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Medical Biochemistry > Metabolic response to trauma/ critical illness > Flashcards

Metabolic response to trauma/ critical illness Flashcards

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USMLE® Step 1 flashcards
1
Q

What are the various factors that can contribute to hyper-metabolic response

A

1) Sepsis
2) Fractures
3) Stress
4) Trauma
5) Burns
6) Major surgery

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2
Q

What are hormonal mediators of stress response?

A

1) Aldosterone
2) Anti-diuretic Hormone (ADH)
3) ACTH
4) Catecholamines

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3
Q

What is the role of aldosterone?

A

Causes renal retention

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4
Q

What is the role of ADH?

A

stimulates renal tubular water absorption

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5
Q

What is the role of ACTH?

A

Acts on aderenal cortex to release cortisol (glucocorticoids). (stimulates lipolysis and mobilized amino acids from skeletal muscles)

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6
Q

What hormones are the flow phase characterized by?

A

High levels of insulin predominant

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7
Q

Patients with type I diabetes may have episodes of _____ following an illness or injury

A

Ketoacidosis

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8
Q

What are the metabolic changes following a wound or trauma?

A
  • Phagocytic release of mediators
  • Rapid loss of fluid and electrolytes
  • Hemorrhage
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9
Q

,Regarding metabolic changes following trauma rapid loss of fluid and electrolytes and hemorrhages lead to what?

A

Hypovolemia

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10
Q

Regarding metabolic changes following trauma, hypovolemia leads to what?

A 
Secretion of:
Catecholamines
Aldosterone
ADH
Glucocorticoids
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11
Q

Regarding metabolic changes following trauma, release of catecholamines ect. is associated with what?

A

Increased proteolysis and lipolysis

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12
Q

What are the inflammatory mediators of stress response?

A

Cytokines
Complement
Eicosanoids
PAF

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13
Q

What are the general roles of the catecholamines, epinephrine and norepinephrine?

A

stimulate hepatic glycogenolysis, fat mobilization, gluconeogenesis

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14
Q

Where are catecholamines released from?

A

Adrenal medulla

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15
Q

Which cytokines are released by phagocytes in response to tissue damage, infection, inflammation?

A

Interleukins,
tumor necrosis factor (TNF),
eicosanoids

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16
Q

What are the roles of cytokines in response to tissue damage, infection, inflammation?

A

Promote wound healing,
increase blood supply,
Localize wound
Increase white cell counts and fascilitate migration
Responsible for fever (inc metabolic rate)
Stimulates acute phase protein synthesis

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17
Q

What 2 eicosanoids are important mediators of inflammation?

A

PGE2

PGF2-alpha

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18
Q

What is the Ebb phase also known as?

A

Unresuscitated Phase

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19
Q

What is the Flow phase also known as?

A

Adrenergic - corticoid

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20
Q

What is the Anabolic phase also known as?

A

Recovery/ convalescent phase

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21
Q

Nitrogen balance is _______ in the anabolic phase.

A

Positive

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22
Q

What is the nitrogen balance in the Ebb and Flow phase?

A

Negative

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23
Q

What characterizes the Ebb phase?

A
  • Hypovolemia
  • Shock
  • Tissue hypoxia
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24
Q

Why do many patients have lactic acidosis in the Ebb Phase?

A
  • Glucose is oxidized anaerobically to form lactate
  • Low blood flow (impaired transport to liver - disrupt Cori cycle)
  • May also be seen in flow phase
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25
Q

How is the metabolic rate in patients in the Ebb phase?

A

Decreased

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26
Q

How are the insulin levels in the Ebb Phase?

A

Normal to Low

Mostly low

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27
Q

Characteristically, how are the insulin levels in the Flow Phase?

A

High due to insulin resistance

28
Q

How are the cardiac output, body temperature, and energy expenditures in the flow phase?

A

Increased

29
Q

In the flow phase, there is an increase in circulating levels of what?

A

Catecholamines
Insulin
Glucagon/cortisol
inflammatory cytokines

30
Q

Total body catabolism begins in what phase post trauma?

A

Flow phase

31
Q

During the flow phase, catabolized muscle protein provides amino acids for the liver to synthesis of what?

A

Acute phase proteins

32
Q

What are the acute phase proteins synthesized in the liver in the flow phase?

A

C-reactive protein

Alpha1-antitrypsin

33
Q

Which amino acids are utilized for maintenance of immune function in the Flow phase?

A

Glutamine

34
Q

Besides synthesis of acute phase proteins and maintenance of immune function, what else are amino acids used for during the flow phase?

