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Few fields in medicine have blossomed as dramatically as critical care. When we published the first edition of Principles of Critical Care in 1992, the critically ill were treated based largely on knowledge of pathophysiology, often derived from whole animal models. The evidence base for treatment was sparse and, with few exceptions, large, well-conducted clinical trials were lacking. What a change the past two decades have brought! The nature of critical illness is far better understood at molecular, cellular, organ, whole patient, and population levels. Diagnostic and monitoring tools, such as point-of-care ultrasound, stroke volume estimating equipment, and biomarkers, have altered the way we examine our patients. New drugs and devices have been devised, tested, and applied. Large clinical trials now inform a broad range of treatments, including those for respiratory failure, septic shock, acute kidney injury, raised intracranial pressure, and anemia of critical illness. Protocols and bundles aid, and sometimes frustrate, our provision of care. 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. To guarantee that this text remains useful in its electronic and print versions, 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 should both explicate the common mechanisms that transcend all critical illness and provide an in-depth, specific discussion of important procedures and diseases. The exceptional response to the first three editions of Principles of Critical Care showed us that we have succeeded. In this fourth edition, we have added new chapters on ICU Ultrasound, Extracorporeal Membrane Oxygenation, ICU-Acquired Weakness, Abdominal Compartment Syndrome, and Judging the Adequacy of Intravascular Volume, among others. The changing nature of modern critical care spawned new or completely revised chapters regarding Preventive Bundles, Informatics, Statistics, Rapid Response Teams, Physical Therapy, and more. In addition, we recognize that critical illness stresses entire systems, not just individual patients, so we have created new contributions on caregiver and family issues and on the implications of disordered sleep for the critically ill.

We have collected up front many of the issues of organization that 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 three editions: a solid grounding in pathophysiology, appropriate skepticism based in scholarly review of the literature, and user-friendly chapters beginning with “Key Points.”

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. It is our hope that this textbook is a reflection of the interweaving and mutually supporting threads of critical care practice, teaching, and research.

In addition to our author-contributors, we are indebted to our own students of critical care at the University of Chicago and the University of Iowa 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 and the Carver College of Medicine. It has also been a source of knowledge and inspiration to interact with practicing physicians from around the world in many courses and symposia, helping us to understand the breadth of critical care as it is practiced and continues to evolve. All of these colleagues make our practice of interdisciplinary critical care at the University of Chicago and the University of Iowa interesting and exciting.

While the field of critical care has changed greatly since the last edition of our textbook, so has the core of senior authors. Thirty years ago, Larry Wood inspired Jesse Hall and Greg Schmidt to join him in the pursuit of excellence in the practice, teaching, and study of critical care medicine, and they have remained steadfast in their appreciation of his mentorship along this path. More than 20 years ago, Larry invited these colleagues to join him in the creation of the first edition of this textbook, a project that has remained a valued task by us all as the reputation of the text has grown and it has mapped the course of a dynamically changing field. Several years ago, Larry retired and chose to end his participation in this project. While we miss his sage advice, keen insight, and mastery of critical care, we believe he feels this project is in good hands, because he trained us well and we have now been joined by John Kress, professor of medicine, anesthesia, and critical care at the University of Chicago. John is another trainee of Larry’s, and a much valued colleague ever since his residency and fellowship training with us. John has moved seamlessly into a role as associate editor and without his help this endeavor would surely have been impossible. We look forward to his engagement in future editions. 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. We also appreciate the consistent organizational efforts of our editorial assistant, Deborah Hunter, who coordinated the many responsibilities that underlie such a mammoth undertaking. Her perseverance, sense of purpose, and sunny optimism made our task much easier.

Jesse B. Hall, MD

Gregory A. Schmidt, MD

John P. Kress, MD

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