MNT for Metabolic Stress, Sepsis, Trauma, Burns, and Surgery

Question 1

Metabolic Stress

Answer 1

• Sepsis
• Trauma
• Surgery: systemic response is activated, physiologic and metabolic changes follow and may lead to shock and/or other negative outcomes

Question 2

Metabolic Response to Stress

Answer 2

Involves most metabolic pathways. Rapid loss of LBM results in:

• negative nitrogen balance
• muscle wasting

Question 3

Ebb Phase

Answer 3

• Immediate- hypovolemia, shock, tissue hypoxia
• Decreased cardiac output
• Decreased oxygen consumption
• Lowered body temperature
• Insulin levels drop because glucagon is elevated

Question 4

Flow Phase

Answer 4

• Follows fluid resuscitation and O2 transport
• Increased cardiac output begins
• Increased body temperature
• Increased energy expenditure
• Total body protein catabolism begins
• Marked increase in glucose productions, FFAs, circulating insulin, glucagon, and cortisol

Question 5

Hormonal and Cell-Mediated Response

Answer 5

There is a marked increase in glucose production and uptake secondary to gluconeogenesis, and:

• elevated hormonal levels
• marked increase in hepatic amino acid uptake
• protein synthesis
• accelerated muscle breakdown

Question 6

Starvation vs Stress

Answer 6

Metabolic response to stress differs from the responses to starvation.

Question 7

Starvation

Answer 7

Decreased energy expenditure, use of alternative fuels, decreased protein wasting, stored glycogen used in 24 hours.

Question 8

Late Starvation

Answer 8

Fatty acids, ketones, and glycerol provide energy for all tissues except brain, nervous system, and RBCs.

Question 9

Hormonal Stress Response

Answer 9

• Aldosterone
• Antidiuretic Hormone (ADH)
• ACTH
• Catecholamines

Question 10

Aldosterone

Answer 10

Corticosteroid that causes renal sodium retention.

Question 11

Antidiuretic Hormone (ADH)

Answer 11

Stimulates renal tubular water absorption. These conserve water and salt to support circulating blood volume.

Question 12

ACTH

Answer 12

Acts on adrenal cortex to release cortisol (mobilizes amino acids from skeletal muscles).

Question 13

Catecholamines

Answer 13

Epinephrine and norepinephrine from renal medulla to stimulate hepatic glycogenolysis, fat mobilization, and gluconeogenesis.

Question 14

Cytokines

Answer 14

-Interleukin 1
-Interleukin 6
-Tumor necrosis factor (TNF)
Released by phagocytes in response to tissue damage, infection inflammation, and some drugs and chemicals.

Question 15

Interleukin 1

Answer 15

Metabolic effect that increases body temperature.

Question 16

Interleukin 6

Answer 16

Metabolic effect that activates and release of cellular communication and mediators.

Question 17

Tumor Necrosis Factor (TNF)

Answer 17

Metabolic effect that alters metabolism: catabolism and hypermetabolism.

Question 18

Systemic Inflammatory Response Syndrome (SIRS)

Answer 18

Describes the inflammatory response that occurs in infection, pancreatitis, ischemia, burns, multiple trauma, shock and organ injury. Pts with SIRS are hypermetabolic.

Question 19

Multiple Organ Dysfunction Syndrome

Answer 19

Organ dysfunction that results from direct injury, trauma, or disease or as a response to inflammation; the response usually is in an organ distant from the original site of infection or injury.

Question 20

Diagnosis of Systemic Inflammatory

Answer 20

Site of infection established and at least two of the following are present:
-Temp >38 or 90
-Respiratory rate >20
-PaCO2 12,000/mm3 or <4,000/mm3
-Bandemia
May be caused by bacterial translocation

Question 21

Bandemia

Answer 21

Presence of >10% bands (immature neutrophils) in the absence of chemotherapy-induced neutropenia and leukopenia

Question 22

Bacterial Translocation

Answer 22

Changes from acute insult to the gastrointestinal tract that may allow entry of bacteria from the gut lumen into the body; associated with a systemic inflammatory response that may contribute to multiple organ dysfunction syndrome. Well documented in animals, may not occur to the same extent in humans. Early enteral feeding is thought to prevent.

Question 23

Postoperative Nutrition Support

Answer 23

• Introduction of solid foods depends on condition of GI
• Oral feedings may be delayed for first 24-48 hours post surgery until return of bowel sounds, passage of flatus or soft abdomen
• Traditional practice has been to progress from clear liquids, to full liquids, and then to solid foods. However, there is no physiological reason not to initiate solid foods once small amounts of liquids are tolerated.

Question 24

Hypocaloric Feedings Have Been Recommended In:

Answer 24

• Class III obesity (BMI >40)
• Refeeding syndrome
• Severe malnutrition
• trauma pts following shock resuscitation
• Hemodynamic instability
• Acute respiratory distress syndrome or COPD
• MODS, SIRS, or sepsis

Question 25

Protein and Nitrogen Requirements in Surgery

Answer 25

1.2 to 1.5 g/kg of protein a day of CBW for anabolism mild or moderate stress. Nitrogen requirements estimated from energy requirements.