A

Gluconeogensis precursors

-maintain blood glucose levels

35
Q

Epinephrine and cortisol stimulated increased levels of what during the flow phase?

A

Lipolysis

- circulating free fatty acids

36
Q

What hormone is characteristic in the flow phase?

A

Insulin

37
Q

Which hormones contribute to insulin resistance in the flow phase?

A

Catecholamines
Cortisol
Cytokines

38
Q

Regarding Carbohydrate metbolism, what is predominant in the flow phase?

A

Glucose productions

Hyperglycemia

39
Q

The metabolic rate is proportional to what in the flow phase?

A

Extent and severity of injury

40
Q

Why is there hyperglycemia during the ebb phase?

A
  • Epinephrine & Glucorticoids stimulate glycogenolysis and gluconeogenesis
  • Low insulin levels
41
Q

What may patients with type I diabetes have episodes of following an injury/infection

A

Ketoacidosis

42
Q

Why do patients with type I diabetes may have episodes of ketoacidosis following an injury/infection?

A

Patient does not respond to the normal doses of insulin due to the occurrence of insulin resistance

43
Q

What is the definition of insulin resistance?

A

Any requirement of insulin during critical illness is greater than 200 Units/day

44
Q

During the flow phase, what is the wound & hypoxic tissues convert most of the glucose to?

A

Lactacte (anaerobic glycolysis)

45
Q

Once lactate is made in anaerobic glycolysis in the flow phase, where does it go?

A

Liver - Cori cycle

46
Q

What are he energy providers for the brain in both flow phase and prolonged starvation?

A

Flow Phase: Glucose

Starvation: Glucose + Ketone bodies

47
Q

Compare GLUT 4 activity in the flow phase and starvation.

A

Flow: low due to insulin resistance
Starvation: Low due to low levels of insulin

48
Q

Why do patients with major trauma rapidly deplete their fat sotres?

A

Epinephrine/norepinephrine, glucocorticoids activate Hormone-Sensitive lipase causing high rate of TAG mobilization and oxidation.

49
Q

Why is ketogenesis not observed in patients with major trauma?

A
  • High insulin levels

- Peripheral tissues use free fatty acids or ketone bodies rapidly

50
Q

Ketogenesis is __________ to severity of injury

A

inversely proportional

51
Q

Protein catabolism is ______ to severity of illness.

A

proportional

52
Q

Both critical illness and starvation are states of negative nitrogen balance, but protein depletion is_________ in critical illness.

A

More severe

53
Q

How do you evaluate degree of muscle proteolysis?

A

Urine Urea Nitrogen (UUN) excretion in gms per day

54
Q

What system in skeletal muscle cells is activated by stress/illness?

A

Ubiquitin-Proteasome system

55
Q

Proteolysis of skeletal muscle during the flow phase is used for what?

A
  • Hepatic gluconeogensis

- maintenance of immune system

56
Q

Which two amino acids are the major type released during proteolysis after trauma?

A

Glutamine

Alanine

57
Q

Acute phase proteins are synthesized by the liver in response to inflammation and are commonly used to monitor what?

A

Progress and prognosis of inflammation.

58
Q

The degree of rise of the acute phase proteins is proportional to?

A

The severity of injury.

59
Q

Extensive protein depletion after trauma results in what?

A
  • Impaired wound healing
  • Decreased immune response
  • Breakdown of gut-mucosal barrier
  • Decreased mobility/respiratory effort
  • Increased predisposition to infection and hypermetabolism (vicious cycle)
60
Q

How much body protein must be depleted for fatality to generally occur?

A

greater than 20-30%

61
Q

In the anabolic/recovery phase, there is what?

A

Positive nitrogen balance and build up of tissue protein.

62
Q

During the flow phase, what is characteristic regarding urea excretion in the urine?

A

Increased

63
Q

What are the goals of nutritional management post trauma?

A
  • Minimalize catabolism
  • Meet protein, energy and micronutrient needs
  • Establish and maintain fluid and electrolyte balance
  • Plan nutrition therapy (oral, enteral, and/or parental nutrition)
64
Q

What is the goal of nutritional support in regards to protein supplementation?

A

May not result in +N balance, but may slow down protein loss and increase protein synthesis.

65
Q

Which amino acids are supplemented for enhancement of immune function?

A

Glutamine

Arginine

66
Q

Which nutritional support preserves intestinal mucosal integrity better?

A

Enteral nutrition

better than perenteral

67
Q

What is a prerequisite for enteral nutrition?

A

Functional GI tract

Medical Biochemistry (35 decks)

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