Inflamation and metabolic response

Systemic
Response to
Injury and
Metabolic
Support
(2020)
surgical club Red Sea University SC(RSU)

Prepared by:
 Dr: Doaa Hashim 18
 Dr: Kholoud Othman 18
 Dr: Alaa 17
 Presented by:
 Dr: Amar Yahia
Registrar of General Surgery
Surgical Club Red Sea University SC(RSU)29/6/2020

THE DETECTION OF CELLULAR
INJURY
Traumatic injury activates the
innate immune system to produce
a systemic inflammatory response
in an attempt to limit damage
and to restore homeostasis.

The Detection of Cellular Injury
 Damage-Associated Molecular Pattern
 pathogen-associated molecular patterns
(PAMPs)
 Pattern Recognition Receptors (Toll-Like
Receptors)
 Pattern Recognition Receptor Signaling
 the Inflammasome

 It includes two general responses:
(a) an acute proinflammatory response
resulting from innate immune system
recognition
(b) an anti-inflammatory response that may
serve to modulate the proinflammatory
phase and direct a return to homeostasis

The clinical features of the injury-
mediated systemic inflammatory
response, characterized by
increased body temperature, heart
rate, respirations, and white blood
cell count, are similar to those
observed with infection

surgical club Red See Univirsity SC(RSU)

Mediators of injury response
Neuro endocrine ( Hormonal )
Immune System Metabolic and
Cytokine

Neuroendocrine Response to
Injury:
The Neuro-endocrine response to
severe injury/critical illness is biphasic

1. Acute phase characterized by an
actively secreting pituitary & elevated
counter regulatory hormones (cortisol,
glucagon, adrenaline).Changes are
thought to be beneficial for short-term
survival.
2. Chronic phase associated with
hypothalamic suppression. Changes
contribute chronic wasting.

Purpose of Neuro- endocrine
changes following injury
The constellation of Neuro-endocrine
changes following injury acts to
1. Provide essential substrates for survival
2. Postpone anabolism
3. Optimize host defense

Metabolic and Cytokine axes
Proinflammatory cytokines
IL-1β,
IL-6, and
TNF-α
2. NO
3. Endothelin 1

Anti inflammatory cytokines
(IL)-1 receptor antagonist,
IL-4,
IL-10,
IL-11, and
IL-13

HOMEOSTASIS :
DEFENITION :
Is the coordinated physiological
process , which maintain most of
steady states of the organism

Basic Concepts in Homeostasis
1. Homeostasis is the foundation of
normal physiology.
2. Stress-free peri-operative care helps
to restore homeostasis following elective
surgery.
3. Resuscitation, surgical intervention &
critical care can return the severely
injured patient to a situation in which
homeostasis becomes possible once
again. surgical club Red Sea University SC(RSU)

elective surgery practice seeks to reduce
the need for a homeostatic response by
minimizing the primary insult (as for e.g –
Minimal access surgery )

Metabolic Response To Injury
 Restore tissue function
 Eradicate invading Microorganisms.

Ebb and Flow
surgical club Red See Univirsity SC(RSU)

Key catabolic elements of flow
phase
Hypermetabolism
Alterations in skeletal muscle
protein
Alterations in Liver protein
 Insulin resistance

Skeletal muscle wasting
Provides amino acids for protein synthesis
in central organ/tissues
Can result in immobility & death if
prolonged and excessive

Hepatic acute phase response
 The Hepatic acute phase response
represents a reprioritization of body
protein metabolism towards the liver & is
characterized by:
1. Positive reactants (CRP) plasma
concentration increases
2. Negative reactants (albumin) plasma
concentration decreases

Insulin resistance
 The degree of insulin resistance is directly
proportional to magnitude of the injurious
process.
 Following routine upper abdominal
surgery, insulin resistance may persist for
approximately 2 wks.

• Postop patients with insulin resistance
behave in a similar manner to individuals
with type 2 diabetes
• The mainstay of treatment is i.v insulin

 Main labile energy reserve in the body is
fat
 Main labile protein reserve in the body is
skeletal muscle

While fat mass can be reduced
without major detriment to function,
loss of protein mass results not only in
skeletal muscle wasting, but also
depletion of visceral protein mass

 Loss of body weight accounting for
the survival of hunger strikers for a
period of 50-60 days
 As with total starvation, once loss
of body protein mass has
reached 30-40 % of the total,
survival is unlikely.

Sequence of events In critically
ill patients with resuscitation
<24 hrs. – Body weight increases due to
extracellular water
expansion by 6-10 liters.
This can be overcome by careful intra
operative management of fluid balance

1-10 days – Total body protein will
diminish by 15% and body weight will
reach negative balance as the
expansion of extra cellular space
resolves
 This can be overcome by blocking
Neuro endocrine response with
epidural analgesia and early enteral
feeds surgical club Red Sea University SC(RSU)

 Postop patients with insulin resistance
behave in a similar manner to individuals
with type 2 diabetes
 The mainstay of treatment is i.v insulin

Avoidable factors in response to
injury
1. Continuing hemorrhage
2. Hypothermia
3. Tissue edema
4. Tissue under perfusion
5. Starvation
6. Immobility

Maintaining the normoglycemia with
insulin infusion during critical illness has
been proposed to protect the
endothelium, via inhibition NO release ,
and thereby contribute to the prevention
of organ failure and death

Metabolism during Starvation
During starvation, the body is faced
with an obligate need to generate
glucose to sustain cerebral energy
metabolism(100g of glucose per
day)

 This is achieved in the first 24 hours by
mobilizing glycogen stores and
thereafter by hepatic
gluconeogenesis from amino acids,
glycerol and lactate.
 The energy metabolism of other
tissues is sustained by mobilizing fat
from adipose tissue

 Such fat metabolization is mainly
dependent on a fall in circulating insulin
levels.
 the liver converting free fatty acids into
ketone bodies, which can serve as a
substitute for glucose for cerebral energy
metabolism

 Provision of 2 liters of iv 5% D as iv fluids for
surgical patients who are fasted provides
100g of glucose per day and has a
significant protein sparing effect.
 Modern guidelines on fasting prior to
anesthesia allow intake of clear fluids up to
2 hours before surgery.

Immobility : Has been recognized as a
potent stimulus for inducing muscle
wasting. Early mobilization is an essential
measure to avoid muscle wasting

How to minimize the surgical stress
response
1. Minimal access techniques
2. Blockade of afferent painful
stimuli (epidural anesthesia)
3. Minimal periods of starvation
4. Early mobilization

References
❑ Schwartz's Principles of Surgery, 11th edition
❑ Bailey & Love's Short Practice of Surgery, 27th edition

Inflamation and metabolic response

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