Metabolic Response to Trauma

Palin Suwannarit
R1 CBH
• An attempt to preserve vital organ
Detection of cellular injury
CNS regulation of inflammation response to
injury
• Neuroendocrine – 2 principle pathways
– HPA axis:
• Adrenal cortex: glucocorticoids
» Cortisol
» Critical Illness Related Corticosteroid Insufficiency – CIRCI
• Adrenal medulla “Sympathetic nervous system”:
catecholamines
» Epinephrine
» Norepinephrine
• Aldosterone
• Insulin
: Hyperglycemia และ insulin resistance เป็ น
hallmarks สำคัญของ injury and critical illness
เนือ
่ งจากผลของ Catabolic effect ของ hormones
ต่างๆ ได ้แก่ catecholamines, cortisol, glucagon,
GH
โดยเฉพาะอย่างยิง่ EPI ทีก ่ ระตุ ้นให ้เกิด
glycogenolysis, lipolysis, and increased lactate
production โดยไม่สม ั พันธ์กบั ปริมาณ O2 ทีเ่ รียกว่า
“aerobic glycolysis”
 Cellular stress response
• Reactive oxygen species (ROS)
– เป็ น signaling messengers ของ immune system
– ผลผลิตของ O2 metabolism โดยเฉพาะที่
mitrochondria
– สามารถ suppress cell function และทำให ้เกิด cell
death ได ้
Autophagy
Apoptosis
Necroptosis
Pyroptosis
 Mediators of inflammation
• Cytokines
• Eicosanoids
– Arachidonic acid (AA)

Serotonin
Histamine
 Cell mediated inflammatory response

• Neutrophils
• Monocyte/Macrophages
• Lymphocytes and T-cell
• Dendritic cells
• Platelets
• Mast cell
Endothelium mediated injury
 Surgical metabolism
• Metabolism during fasting
• Metabolism after injury
• Lipid metabolism after injury
• Ketogenesis
• Carbohydrate metabolism
• Protein and amino acid metabolism
 Metabolism during fasting
• Basal metabolic needs: 22-25 kcal/kg/day
• Short term fasting (<5days)
– Muscle protein and body fat
 Nutrition in the surgical patient
• Estimation of energy requirements
 Nutrition in the surgical patient
• Vitamins and minerals
 Nutrition in the surgical patient
• Overfeeding
 Enteral nutrition
• Rationale for enteral nutrition
 Enteral nutrition
• Early vs late feeding
 Enteral nutrition
• Enteral fomulas
– Standard polymeric formulas
– Fiber containing formulas
– Immune enhancing formulas
– Calorie dense formulas
– High protein formulas
– Elemental formulas
– Renal failure formulas
– Hepatic failure formulas
– Glutamine
– Arginine
Access for enteral nutritional support
 Parenteral nutrition
• Rationale
• Total
• Peripheral
• Initiation
• Complications
Fluid and Electrolytes management