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88 T. M. Dunn and A. M. Nussbaum
Ö Have symptoms that cannot be directly observed, or are not
present, when a physician is present.
Ö Have sudden and unexplained setbacks during their hospital
course.
Treating this condition is very difficult.
Ö Individual psychotherapy is indicated, but rarely do these indi-
viduals have enough insight into their situation to participate.
Ö Despite suspecting that the patient may suffer from Factitious
Disorder, the patient often engages in behavior that requires
surgical intervention.
Ö Certainly it is prudent to involve a psychiatrist or psychologist in
the case, but these individuals will often move on to another
hospital once they are challenged.
{ Illness Anxiety Disorder (formerly hypochondriasis)
Some people are preoccupied with the fear that they have, or are going
to acquire, a serious medical condition.
Despite assurances that they are well, they continue to have irrational
fear about their health.
Typically, somatic complaints are minimal or absent.
These individuals do well with individual psychotherapy and other
traditional treatments for anxiety.
Ö Unfortunately, they may see referral to a mental health specialist
by a surgeon as being dismissive.
{ Somatic Symptom Disorder (formerly somatoform disorder, hypochon-
driasis, pain disorder)
Individuals with somatic symptoms (often pain, but does not need to
be) whose thoughts, feelings or worry about their complaints are out
of proportion and are disrupting their daily life.
This could manifest itself by:
Ö Having excessive anxiety or stress about symptoms.
Ö Obsessing about their symptoms.
Ö Spending an excessive amount of time and energy devoted to their
symptoms or health concerns.
These individuals tend to be unhappy with explanations by medical
providers and are often deaf to assurances by physicians that their
symptoms are not indicative of a major illness or surgical emergency.
Surgical Critical Care and Behavioral Health 89
While resistant to treatment by a mental health provider, these
individuals tend to suffer from co-occurring depression.
Ö There is an elevated risk of suicide with such patients, making
referrals to an outpatient mental health provider very important.
{ Delusions of Somatic Nature
Delusions of grandeur or of persecution are not uncommon in patients
suffering from psychosis.
Less common are somatic delusions, but do occur with some
frequency in those suffering from Delusional Disorder.
Ö Some may believe that they have a foul odor emanating from their
body.
Ö Others may believe that somatic sensations indicate the presence
of animals in their body or insects under their skin.
Ö Infrequently, some people believe that they are missing vital
organs, or organ systems are missing.
Antipsychotic medications are effective in treating such delusions.
• Patients Requesting Amputation
{ Infrequently, patients may present to the surgeon asking that a healthy
limb be removed.
{ Generally, patients without a surgical problem asking that a limb be
removed fall into one of three categories:
Body Integrity Identity Disorder
Ö The sense that a portion of an individual’s body (usually a limb)
foreign.
Ö A paradoxical perception then sets in: in order to feel complete, an
individual must have part of their body amputated.
Ö There are reports in the literature of individuals with this condition
amputating their own limbs.
— And on occasion, amputating a limb that had already been
surgically re-attached.
Apotemnophilia
Ö These are individuals who have an erotic association with losing a
limb.
Ö Their drive for sexual satisfaction may be sufficient to deliberately
injure the limb in hopes that it will need to be amputated.
90 T. M. Dunn and A. M. Nussbaum
Severe Psychosis
Ö There are numerous case reports of patients suffering severe
psychosis and having the delusional belief that an end can be
achieved by undergoing an amputation.
Ö We have treated a patient who believed world peace could be
achieved by amputation of his dominant hand.
— When rebuffed by a surgeon, he mangled his hand in a garbage
disposal.
{ Obviously, patients requesting amputation are often suffering from severe
mental illness.
In many cases, these individuals may benefit from psychiatric inter-
vention, particularly those who are psychotic.
• The Psych Consult
{ There are some surgical patients that require consultation by a psychologist
or a psychiatrist.
Those whose surgical admission is secondary to self-harm.
Patients who have been placed on mental health holds.
Psychotic patients whose delusional beliefs have resulted in hospital
admission.
Individuals who have clozapine (Clozaril) as a home medication.
{ Strongly consider consultation for these patients:
Psychotic patients.
Patients with severe mental illness that is untreated.
Ongoing questions about a patient’s capacity to make medical decisions.
Any patient who has become threatening and/or assaultive while not
intoxicated, withdrawing, or confused.
For any patient who requests it (or whose family, spouse, or partner
makes such a request).
{ Before placing a psych consult
Request necessary medical records from existing prescribers, or notes
from recent psychiatric admission.
Inform the patient that a behavioral health provider will visit and
assess them.
Verify that outpatient psych medications have been restarted or there
is a rationale for deferring their administration.
Surgical Critical Care and Behavioral Health 91
Practical Algorithm(s)/Diagram
Fig. 1. Danger if patient leaves AMA algorithm.
92 T. M. Dunn and A. M. Nussbaum
Review of Current Literature with References
• Prazosin for PTSD Symptoms and Nightmares in Active-Duty Combat
(Am J Psychiatry 2013; 170: 1003–1010).
