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Metabolic response to trauma a a Prof. H yder M. Abduln bi It is any reaction by the body to a speci ic impact or injury Example: surgery, burn, sepsis The body try to maintain homeostasis and to keep f metabolic balance Metabolic response Consist of two main parts Ebb & low In Ebb the body...

Metabolic response to trauma a a Prof. H yder M. Abduln bi It is any reaction by the body to a speci ic impact or injury Example: surgery, burn, sepsis The body try to maintain homeostasis and to keep f metabolic balance Metabolic response Consist of two main parts Ebb & low In Ebb the body try to decrease energy consumption at the beginning of trauma It last for few hours f f Followed by low phase EBB There is stimulation of sympathetic system (Fight and light) Secretion of catecholamin ( adrenalin and noradrenalin ) f From adrenal medulla Charecterized by 1. Increase pulse rate 2. Increase respiratory rate 3. Increase cardiac out put 4, Hyperthermia f begins the low phase Flow Consist of two phases Catabolic phase ( destruction) Anabolic phase ( construction) Catabolism Destruction Anabolism Construction ( building) Catabolic phase Charecterized by 1. Decrease cardiac output 2. Hypotention 3. Weak pulse 4. Decrease O2. Consumption 5. Hypothermia The body needs glucose for energy to keep body organs especially the brain and kidney this is done by 1. Glycogenolysis in the liver ( conversion of glycogen to glucose) 2. Gluconeogenesis also in the liver which is (production of glucose from protein and lipids) 3. Decrease insulin secretion from pancreas cause increase blood glucose level Body energy sources Glycogen in the liver Fat of the body (lipid) Protein in the skeletal muscle Increase secretion of cortisole and aldosterone from adrenal cortex This cause increase Na absorption from kidney and K mobilization from the body cell to the blood And provide body with glucose Also there is increase secretion of anti diuretic hormon ftom pituitary gland (ADH) cause increase water absorption from the kidney So cortisole, aldosterone,and ADH will cause increase Na, increase K and water retention Glycogenolysis—- glycogen—o— lysis Gluconeogenesis —- gluc—o—neo—genesis Lipolysis ——- lip—-o —- lysis Glycogenesis—- glyc—o—genesis Conversion to glucose cause decrease body weight , decrease body fat, skeletal muscle wasting and increase glucose in the blood ( hyperglycemia) Break down of protein to glucose cause increase nitrogen secretion in urine ( negative nitrogen balance) In case of prolonged trauma (Major surgery, burn, sepsis ) Or in starvation Cannibals The body is cosidered to eat itself ( cannibalism ) In hunger strike the body will survive 50-60 days Once protein loss reaches 30-40% of body weight survival is unlikely ADH secretion from pituitary gland Factors increase response to injury and treatment 1. Hypothermia ——- warming 2. Pain ——- analgesia 3. Starvation ——- glucose luid infusion, early feeding 4. Immobilization ——— early mobilization 5. Sepsis——- antibiotics f f 6. Hypotension ——— luid infusion Anabolic phase 1. No more cortisol secretion 2. Insulin secretion starts from pancreas 3. No more lipolysis 4. Protein synthesis starts and muscle built with increase in body weight 5. No more nitrogen secretion with urine ( positive nitrogen balance) Reversal of all metabolic changes of catabolic phase Body homeostasis return and then you and the patient will be happy Nutritional support of surgical patient a a Prof. H yder M. Abduln bi Nutritional therapy Is the the supply of nutrients either Orally—- exapmle: foti ied food or supplements Enteral ( EN ) —- through Gastrointestinal root Parenteral ( PN ) —- through venous system f All purposes to prevent or treat malnutrition Malnorished patients make poor surgical candidates Surgery cause a stress that leads to hyper metabolic or even catabolic response Malnutrition increase risks of post operative complications such as, reduced wound healing and increase infection rates Nutritionalal methods 1. If unable to eat enough calories orally —— oral nutritional supplements ( ONS ) 2. If unable to take enough calories orally—— nasogastric tube feeding ( NGT) 3. If esophagus blocked —- gastrostomy feeding 4. If stomach out low is obstructed —— jejunal feeding ( jejunostomy) f 5. If there is intestinal failure —— parenteral nutrition Rapid recovery after surgery Needs 1. Drecrease ( Nil By Mouth ) time before surgery 2. Carbohydrate loading before surgery 3. Minimal surgery 4. Rapid feeding after surgery 5. Early mobilization Diagnostic points for malnutrition 1. BMI ( basal metabolic index)< 20 kg/m2 2. Weight loss > 10% of body weight over the last 3 months 3. Albumin serum level <30gm/L ( in the abscence of hepatic or renal disease) Basal metabolic index ( BMI) Is a person weight in Kg ÷ square of height in meter It can indicate body fatness BMI of 20 indicates healthy weight MBI of 25-30 indicates overweight BMI of 30 or more indicates obesity If BMI is more than 40 sleeve operation may be considered Energy sourses Carbohydrate —- give 3.5 Kcal/gram Fat —— gives 9 Kcal/gram Protein —— gives 4 Kcal/gram Nutritional requirement Calories—- 35 Kcal/Kg Protein —— 1 gm/Kg Fluid —— 35ml/Kg Body sourses of energy Glycogen in the liver Fat of the body (lipid) Protein in the skeletal muscle Oral feeding Should be started when bowel function returns starting with oral clear luids ( water, juices) If patient can not eat enough for 5-7 days start f with enteral nutrition Enteral nutrition Enteral types 1. Nasogastric. — tube enter from nose to stomach 2. nasoenteric —- from mouth To small bowel 3. Gastrostomy —- opening in the stomach to the abdominal skin 3. Jejunostomy— opening if the jejunum to the skin Complications of enteral nutrition 1. Nausea and vomiting 2. Malabsorption—- unexplained weight loss, steatorrhea( loss of fat with stool ) 3. Diarrhoea 4. Aspiration pneumonia Parenteral nutrition Or called total parenteral nutrition ( TPN ) Special liquid mixture given to patient by a catheter in a vein The mixture contains proteins, carbohydrates,fat,vitamins and minerals Indications It is indicated when enteral feeding is not possible -as in Paralytic ileus Mesenteric thrombosis Small bowel obstruction f Enteric istula distal to enteric access sites Complications of TPN f 1. Hepatic steatosis —- fatty liver in iltration 2. Cholestasis — because there no stimulation of bile excretion by occur by normal oral feeding 3. Gastrointestinal atrophy leading to gastric mucosal atrophy TPN is either Peripheral using a peripheral vein or Central using a central vein ( subclavian vein ) Peripheral root is used for short time and using luids that are not irritating and damaging the vein f Like normal saline, 5% glucose and some times lipid Central root is used for longer time and withstand hyperosmolar luids and there will be less irritation and damaging to veins f Example- hyper osmolar dextrose, amino acids and lipids Lipid 20% glucose Amino acids