Surgical Metabolism PDF

Basic Surgery (NGAYON NIYO SABIHING BASIC ‘TO) NUTRITION AND METABOBOKAPARIN LECTURER: Dr. Omar O. Ocampo, DOC PAG ‘TO HINDI SAMPLEX MAGDADABOG AKO! Primary sources of fue...

Basic Surgery (NGAYON NIYO SABIHING BASIC ‘TO) NUTRITION AND METABOBOKAPARIN LECTURER: Dr. Omar O. Ocampo, DOC PAG ‘TO HINDI SAMPLEX MAGDADABOG AKO! Primary sources of fuel during short-term fasting (20% in 3 months), so in this, patients with underlying conditions must be monitored properly. Metabolism After Injury Sa long-term fasting, naubos na ‘yung liver glycogen stores, tapos ‘di ba nagkaroon ng proteolysis, kaso syempre naubos na rin as source of fuel. Saan na kukuha? Sa ketones na, brain uses ketones na for fuel, tapos kidneys become important participants in gluconeogenesis by the use of glutamine and gulatamate, tapos nagiging primary source na sila ng gluconeogenesis during prolonged starvation. Again, kapag long term, ketone bodies na ang fuel source sa brain, lalo na if by 24 days, principal fuel source na talaga sila. Injuries, infections and surgeries produce neuroendocrine and endocrine responses that differentiate metabolism after injury from that of the unstress fasting. Proteolysis here is 20 g/day and urinary nitrogen excretion During stress state lipid becomes the primary source is 2-5 g/day. In prolonged starvation the body uses ketone energy bodies, as their principal fuel source ○ The brain uses ketone bodies after 2 days of starvation Lipid source within the adipose tissue provides >40% of caloric expenditure during starvation Energy requirement for basal enzymatic muscular function like neurotransmission and cardiac contraction are meant by the mobilization of the TAG by the adipose tissue ○ Mobilization of lipids decreases the rate of glycolysis, gluconeogenesis, and proteolysis as well as overall glucose requirement to sustain the host. KUMUNOY’S IMPROPERTY 2  Basic Surgery (NGAYON NIYO SABIHING BASIC ‘TO) NUTRITION AND METABOBOKAPARIN LECTURER: Dr. Omar O. Ocampo, DOC PAG ‘TO HINDI SAMPLEX MAGDADABOG AKO! If the patient will be subjected to injury or surgeries the magnitude of metabolic expenditure over times appears to be directly proportional to the severity of insult. NUTRITION Gray color - Normal range is the resting expenditure FASTING ○ First few days are not associated with hypermetabolic Our body adapt to fasting state to spare lean body mass: state ○ Reducing metabolic rate ○ 2 weeks after total expenditure increases ○ Activate metabolic pathways dramatically with major burns and sepsis having the Might cause: major demands (but mas increase sa major burn → ○ Lack of energy tandaan mo yan itatanong yan sa shifting) ○ Less ability to function The way our body adapts to this by activating different Which of the following is TRUE regarding metabolic pathways that will spare our lymphatics metabolism during fasting? Proteolysis during However, to those with underlying medical conditions a. Proteolysis during starvation is starvation is associated wherein they cannot eat, they have impaired adaptability associated with elevated urinary with elevated urinary nitrogen excretion Alternative pathways will not be activated, thus there is nitrogen excretion depletion of caloric sources for energy b. Lactate production from skeletal Paalala read every choices lalo na pagmahahaba These will then eventually lead up to malnutrition muscle is sufficient to maintain B- INSUFFICIENT ang lactate Continuation lang ‘to nung mga fasting sa unahan. Sa mga patients systemic glucose needs during production na severely injured or nagka-sepsis or nag-underwent ng mga major short-term fasting C- LIPID KAPAG STRESS operations kapag nagkaroon ng POSTPONING THERAPY, pwedeng c. Carbohydrates is the primary D- Bakit may proteolysis kapag gutom? Para magamit amino mag-lead sa malnutrition with association with higher rate of morbidity source of energy during stressed acids to glucose. Kung tataasan and mortality dahil sa increased wound infection, poor wound healing states mo insulin, uuptake lang din si at longer stays/ increase and readmission sa hospitals a. Proteolysis during starvation results glucose, edi wala rin, sayang primarily from increased in insulin lang. DECREASED INSULIN, PERO MALNUTRITION INCREASED CORTISOL and cortisol release There is increased wound infections that can