Sirs and metabolic support

Systemic Response to Injury and Metabolic Support

Dr. Jesus R. Dabalos Jr.Department of Surgery

SPECIFIC OBJECTIVES

• To Discuss on Systemic Inflammatory Response Syndrome and its effect in relation to Surgical patients

• To Discuss on Metabolic support on surgical patient.

SYSTEMIC INFLAMMATORY RESPONSE SYNDROME

WHAT is SIRS?

Infection, SiRS, Sepsis

Bone, R., Balk, R., Cerra, F., Dellinger, R., Fein, A., Knaus, W., Schein, R., et al. (1992). Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest, 101(6), 1644–1655.

HORMONAL RESPONSE TO INJURY

• Hormone receptors in the cell surface• 3 Major Pathways

- IGF receptors - G-protein receptors - Ligand gated ion channels

HORMONES REGULATED BY THE HYPOTHALAMUS, PITUITARY and AUTONOMIC SYSTEM

HORMONES REGULATED BY THE HYPOTHALAMUS, PITUITARY and AUTONOMIC SYSTEM

HORMONES REGULATED BY THE HYPOTHALAMUS, PITUITARY and AUTONOMIC SYSTEM

• Cortisol and Glucocorticoid

• Macrophage Migration-Inhibiting Factor

• Growth Hormone and Insulin Like Growth Factor

HORMONES REGULATED BY THE HYPOTHALAMUS, PITUITARY and AUTONOMIC SYSTEM

• Cathecolamines

• Aldosterone

• Insulin

• Acute Phase reactants

MEDIATORS OF INFLAMMATION

• CYTOKINES - Mediates broad sequence of cellular response

- Cell migration, DNA replication, Cell turnover, immunocyte proliferation.

MEDIATORS OF INFLAMMATION

• A 25 year old male with a blunt abdominal injury presents with a surgical abdomen

• What is the mediators involved after the injury?

TNF

MEDIATORS OF INFLAMMATION

• After 4 hours patient had Fever, what cytokine should be the culprit?

• After 30 minutes of fever, patient had a BP of 80/50 mmHg, what cytokine should be the culprit?

Interleukin-1

TNF, IL-6

MEDIATORS OF INFLAMMATION

Pro-Inflammatory cytokine

• TNF• IL-1• IL-6

Anti-Inflammatory Cytokine

• IL-4• IL-10• IL-11• IL-12• IL-13

MEDIATORS OF INFLAMMATION

• Heat Shock Proteins

• Reactive Oxygen Species

• Interferon

CELL MEDIATED INFLAMMATORY RESPONSE

• Platelets- nonnucleated structures containing both mitochondria and mediators of coagulation and inflammatory signaling.

• Lymphocytes- are circulating immune cells composed primarily of B cells, T cells, and natural killer cells.

CELL MEDIATED INFLAMMATORY RESPONSE

• Eosinophils -are immunocytes whose primary functions are antihelmintic.

• Mast cells- are important in the primary response to injury because they are located in tissues.

CELL MEDIATED INFLAMMATORY RESPONSE

• Monocytes- are mononuclear phagocytes that circulate in the bloodstream.

• Neutrophils -are among the first responders to sites of infection and injury and as such are potent mediators of acute inflammation.

Endothelium-Mediated Injury

• Prostacyclin- is a member of the eicosanoid family and is primarily produced by endothelial cells

• Endothelins - are potent mediators of vasoconstriction

• ANP -induce vasodilation as well as fluid and electrolyte excretion.

Surgical Metabolism

Metabolic Changes in Surgical Patients

Metabolic events brought about by STIMULI:1. Injury2. Starvation

Metabolic response is directed to restore:1. Homeostasis2. Repair

NUTRITION IN SURGICAL PATIENT

NUTRITION IN SURGICAL PATIENT

• Basal energy expenditure (BEE) may also be estimated using the Harris-Benedict equations:

• where W = weight in kilograms; H = height in centimeters; and A = age in years.

Nutrition in the Surgical Patient

NUTRITION IN SURGICAL PATIENT

VITAMINS AND MINERALS OVERFEEDING

ENTERAL FEEDING

TYPES OF ENTERAL FORMULAS

COMPLICATIONS OF ENTERAL FEEDING

TOTAL PARENTERAL NUTRITION

Parenteral NutritionIndications: Malnutrition, Sepsis, severe surgical or

accidental trauma when the use of the Gastrointestinal tract for feeding is not possible.

Can be supplemental in patients with inadequate oral intake

PARENTERAL NUTRITION

Parenteral Nutrition

Parenteral Nutrition

Parenteral NutritionComplication of TPN:I. Technical complication:

Sepsis secondary to contamination

pneumothorax, hemothorax, hydrothorax, subclavian artery injury

Parenteral NutritionComplication of TPN:II. Metabolic complication:

- Hyperglycemia

- Hepatic steatosis

- Cholestasis and formation of gallstones

- Intestinal Atrophy