Sirs and metabolic support
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Transcript of 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