lead to: What is the most abundant source of ○ Poor wound healing energy during short-term fasting in a Body fats ○ Longer hospital stays healthy adult? ○ Higher patient mortality 180 g sa fats kapag a. Carbohydrates b. Body fats SHORT TERM. “Skeleton in the hospital closet” c. Muscle proteins d. Ketone bodies Which hormones can promote the Norepinephrine So important measures sa hospitals di nakarecord utilization of glycogen stores to be GLYCOGENOLYSIS – like Height and weight, BMI, and nutritional converted to glucose during fasting? glycogen to glucose monitoring is neglected a. Insulin c. Cortisol “VANGvang” 30-50% of hospitalized patients show some V- Vasopressin A- Angiotensin 2 b. Epinephrine d. Norepinephrine N- Norepi G- glucagon evidence of malnutrition Which of the following hormones Nutritional state worsens with length if hospitalization promote utilization of glycogen stores Vasopressin to be converted to glucose during Glycogenolysis “VANG” Which statement is specified in “The fasting? Gluconeogenesis “ECG” Skeleton in the Hospital Closet”? a. Vasopressin c. Cortisol Insulin – Glycogenesis a. More than fifty percent of b. Epinephrine d. Insulin ‘yan, glucose to glycogen hospitalized patients has evidence of Nutritional state worsens Which hormone promotes malnutrition gluconeogenesis during fasting? Epinephrine b. Majority of hospitals in developed with length of a. Epinephrine c. Norepinephrine Glycogenolysis “VANG” countries perform efficient nutritional hospitalization Gluconeogenesis “ECG” A –30-50% lang dapat b. Insulin d. Vasopressin screening and assessment on What is the principal fuel source of the Ketone bodies patients B - Wala yan body during prolonged starvation? Alam niyo yan ketogenesis - c. Malnutrition is rarely seen in C- not rare, malnutrition is biochem a. Fatty acids b. Amino acids This is the fuel source of the brain modern hospitals because of NOT RARELY SEEN c. Ketone bodies d. Glycerol after 2 days, PROLONGED NA KASI advances in management and care d. Nutritional state worsens with length of hospitalization KUMUNOY’S IMPROPERTY 3  Basic Surgery (NGAYON NIYO SABIHING BASIC ‘TO) NUTRITION AND METABOBOKAPARIN LECTURER: Dr. Omar O. Ocampo, DOC PAG ‘TO HINDI SAMPLEX MAGDADABOG AKO! Which of the statements is TRUE regarding the MARASMUS KWASHIORKOR landmark publication “The Skeletal in the Hospital Nutritional state NUTRITIONAL Closet”? worsens with Impaired delivery Impaired utilization DEFECT a. Most modern hospitals accurately reported length of PROTEIN nutritional parameters such as height, weight, hospitalization Compensated Uncompensated CATABOLISM BMI, weight loss and albumin levels compared A – wala naman yang statement na No food, no appetite, to low-grade hospitals Sepsis, major yan ETIOLOGY gut is blocked, b. Malnutrition is rare in modern hospitals in B- its not rare, 30- trauma, burns inflamed or fistulated developed countries because of improved 50% nga raw system and facilities METABOLIC C- dapat wala Normal or Decreased Increased c. Up to eighty percent of hospitalized patients yung word na RATE had evidence of malnutrition in under “under” PROGNOSIS IF Months Weeks developed countries UNTREATED RETAIN NA SA MGA Replenish with d. Nutritional state worsens with length of SMALL BRAINS NIYO Resuscitate and hospitalization standard nutrition, support, control PRINCIPLES OF use simplest available TYPES OF MALNUTRITION sepsis, provide TREATMENT route, treat non-standard MARASMUS underlying illnesses nutritional regimes ○ Chronic malnutrition is the consequence of (if any) decreased nutrient intake CLINICAL Straightforward Complicated ○ Lack or decreased healthy balanced diet over an COURSE excessive period of time ○ Body goes to progressive adaptation with a MIXED/POLYDEFICIENT consequent decrease in metabolism in order to ○ Manifested by patients with symptoms of chronic protect protein energy and protein stores malnutrition which are aggravated by a stressful ○ In adults, this is otherwise known as Cachexia or event Protein Energy Malnutrition (PEM) ○ For example patient has chronic malnutrition then nagkaroon pa siya ng burns or will undergo surgery Naapura speaking: Kapag marasmus, chronic malnutrition agad. Dito merong inadequate intake of balance diet (kaya hinay-hinay sa OVERWEIGHT/OBESITY pagpapayat beh baka mamaya magkita na kayo ni san