Metabolic response to trauma Flashcards
In modern surgery, a major goal is to ________ the metabolic response to surgery in order to _______ recovery times.
minimize; shorten
When a major metabolic response does occur, the emphasis is on managing the patient in a way that minimizes _____________ either at the original site of injury or in other organs
further tissue damage
Systems involved in metabolic response to trauma
________
__________
_____________
________________
Local events
Neural
Endocrine
Neuro-endocrine
In ebb phase
Spectrum of inflammatory processes occur with local and distant effect on other body organs
In current medical practice these processes may attenuated but not abolished by ____________
intravenous fluids
The predominant hormones regulating the ebb phase are:
_________
_____________
__________
Catecholamines
Cortisol
Aldosterone
Flow phase= ______________________
Systemic Inflammatory Response Syndrome(SIRS).
The flow phase may be subdivided into catabolic phase(________) and anabolic phase( _______)
3-10days
weeks
From injury to convalescence opposing effect of _________________ and ______________
inflammatory response syndrome(SIRS)
counter anti-inflammatory
response(CARS)
Local/Systemic effects in metabolic response
Mainly that of acute inflammatory response and its sequelae
Neural
-____________ nervous system
-_____________________ axis
Cellular
-_________
-___________
-____________
Humoral mediated
_________(pro-inflammatory and anti-inflammatory)
Other chemical mediator(prostaglandins,eicosanoids,proteases)
-pituitary and adrenal hormones
-thyroid hormones
sympathetic; hypothalamus pituitary adrenal
neutrophils; macrophages; lymphocytes
Cytokines
Activation of sympathetic nervous system
Impulses generated in afferent pain nerve endings at the site of tissue injury have a role in mediating the metabolic responseto injury.
Pain fibres comprise both ________________ fibres and _____________ fibres.
Pain fibres are stimulated via direct trauma or the release of nerve stimulants such as _________.
Nerve impulses reach the _______ via the _________ of the spinal cord and the ________________ tract.
Afferent impulses reaching the thalamus mediate the metabolic response via several mechanisms
unmyelinated C fibres and myelinated A
prostaglandins; thalamus
dorsal horn; lateral spinothalamic
Summary of metabolic response to surgery and trauma
Thalamus:
Heart and CVS:
Pituitary:
Pyrexia
Increased sympathetic activation leading to tachycardia
Increased ACTH and ADH
Summary of metabolic response to surgery and trauma
Superarenal gland
Pancreas
Bone marrow
Skeletal muscle
Increased aldosterone, adrenaline, and cortisol
Decreased insulin, increased glucagon
Impaired red cell production
Increased muscle breakdown
Important Cytokines in metabolic response to trauma
Pro-inflammatory:
Anti-inflammatory:
Chemokines :
TNF; IFN; IL-1
IL-10; IL-6; TGF-B
IL-8
Negative acute-phase proteins (decrease after injury)
• ● __________
• ●___________ and __________
Albumin
Transferrin
Transthyretin
Clinical use: _______ is a useful marker of systemic inflammation
CRP
Clinical spectrum of infection and SIRS
Sepsis:
Focused source of infection + SIRS
Hypovolaemia
Trigger: blood loss, inflammatory interstitial edema
Natural counteracting mechanism: _____,____ ,______
Prevention: _______________
ACTH,ADH,RAS
volume(fluids,blood) replacement
Hypothermia:
Trigger: cold ambient temperature,hypovolaemia
Untreated may lead to cardiac arrhythmias,coagulopathy acidosis
Prevention: ______________, upper body forced-air heating cover.avoid exposure of viscera and prolonged surgery
warm Intravenous fluids
Hyperthermia:
Trigger: increased ______________,
resetting of ______________ by _____
Consequence: increased evaporatory water loss. Pyrexia may also complicate infection occurring after injury.
