tudor IC, Dietzel C, Multicenter Study of Perioperative Ischemia Research Group, Ischemia Research and Education Foundation: The risk associated with aprotinin in cardiac surgery. N Engl J Med 2006; 354:353Mangano, DT Tudor, IC Dietzel, C
Hogue CW: Aprotinin use during cardiac surgery: A new or continuing controversy? Anesth Analg 2006; 103:1067–70Hogue, CW
Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC, Jr, Jacobs AK, Adams CD, Anderson JL, Antman EM, Buller CE, Creager MA, Ettinger SM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B, Tarkington LG, Yancy CW, American College of Cardiology, American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery), American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society for Vascular Surgery: ACC/AHA 2007 guidelines for perioperative cardiovascular evaluation and care for noncardiac surgery. J Am Coll Cardiol 2007; 50:159–241Fleisher, LA Beckman, JA Brown, KA Calkins, H Chaikof, E Fleischmann, KE Freeman, WK Froehlich, JB Kasper, EK Kersten, JR Riegel, B Robb, JF Smith, SC Jacobs, AK Adams, CD Anderson, JL Antman, EM Buller, CE Creager, MA Ettinger, SM Faxon, DP Fuster, V Halperin, JL Hiratzka, LF Hunt, SA Lytle, BW Nishimura, R Ornato, JP Page, RL Riegel, B Tarkington, LG Yancy, CW American College of Cardiology, American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery), American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society for Vascular Surgery,