pedro eme). ○ A person is too heavy for his height Ayan siyempre inadequate ang intake mo yung katawan kailangan ○ Imbalance between energy consumed and energy mag adapt para maprotect ung energy and protein storage. In adult expended ang tawag dito cachexia (Sige what is cachexia, oo patho muna tayo. Wag ka magscroll up kinakausap pa kita!) ○ increase risk of diet-related non-communical diseases MALNUTRITION AND ITS CONSEQUENCES KWASHIORKOR This is common, but is often unrecognized in surgical ○ Acute Malnutrition patients ○ May be due to trauma, sepsis or acute injury such as Approximately 5% of patients are chronically surgery malnourished (but yung mild or moderate yung need natin ma- ○ The energy and protein need to increase rapidly and treat) are independent of the nutritional state of the patient Severe Malnutrition - >20% weight loss in the past three ○ Stress hormones are increased, which leads to a months hypermetabolic state Up to 50% of patients are affected even in big institutions Naapura again: Sa kwashiorkor ‘yung patient na nagkatrauma, sepsis or nag surgery pwedeng magkaroon ng acute malnutrition dahil Consequences/Problems nagkakaroon ng increase in energy and proteins needs tapos meron If the patient with metabolic stress is not given adequate pang hypermetabolic state so for example sa mga patient na may ulit- nutrition therapy: ulit ang surgery after 1st surgery yung tahi is nabroke down dahil sa ○ loss of weight infection siyempre need uli tahiin edi tataas na naman ung protein ○ slow wound healing need at energy need yan na yung magccause ng acute malnutrition ○ impaired immunity - KWASHIORKOR NA BEH! ○ increase in length of hospital stays ○ increased treatment cost KUMUNOY’S IMPROPERTY 4  Basic Surgery (NGAYON NIYO SABIHING BASIC ‘TO) NUTRITION AND METABOBOKAPARIN LECTURER: Dr. Omar O. Ocampo, DOC PAG ‘TO HINDI SAMPLEX MAGDADABOG AKO! Changes in the intestinal barrier Bago masabi na malnourished and isang tao, under nutritional assessment, itong tatlong components na ito (body composition, Biochemical Data, ○ Intestine is the most affected - altered absorptive, clinical assessment) kailangan munang itake into consideration digestive and immune functions ○ Colon has decreased absorption of water and Which of the following is TRUE regarding Inadequate intake over electrolytes with increased secretory function - Marasmus? a. All of the choices are correct an extended period of possible cause of diarrhea in malnourished patients b. Hypermetabolic state time Reduction in glomerular filtration and cardiac function c. Acute Increased morbidity and mortality B-normal metabolic rate d. Inadequate intake over an extended C-not acute it is chronic Goal of Nutritional Support period of time Which of the following is TRUE regarding Prevent or reverse the catabolic effect of disease and injury Secondary to sepsis Kwashiorkor? Meet the: a. Secondary to sepsis Kwashiorkor – secondary to trauma sepsis and amjor surgery, ○ energy requirements for essential metabolic b. Chronic energy protein needs increase processes and tissue repair c. Cachexia rapidly and hypermetabolic state. B and C kay maramus yan ○ substrate requirements for protein synthesis d. All of the choices are correct Improvement in clinical outcome and restoration of Which of the following characterizes Inadequate intake over function is the validation for nutritional support Marasmus? an extended period of a. Inadequate intake over an extended Failure to provide adequate non-protein energy sources time period of time will lead to consumption of lean tissue stores B-naka depend kasi need b. Energy and protein need increase  The first critical step in providing nutrition therapy is to and are independent of the nutritional nila idecrease yung perform nutritional screening and nutritional assessment to metabolism to protect state identify patients that are at risk for nutritional problem to energy and protein stores c. Healthy patient undergoing major C-di sila secondary to reduce complications, treatment failure, physiological intestinal resection surgery problems and health care costs. d. Hypermetabolic state Which statement regarding protein Marasmus is associated SCREENING ASSESSMENT energy malnutrition is correct? a. Kwashiorkor is associated with with impaired delivery of Identify the characteristics Collect and