Professional Documents
Culture Documents
Response to Injury
Gerardo R. Wenceslao, MD, FPCS, FPSGS
Diplomate, Philippine Board of Surgery
Fellow, Philippine College of Surgeon
Systemic and Metabolic
Response to Injury
Phases of SIRS:
Anti-inflammatory phase
By way of the parasympathetic nervous system
through neurotransmitter Acetylcholine
Pain
Anxiety
Angiotensin II
Chocystokinin
Catecholamines
VIP
Hormonal Response to
Injury
Cortisol
A glucocorticoid hormone from the adrenal gland
Decreases glycogenesis
Increases gluconeogenesis
Hormonal Response to
Injury
Cortisol
Facilitates breakdown of protein and AA
Immunosuppressive properties
Thymic involution
Released is by:
ACTH
Angiotensin II
Hyperkalemia
Retain Na
Eliminate K and H
Hormonal Response to
Injury
Renin-Angiotensin - Aldosterone
B-adrenergic stimulation
Renin
Converts angiotensinogen-angiotensin I
Angiotensin I
Converted to angiotensin II in the lungs by angiotensin-
converting enzyme
Hormonal Response to
Injury
Angiotensin II
Potent vasoconstrictor
Eliminates K and H
Hormonal Response to
Injury
Stimulation of gluconeogenesis
Hormonal Response to
Injury
Aldosterone Deficiency
Hypotension
Hyperkalemia
Aldosterone Excess
Edema
Hypertension
Hypokalemia
Metabolic alkalosis
Hormonal Response to
Injury
ADH
From the supraoptic paraventricular
nuclei of the hypothalamus
Osmoregulator
Resorption of solute free water in the distal tubule
and collecting ducts
Vasoactive
Vasoconstriction
Metabolic
Glycogenolysis/Gluconeogenesis
Hormonal Response to
Injury
Catecholamines
Levels are increased 3 - 4x after an
injury
Hemodynamic actions
Metabolic
Increase glucose production in the liver
Immunodepressant
Through the activation of B2 receptors on
immunocytes
Glucose
Fatty acids
Ketone bodies
Hormonal Response to
Injury
Insulin
Stimulates hepatic glycogenesis
Glycolysis
Lipogenesis
Protein synthesis
Glycosylation of immunoglobulin
Decreased phagocytosis
Hormonal Response to
Injury
Growth Hormones and Insulin-like
Growth Factors
Metabolic effects
Increase protein synthesis and lipogenesis
Increase glycogenesis
Immunomodulatory function
Enhances the phagocytic activity of
immunocytes through increased
lysozomal superoxide production
IL-6
TNF-a
IL-1
Anti-oxidants (ceruloplasmins)
Increased Copper
Interleukin 10
Strongest anti-inflammatory cytokine
Interleukin 6
Stimulate PGE2 - febrile response
Interleukin 13
Mediators of Inflammation
Pyrogenic Interleukins
IL-1
IL-6
TNF
Mediators of Inflammation
Interferons
A cytokine produced by leukocytes, T
cells and fibroblast
Type 1
Type 2
Mitochondria
Mediators of Inflammation
Eicosanoids
Derived from oxidation of membrane phospholipid-arachidonic acid
They are not stored in the cells but are produced rapidly in response to:
Injury
Epinephrine
Vasopressin
Bradykinin
Acetylcholine
Angiotensin II
Mediators of Inflammation
Eicosanoids
Generate mostly pro-inflammatory reaction
with deleterious effects on the host such as:
Renal Failure
Pancreatitis
Mediators of Inflammation
Eicosanoids
Prostaglandin
Promotes inflammation
Thromboxane
Vasoconstrictor and platelet aggregating factor
Leukotriens
Capillary leakage, bronchospasm, vasoconstriction
Mediators of Inflammation
Eicasanoids
Metabolic Effect
Cyclooxygenase pathway
Lipooxygenase pathway
Eicosanoids
NSAID
Leukotriene inhibitors
Mediators of Inflammation
Kallikrein-Kinin System
Group of proteins that contributes to:
Pain response
Inflammation
Coagulation
Trypsin
Plasmin
Factor XI
Glass surface
Mediators of Inflammation
Kallikrein-Kinin System
Activates renin-angiotensin-aldosterone
Tissue edema
Broncho-constriction
Inhibits gluconeogenesis
Mediators of Inflammation
Kallikrein-Kinin System
Endotoxemia
Tissue injury
Hemorrhage
Hypotension
Mediators of Inflammation
Serotonin
Derived from tryptophan
Serotonin
Functions
Vaso and broncho-constrictor
Platelet aggregation
Histamine
Derived from decarboxylation of AA Histidine
Receptors
H1
Omega 3
Anti-inflammatory effect by:
Monocytes
Phagocytes that can differentiate into macrophages, osteoclast and
dendritic cells
Vasodilator
Prostacyclin
Eicasanoid produced by endothelial cells
Vasodilator
Platelet deactivator
Surgical Metabolism
Normal metabolic activity is described as the macronutrients, carbohydrates,
and fat are converted to energy or fat and protein intake is diverted to protein
synthesis and maintenance of lean body mass. These pathways are controlled
by hormonal balance with the anabolic hormones maintaining protein
synthesis. There is continuous balance of energy between the fat and energy
store
Surgical Metabolism
Protein
Nearly all are functional
Neurons
Leukocytes
Erythrocytes
Kidneys
Surgical Metabolism
Substances that promotes
Glycogenolysis
Norepinephrine
Angiotensin II
Vasopressin
Glucagon
Surgical Metabolism
Metabolism during fasting:
Stored source of fuel
Lacks glucose-6-phosphatase
Pyruvate
Glycerol
Amino acids
Alanine
Glutamine
Surgical Metabolism
Site of Gluconeogenesis
Liver - primary site
Kidney
Epinephrine
Cortisol
Surgical Metabolism
Sources of Lactate
Skeletal muscle
Breakdown of endogenous glycogen( glycogenolysis)
Erythrocytes
Deceased insulin
Increased cortisol
Increased glucagon
Surgical Metabolism
Prolonged fasting (>5 days)
Decrease in alanine
Proteolysis is reduced to 20 gm/day
Body Fat
Provides 40% or more of calories
Decreased glycolysis
Decreased Gluconeogenesis
Flow phase
Lipolysis
Cathecholamine
Triglyceride lipase
Hormonal influences
Major trauma
Cytokines
Hormonal changes
Increased cortisol
Increased catecholamines
Increased glucagon
Surgical Metabolism
Metabolism during Stress or Trauma
Hyperglycemia
Increased glucose production by:
Hyperglycemia
Increases gluconeogenesis
Inadequate lipolysis
Continued insulin production due to hyperglycemia
Conversion to fat
Elevation of CO2
Immune suppression
Surgical Metabolism
Metabolism under stress or injury
Decreased phagocytosis
Decreased monocytes
Surgical Metabolism
Metabolism after Stress or Injury
Poor utilization of glucose
Increased proteolysis
Mediated by glucocorticoids
6 gm of protein - 1 gm of nitrogen
Body Composition
Post-traumatic nitrogen excretion correlates with
mass of total protein
Nutritional Status
There is causal relationship between pre-operative
protein depletion and post-op complication
Age
Increase in fat mass and decrease in muscle
mass that occurs in aging
Gender
Lean body mass in proportion to body weight is
lower in females than in males
The End