2. جمهوری اسلامی افغانستان
وزارت صحت عامه
ریاست شفاخانه استقلال
دیپارتمنت جراحی عمومی

3. موضوع کنفرانس
Systemic Metabolic Response to
Injury
ترتیب کننده :-داکتر صلاح الدین )احدی(ترینی سال اول
جراحی عمومی
استاد رهنما:-داکتر استاد سید حمیدالله )سادات(ترینر
متخصص جراحی عمومی
سال 1393 هه شمسی

4. Definitions
سیستم معافیتی به منظور جواب به میکرواورگانیزمهای
پتالوژیک-خنثی کردن اثرات آنهاوهماهنگی باترمیم نسجی
شکل گرفته است. جواب التهابی به اسیب یاالتهاب شامل
مراحل ذیل است . -
پیام های حجروی cell signaling -1
مهاجرت حجروی cell migration - 2
ازادسازی مدیاتورها mediator release -3

6. The Systemic Inflammatory Response Syndrome
(SIRS)

7. CNS regulation of inflammation
 Integral role in inflammatory
response that is mostly involuntary
 Autonomic system regulates HR,
BP, RR, GI motility and temp

8. CNS Regulation of Inflammation

9. Hormonal Response to Injury
 Includes:
 Cytokines
 Glucagon
 Insulin
 Epinephrine
 Serotonin
 Histamine
 Glucocorticoids
 Prostaglandins
 leukotrienes

10. ACTH
 A. Its synthesized in the anterior
lube of pituitary gland.
 B. Its increased by pain, anxiety
and injury
 C. Continues to be released in a
circadian pattern in injured patients
 D. Causes the release of
mineralocorticoids from the adrenal
in a circadian pattern

11. ACTH

12. Cortisol
 Essential for survival during physiologic
stress
 Potentiates the effects of glucagon and
epinephrine manifesting as
hyperglycemia
 In liver, stimulate gluconeogenesis
 Induces insulin resistance in skeletal
muscle and adipose tissue
 In skeletal muscle induces protein
breakdown and release of lactate
 Immunosuppressive agent

13. A primary action of aldosterone is
to:
 A. Convert angiotensinogen to
angiotensin
 B. Decrease Cl reabsorption in the
renal tubule
 C. Decrease K secretion in the
renal tubule
 D. Increase Na reabsorption in the
renal tubule
 E. Increase renin release by the
juxtaglomerular apparatus

14. Catecholamine elevation after
injury
 A. Its limited to epinephrine
only
B. Its limited to norepinephrine
only
C. Increases by 3- to 4-fold
after injury
D. Its sustained 24-48 hours
before decreasing

15. C-reactive protein
 A. Its increased or decreased plasma
concentration in response to inflammatory
stimuli such as traumatic injury and infection.
 B. Specifically, CRP has been studied as a
marker of proinflammatory response in many
clinical settings, including appendicitis,
vasculitis, and ulcerative colitis.
 C. Does not increase in response to stress in
patients with liver failure
 D. Its less sensitive than ESR as a marker of
inflammation

16. Mediators of Inflammation
 Cytokines
 Heat shock proteins
 Reactive oxygen metabolites
 Eicosanoids
 Includes prostaglandins, leukotrienes,
thromboxane
 Fatty Acid metabolites
 Kallikrien-Kinen system
 Serotonin
 histamine

17. Cytokine Response to Injury
 Lots of cytokines
 Most potent mediators of
inflammatory response
 Pro- and anti-inflammatory

18. Cytokines….
 TNF
 one of the earliest and most potent mediators of
host response
 Primary source: monocytes/macrophages and T
cells
 Half life of 20 min but potent
 IL-1
 Primarily released by macrophages and endothelial
cells
 Half life less than 6 mins.
 Classic febrile response to injury
 IL-6
 Linked to hepatic acute phase proteins production

19. Impt Eicosanoids
 Prostacyclin (PGI2)
 From endothelium
 Decreases platelet aggregation
 Promotes vasodilation
 Thromboxane (TXA2)
 From platelets
 Increases platelet aggregation
 Promotes vasoconstriction

21. Nitric Oxide
 A. Its primarily made in hepatocytes
 B. Has a half-life of 20-30 minutes
 C. Its formed from oxidation of
L-arginine
 D. Can increase thrombosis in
small vessels

22. Surgical Metabolism
Basic metabolic needs = 25 kcal/kg/day

23. Where do we get our caloric needs?
 Fat 9 kcal/g
 Protein 4 kcal/g
 Oral carbs 4 kcal/g
 Dextrose (in IV fluids) 3.4
kcal/g

24. Surgical Metabolism during fasting
 Starvation: fat is the main source
of energy in trauma and starvation
 Carbohydrates are stored in the
form of glycogen (2/3 skeletal
muscle, 1/3 liver)
 Due to deficiency in glucose-6-
phosphatase, skeletal muscle not
available for systemic use and
therefore, liver stores are used
quickly

25. Gluconeogenesis
 Occurs in the liver
 Precursors include:
 Amino acids
(alanine)
 Lactate
 Pyruvate
 Glycerol
 Cori cycle
 In late starvation gluconeogenesis
occurs in kidney

26. Metabolism following Injury

27. Fat digestion
 Broken down into micelles and FFAs
 Micelles enter enterocytes
 Chylomicrons are formed which
enter thoracic duct
 Medium and short chain amino
acids enter portal system with
amino acids and carbs

29. Protein Metabolism
 6 g protein = 1 g N
 Provides substrates for
gluconeogenesis and acute phase
proteins
 1g protein=4kcal

30. Protein metabolism

31. Healthy patients undergoing uncomplicated surgery
can remain NPO (with IVF) for how many days
before significant protein catabolism occurs?
 2 days
 4 days
 7 days
 10 days
Healthy patients without malnutrition
undergoing uncomplicated surgery
can tolerate 10 days of partial
starvation before any significant
protein catabolism occurs

32. REFRENCE ;
Schwartz's Principles of Surgery, Ninth
Edition

33. تشکر از توجه
شما