evaluate clinical reduced metabolic rate nutrients associated with nutritional conditions, diet, body Si kuya grab maramus na hindi b. Kwashiorkor has compensated problems; patient who are at consumption, biochemical nakapagdeliver protein catabolism A-INCREASED DAPAT metabolic risk data c. Marasmus is associated with rate Classify patients by nutritional state: well-nourished or impaired delivery of nutrients B-uncompensated too malnourished This is for kwashiorkor yung may d. Marasmus is usually secondary to the trauma/sepsis/major surgery Determine the severity of nutrient deficiency or excess effect of sepsis and peritonitis Predict nutritional requirements Which of the following characterize/s Compensated protein marasmus? No food, no appetite, gut is Sepsis, major trauma, burns catabolism b. Compensated protein catabolism blocked, inflamed or fistulated Only B-ewan ko rin kas tama c. Metabolic rate is normal or naman din to na, sa kwashiorkor So hindi enough and observation lang para madiagnose ang reduced increased naman d. Nutritional defect is impaired C-ito rin tama bc kay kwashiorkor nutritional status kahit pa sabihin mo na halata naman physically kung impaired utilisation naman. ano ang nutritional status ni patient kailangan pa din ng thorough delivery I vote for all of the choices are physical examination at history taking (pasok cd ward) a. All of the choices are correct corect Which statement regarding protein Marasmus is associated Sa screening tools mga survey lang yan so madali lang siya maobtain, energy malnutrition is correct? with impaired delivery of merong involuntary increase or decrease in weight >10% of usual a. Marasmus is associated with nutrients weight over 6 months o di kaya >5% of usual weight over 1 month impaired delivery of nutrients Si marasmus Na grab rider di kasasma din dito inadequate oral intake (quality oral intake type of makapagdeliver Kasi blocked, b. Kwashiorkor is associated with short,inflamed or fistulated yung daan so diet over the past few days) reduced metabolic rate in order to compensate, don sa customer na no food nawalan na ng Common Objective of Both Screening and Assessment c. Marasmus is usually secondary to the apetite kasi ang tagal ni kuya MONTHS Reduce effect of sepsis and peritonitis inabot pero normal pa naman metabolism. Hindi nalang sya d. Kwashiorkor has compensated ○ Complications; Treatment failures; Physiological magsshortcut kundi straightforward using protein catabolism the simplest available route in order to problems; Health care costs replenish yung standard nutrition ng customer. KUMUNOY’S IMPROPERTY 5  Basic Surgery (NGAYON NIYO SABIHING BASIC ‘TO) NUTRITION AND METABOBOKAPARIN LECTURER: Dr. Omar O. Ocampo, DOC PAG ‘TO HINDI SAMPLEX MAGDADABOG AKO! Which of the following characterizes Consequence of GI symptoms persistent for 15 days or 2 weeks Kwashiorkor? traumatic injury ○ Nausea a. Consequence of traumatic injury -Kwashiorkor is secondary to ○ Vomiting b. Cachexia —Trauma/sepsis/major ○ Diarrhea c. Progressive adaptation with surgery ○ Anorexia consequent decrease in metabolism - Energy and protein needs d. Best replenish with parenteral increase rapidly due to GI symptom, there is decreased appetite nutrition - Hypermetabolic state This is not the same with anorexia nervosa Which of the following best describes Functional Capacity Kwashiorkor? A consequence of ○ Duration a. The energy and protein need ○ Type complicated major decrease rapidly with consequent surgery in a previously Ambulatory decrease in stress hormones Bedridden producing a hypermetabolic state healthy patient b. All of the choices are correct A- Energy and protein needs Link between disease and nutritional requirements c. A consequence of complicated INCREASE rapidly Physical exam is focused on nutritional aspects D- this is marasmus major surgery in a previously Tandan acute lang si kwashior, si Process of Digestion healthy patient marasmus ay chronic kaya over a. Due to reduced nutrient intake an extended period of time. over an extended period of time DETAILED NUTRITIONAL ASSESSMENT A. Body Composition Weight and Height BMI = kg/m2 Skin fold thickness ○ Triceps, biceps, subscapular, suprailiac ○ Triceps is the most reliable Mid arm muscle circumference and muscle area B. Biochemical Data PARAMETERS CHECKED AT RISK LEVELS SERUM ALBUMIN