Highlights of Metabolic Response

8/10/2019 Highlights of Metabolic Response

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B A S H I R U A M I N U

T I R E D O F L O N G W I N D E D S P E E C H E S ?

JUST THE HIGHLIGHTS:METABOLIC RESPONSE TO

INJURY


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OUTLINE

WHAT IS IT? ANATOMYCOMPONENT RESPONSES

CONSEQUENCE OF RESPONSES WHO HAS THE GREATEST RESPONSE?HOW DO WE INFLUENCE RESPONSES TO OUR

ADVANTAGE?RECENT ADVANCES


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WHAT IS IT?

DEFINE IT- adaptive reactions to promote recovery-Response is similar, irrespective of type of

insult( injury, operative trauma or infection) COMPONENT ORGANS HOW THEY MAINTAINCONSTANCYULTIMATELY FOR PRESERVATION OF THE

PATIENTRESPONSE IS GRADEDRESPONSE IS PHASED


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WHAT IS IT?-EBB PHASE

Low C.O shock

Low B.M.RLow body temp.Hyper lactacidaemiaCorresponds to shock phase


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FLOW PHASE

Acute/Catabolic

INCREASE C.O INCREASE B.M.R

CATECHOLSHYPERGLYCAEMIALOW I/G RATIO INCREASE LIPOLYSIS

CYTOKINES-TNF-a,IL-1b,IL-6,pgE2

Adaptive/Anabolic

INCREASEGLUCOCOTICOID

HYPERGLYDECREASE /NormalizingI/G RATI LIPOLYSIS


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ANATOMY

INJURED AFFERENT NERVES-UNMYELINATEDC AND MYELINATED A PAIN FIBRESDORSAL HORN

LATERAL SPINOTHALAMIC TRACTTHALAMUSHYPOTHALAMUS

PITUITARYEFFERENTEFFECTORS-ADRENAL, RENAL TUBULES ETC


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WHAT ARE THE COMPONENTS?

VASCULAR EVENTSCELLULAR/CYTOKINE EVENTSNEURAL EVENTS

METABOLIC EVENTS


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COMPONENTS AGAIN


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WHAT HORMONES?


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What are the changes?

Hypermetabolism-REE=6300-7500J/24HRS,STORAGE IN LIVER/MUSCLES=400g GIVING6700J/24HRS Altered sources of energyUtilization of CHOMobiliztion of fat Weight changes

Plasma proteinsGut intergrityimmunosuppression


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Triggers?

PainHypovolemiaInflammatory reaction

Complications of the disease-sepsisinfections


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EXAMPLE OF A TRIGGER

:HYPOVOLEMIA

HYPOVOLEMIA-BLOOD-BLEEDING-ELECTROLYTE CONTAINIG FLUIDS= VOMITING,

DIARHOEA- PLASMA LIKE FLUIDS=THIRD SPACE LOSS


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:HYPOVOLEMIA

ADH :HOW IS IT STIMULATED?= AFFERENT NERVES

direct afferent nerve impulses from the site of injury afferent nerve impulses from atrial stretch receptors

(responding to reduced volume) and the aortic andcarotid baroreceptors (responding to reduced pressure)

input from higher centres in the brain (pain, emotionand anxiety

INCREASED PLASMA OSMOLALITY increased plasma osmolality (principally sodium ions)detected by hypothalamic osmoreceptors


14/21


:HYPOVOLEMIA

ADH= WHAT DOES IT DO?= ADH promotes the retention of free water (withoutelectrolytes) by cells of the distal renal tubule and

collecting duct.If excess water is administered during the period ofincreased ADH secretion, plasma hypotonicity andhyponatraemia may occur.


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:HYPOVOLEMIA

ALDOSTERONE HOW IS IT STIMULATED?Secretion is raised via the renin angiotensin systemat the juxtaglomerular apparatus within nephrons.

Renin is released from afferent arteriolar cells inresponse to stimuli activated during hypovolaemiaand reduced renal blood flow.These include reduced afferent arteriolar pressure,tubuloglomerular feedback (signalling via the maculadensa of the distal tubule according to electrolyteconcentration) and activation


16/21


:HYPOVOLEMIA

ACTH SECRETION INCREASES IN:response to hypovolaemia and hypotension viaafferent nerve impulses from stretch receptors in the

atria, aorta and carotid arteries. It is also raised by ADH. Hyponatraemia or hyperkalaemia directlystimulates adrenal cortex cells to increase secretion.


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WHO HAS GREATEST RESPONSES?

I. The nature and severity of the injury2. The nutritional status of the patient3. Age and sex

4. Environmental temperature5. Treatment6. Complications

7.Emmergency surgery8. Smoking9. Ischemia reperfusion injury


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HOW DO WE INFLUENCE IT TO OUR ADVANTAGE?

PREOPERATIVELY-COUNSEL PATIENT TO ALLAY ANXIETY-NUTRITION

-SELECTIVE DIGESTVE DECONTAMNATION (SDD)-CORRECT VOLUME-CORRECT ELECTROLYTES-GIVE ANTIBIOTICS-CONTROLL PAIN-ENSURE OPTIMAL FUNCTION OF ORGANS

MODULATING IT EG: HEART, KIDNEYS, BRAIN


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HOW DO WE INFLUENCE IT TO OUR ADVANTAGE

INTRAOPERATIVE-ASEPTIC TECHNIQUE-MINIMALLY INVASIVE PROCEDURES

-SPINAL, EPIDURAL GIVES LESS RESPONSE TOTRAUMA-MAINTAIN VOLUME-ANTIBIOTICS-PREVENT OR CONTROLL

INFECTIONS-GOOD SUGER CONTROL-KEEP PATIENT WARM


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HOW DO WE INFLUENCE IT TO OUR ADVANTAGE

POST OPERATIVELY-GOOD PAIN CONTROL-JUDICIOUS USE OF ANTIBIOTICS

-MAINTAIN HYDRATION-MONITOR URINE OUTPUT-BALANCED SERUM ELECTROLYTES

-ADEQUATE NUTRITION-EARLY MOBILISATION-DEEP VENOUS THROMBOPROPHYLAXIS


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RECENT ADVANCES

MONOCLONAL ANTIBODY TO CYTOKINESENDOSCOPIC SURGERYPATIENT CONTROLLED ANALGESIA

CONTROLLED BLOOD TRANSFUSION-HAVE ATRANSFUSION TRIGGER,REPLACE LOSTCOMPONENT, AVOID TRANSFUSION RELATEDIMMUNOSUPPRESION

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Highlights of Metabolic Response