{ Both Acute Stress Disorder and PTSD are associated with nightmares and
hyperarousal, such as irritability, insomnia, and hypervigilance.
{ The use of the antihypertensive prazosin, a CNS alpha-1 antagonist, has
been associated with reducing nightmares.
Typically, 1 mg is started at hs for three nights, followed by 2 mg
through day 7.
If nightmares continue, and hypotension/orthostasis is not significant,
the dose may be increased to 4 mg. Some patients may require titration
to a maximum daily dose of 15 mg over four weeks.
There may be an increased risk of priapism if trazadone and prazosin
are given together.
{ A recent study evaluated the reduction of hyperarousal using higher doses
(and twice daily dosing) of prazosin in a randomized, placebo controlled
experiment involving soldiers with PTSD.
Sixty-seven soldiers (10 women) meeting criteria for PTSD and
combat related nightmares at least twice a week comprised the sample.
Ö Exclusion criteria included:
— Supine systolic blood pressure < 110 mmHg
— Orthostatic hypotension
— Acute or unstable medical condition
— Severe psychiatric illness or suicidality
— Substance use disorders
The prazosin group showed clear reduction in both nightmares and
symptoms of hyperarousal, with improved sleep and daily functioning.
Mean first dose (given mid-morning) for men was 4 mg, and 2 mg for
women. Mean hs dose was 16 mg for men and 7 mg for women.
Three individuals in the prazosin group had a remittance of their
PTSD, no members of the placebo condition did.
Blood pressures did not differ between groups; there were no adverse
effects associated with prazosin.
{ While an impressive study, it should be noted that its participants were
physically fit and were not injured.
Surgical Critical Care and Behavioral Health 93
Obviously, a drug that may cause hypotension is contraindicated in
some surgical patients.
• Dexmedetomidine [Precedex] and the reduction of postoperative delirium
after cardiac surgery (Psychosomatics 2009; 50: 206–217).
{ This study observed the occurrence of delirium in patients managed on
one of three different agents used for postoperative sedation: dexmedetomidine, midazolam, or propofol.
{ The design was a prospective, randomized controlled (but not double
blinded) study of elective cardiac valve replacement patients.
{ Exclusion criteria included:
Children and adults over age 90.
A preexisting diagnosis of dementia, schizophrenia, or substance use
disorder.
CVA in the last six months.
Evidence of a heart block.
Anticipated intraoperative deep hypothermic circulatory arrest.
{ A total of 90 patients completed the study, 30 in each treatment arm:
Dexmedetomidine patients received a loading dose of 0.4 µg/kg fol-
lowed by a maintenance infusion of 0.2–0.7 µg/kg/hr.
Those in the propofol arm were dosed at 25–50 µg/kg/hr.
Midazolam patients were given 0.5–2 mg/hr.
Randomized assignment into one of the three conditions resulted in
roughly equivalent groups based on age, baseline cognitive functioning, length of procedure, time on bypass, and period of time under
anesthesia.
{ In the first 24 hours postoperatively, only fentanyl was used for pain
management.
After 24 hours, ketorolac, hydrocodone, and oxycodone were all used
for analgesia.
{ Whether delirium developed in the first three days postoperatively was
assessed using the Delirium Rating Scale.
{ The incidence of delirium was then compared between the three groups
and the results were striking and statistically significant:
Incidence of delirium for dexmedetomidine: 3%
Incidence of delirium for midazolam: 50%
Incidence of delirium for propofol: 50%
94 T. M. Dunn and A. M. Nussbaum
{ The dexmedetomidine group also had significantly shorter ICU length of
stay, briefer hospital course, and reduced financial costs.
{ In this study, dexmedetomidine was associated with significantly reduced
occurrence of delirium.
5. Cardiovascular
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Chapter 5-(i)
Fundamentals of Oxygen Transport
and Cellular Metabolism
Teresa Jones, MD* Robert McIntyre, Jr., MD† and Erik Peltz, DO
* Surgical Resident, University of Colorado School of Medicine
†
Professor of Surgery, University of Colorado School of Medicine
‡
Assistant Professor of Surgery, University of Colorado School of Medicine
Take Home Points
• The principal goal of “ resuscitation” is to provide optimal/adequate oxygen
at the tissue level.
• Oxygen balance is dependent on: arterial oxygen delivery (oxygen con-
tent and cardiac output), patient metabolic demand and cellular oxygen
consumption (VO2).
• Oxygen delivery (DO
oxygen content and cardiac output than patient metabolic demand or
cellular VO
.
2
• Oxygen content is dependent on arterial hemoglobin oxygen saturation (SaO
and hemoglobin.
) is more readily modified by augmenting arterial
2
2
‡
)
Contact information: Department of Surgery, 12631 East 17th Ave, C313, Aurora, CO
80045. Email: Teresa.jones@ucdenver.edu; Robert.mcintyre@ucdenver.edu; Erik.peltz@
ucdenver.edu
97