Brain, Vol. 125, No. 11, 2579-2581,
November 2002
© 2002 Oxford University Press
Book Review |
NEUROLOGIC COMPLICATIONS OF CRITICAL ILLNESS, 2ND EDITION
Walton Centre for Neurology and Neurosurgery, Liverpool, UK
NEUROLOGIC COMPLICATIONS OF CRITICAL ILLNESS, 2ND EDITION
By Eelco F. M. Wijdicks
2002. Oxford: Oxford University Press
Price £79.50. pp. 435. ISBN 0195140796.
This monograph is the latest in the Contemporary Neurology series and is written entirely by one author. Professor Wijdicks is the director of the neurological and neurosurgical intensive care unit (ICU) at the Mayo Clinic, and his great experience of neurology in the ICU is readily apparent throughout the book. He writes in a consistent and authoritative fashion on the acute neurology which finds its way to the ICU. In the UK at least such patients would usually be under the care of other doctors before neurologists are consulted, often quite late. The book is very comprehensive in its coverage, including something on virtually every critical illness with serious neurological complications (the only omission I could think of was porphyria).
Part 1 is the most rewarding section of the book. It is an overview of coma and its assessment, with a discussion of some of the general problems which may arise in such patients. The discussions on coma and its assessment are quite standard, and could be found in other text books. However, what most advanced readers will like is the overview of the common clinical presentations with which they are faced, such as ‘failure to awaken after surgery’, the consideration of coma in patients with normal CT scans, and then entire chapters dealing with issues such as seizures or generalized weakness in the ICU, and neurological complications of invasive procedures. These sections and chapters contain the real gems of the book in which the clinically likely and relevant is stressed by Professor Wijdicks.
It should be self-evident that the clinical condition of the vast majority of patients on the ICU is influenced by various drugs, but most neurologists, knowledge of many of these is rather poor. The chapter on such drugs is likely to be an education for all. It deals with the pharmacodynamics and pharmacokinetics of the commonly used agents used in sedation. In addition, drugs with direct neurotoxic effect are well outlined.
Part 2, entitled ‘Neurologic Complications in Medical and Surgical Intensive Care Units and Transplantation Units’, deals with the problems arising in individual disorders or groups of disorders (e.g. cardiac arrest, acute hepatic failure, organ transplantation, etc.). Background general medical information is provided, along with short pieces on pathophysiology where relevant. This sets the scene for the neurology in each chapter. Much of this information is naturally available in other standard neurological texts, but here it is collected together and the chapters such as that on acid–base, electrolyte and endocrine disorder have much information that will have seeped away from most neurologists after their Membership.
One of the more common requests for a neurological consultation on the ICU is for assessment of patients who have failed to ‘wake up’ after an otherwise successful resuscitation of a cardiac arrest. A 20-page chapter is devoted to this subject, with the summaries of those bits which occur before and after the neurologist’s visit(s), as well as a longer section on the strictly neurological. Whilst acknowledging the primacy of the clinical assessment, the author runs through this in three and a bit pages, and then devotes six to special investigations. I have no problem with the latter, but would have preferred to see the clinical part expanded and re-focused to address the issue of assessment of prognosis (this is dealt with separately in Part 3). In the UK, this is the main question we are being asked, and, limited as the data is, I found the recent contributions from Bates (2001
) and Overell et al. (2001) more helpful.
Another chapter involves the ‘Neurologic Complications of Multi-system Trauma’, which is a useful summary for those neurologists asked to see trauma patients in hospitals not immediately served directly by neurosurgeons. The usual scenario is that the neurosurgical team has already been consulted by telephone and electronic image transfer, and that transfer of the patient was not thought to be appropriate. The patient then deteriorates without obvious new haematoma on the CT brain scan, or is failing to improve, or the ICU staff have noticed something else vaguely neurological that seems not to have been explained. Here the ability to interpret scans oneself is of greatest importance, and this is one of the instances where more emphasis on the imaging with examples may have been welcomed. However, in general, the account summarizes the management of head injury quite well, in an area where many British neurologists are probably relatively lacking. It also extends its scope to include injuries to the spinal cord, plexuses and peripheral nerves, and the fat embolism syndrome, areas where I suspect we are better informed.
Discussions about head injury management do not stray into the surgical domain but relate more to general medical principles. Intracranial pressure monitoring devices are used far less in UK ICUs than advocated in this book, presumably partly because of resources. There is little or no debate in this chapter of their potential effects on outcome, their problems or their reliability. The debate has obviously been settled in North America, and shifted to one of the precise indications. Despite this, the book does discuss at some length the problems of controlling raised intracranial pressure, both by reducing provoking factors and by direct pharmacological means, and mentions the recent Cochrane review’s conclusions about the lack of trial evidence for such interventions. Overall the chapter raised more questions in my mind than it answered, but I found it valuable nevertheless.
Part 3 consists of two chapters. The first discusses outcomes in coma due to some of the more common problems discussed in Part 2; the main ones are post-resuscitation, after stroke and after trauma. I thought this section could have been usefully expanded. The second chapter considers withdrawal of life support; the legal aspects may be somewhat different in the US but the medical issues and practical difficulties are common. Once again Professor Wijdicks provides experienced, common sense comment.
Chapters are generally 10 to 20 A3 sized pages each. All could readily have been longer but the writing is concise and tight. It is not easy reading, but the frequent tables, patient photographs, scans, etc., all help considerably not only to clarify the text but also to break it up. Numerous references are provided if further detail is required, though I doubt this is likely.
The book is written for neurologists and at a high level. I cannot see it appealing to any other readership. It will be particularly useful for those who are attached to teaching hospitals with large ICUs and a wide range of specialist units. It is the sort of book to be kept in your desk drawer or nearest book shelf, to be dipped into frequently before or after those visits to ICU. It deals with some very challenging situations, many of them occurring infrequently. Unless you are blessed with spare memory to accommodate and retain such chunks of information, you (and I) would have much to gain from having this book readily to hand. Now, as for that bleeding, hypomagnesaemic, liver transplant patient on cyclosporine who developed fungal infective endocarditis, started fitting and had a cardiac arrest, why has he not woken up yet?
References
Bates D, The prognosis of medical coma. J Neurol Neurosurg Psychiatry 2001; 71 (Suppl I): i20–3.
Overell J, Bone I, Fuller GN. An aid to predicting prognosis in patients with non-traumatic coma at one day. J Neurol Neurosurg Psychiatry 2001; 71 (Suppl I): i24–5.
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