Metabolic rate increases by _____% for each 1°C change in body temperature
Counteracting effects: Drugs- _______,______ . liberal fluid intake,rehydration
resting energy metabolism
hypothalalamic thermostat by IL-1
6–10
NSAIDS,paracetamol
Weight loss
May be up to _____kg per day in severe trauma. More so if complicated by _____
Mechanism: increased ______________, perioperative ————-
Weight gain in severe trauma and sepsis may suggest ____________
0.5; sepsis
protein and fat catabolism; starvation
over hydration
Immunosupression
Due to secretion of stress hormones( _________,_________) and ____________
catecholamines
glucocorticoids
prostaglandins
INTRODUCTION TO PRINCIPLES OF
ENHANCED RECOVERY AFTER
SURGERY(ERAS) PROGRAM
•Commence ________ of _________ or even _________ the _________ after surgery
•_________ and _________ patients by within _________ of surgery
•_________ from the hospital.
•Faster _________ recovery.
oral intake; fluid ; food ; same day
Sit out of bed ; ambulate patients ; 24 hours
Early discharge
home
Some clinical Interventions to reduce
metabolic response to surgery and
trauma
__________ techniques
Blockade of __________ stimuli (e.g. __________ analgesia)
Minimal periods of __________
Correct __________
Correct __________
Correct __________
Early __________
Minimal access techniques
painful stimuli ; epidural analgesia
starvation ; hypovolaemia
hypoxia; acidosis
mobilization
PRINCIPLES OF ERAS
Pre-operative
Preadmission __________
__________ and __________ loading
__________ fasting
__________ bowel preparation
__________ prophylaxis
__________ prophylaxis
counseling
Fluid and carbohydrate
No prolonged
No/selective
Antibiotic
Thrombo
PRINCIPLES OF ERAS
Intra-operative
_______ acting anaesthetic agents
No ______
Goal-directed ______ therapy
Mainateance of _________
Short
drains
fluid
normothermia
PRINCIPLES OF ERAS
Post -operative
______ anesthesia
No nasogastric tubes
Prevention of nausea and vomiting
Goal directed fluid therapy
Early removal/avoidance of catheter
Early oral nutrition
Non-opioid oral analgesia
Early mobilization
Stimulation of gut motility
Audit of complainer or outcomes
Four systems control the metabolic response
SNs
Acute phase response
Vascular endothelium and blood response
Endocrine response
Factors responsible fro systemic response
Fall in intravascular volume
Reduced cardiac output and peripheral perfusion
Pain
Stress
SIRs
Inflammation
Excess heat loss
Sec effects on blood
Starvation
Mild tachycardia in post operative PT is due to
Increase BP and PR from falling intravascular volume
Counteracting heat loss in Op thru
Raising ambient temp
Wrapping exposed parts of body with insulating material
Warm water under blankets
Warming fluids IV infection
Indicators of starvation
1)lack of nutritional intake for more than 10daus
2)reduced grip length
3)weight loss of more than 10% of normal body weight
4)low serum albumin >26mg/do
5)low serum transferring
6)reduced lymphocyte count
Surgical.catabolism.
Key factors in response to systemic insults
Increased sympathetic activity
Circulating catecholamines
Insulin
Surgical.catabolism.
Hormones and function
Reduced insulin secretion-utilisation of glucose
Stimulation of glucagon secretion-enhances glycogenesis and glycogenesis
Catecholamines and glucagon-lipolysis stimulation(main source of energy for peripheral tissues)
Increased pit ACTH-Increasing circulating glucocorticoids
GLUCOCorticoids-enhnace gluconeogenesis and catabolism of protein
Increased secretion of growth hormone and thyroid hormone-inhibit insulin and promote catabolism
Raised cortisol -suppresses immunity
SIRS occurs if:
Two or more are present:
1)Temp>38 or <36
2)HR >90BEATS/MINS
3(RR->20BREATHS/MIN for spontaneous ventilation or PCO2-<4.3kpa(33mmhg)
White cell count >12,000cells/mm3 or <4000cells/mm3 or more than 10%immature forms in peripheral blood smear
