جمهوری اسالمی افغانستان

وزارت صحت عامه

ریاست شفاخانه استقالل

دیپارتمنت جراحی عمومی

ترینی سال اول(احدی)داکتر صالح الدین -:ترتیب کننده

جراحی عمومی

ترینر (سادات)استاد سید حمیدهللا رداکت-:استاد رهنما

متخصص جراحی عمومی

هه شمسی1393سال

موضوع کنفرانسSystemic Metabolic Response to

Injury

Definitions

سیستم معافیتی به منظور جواب به میکرواورگانیزمهای

خنثی کردن اثرات آنهاوهماهنگی باترمیم نسجی -پتالوژیک

یاالتهاب شامل به اسیب جواب التهابی . شکل گرفته است

-. مراحل ذیل است

های حجرویپیام cell signaling -1- cell migrationمهاجرت حجروی 2

مدیاتورهاازادسازی mediator release -3

The Systemic Inflammatory Response Syndrome (SIRS)

CNS regulation of inflammation

Integral role in inflammatory response that is mostly involuntary

Autonomic system regulates HR, BP, RR, GI motility and temp

CNS Regulation of Inflammation

Hormonal Response to Injury

Includes:

Cytokines

Glucagon

Insulin

Epinephrine

Serotonin

Histamine

Glucocorticoids

Prostaglandins

leukotrienes

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

ACTH

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

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

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

C-reactive proteinA. 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

Mediators of Inflammation

Cytokines

Heat shock proteins

Reactive oxygen metabolites

Eicosanoids Includes prostaglandins, leukotrienes,

thromboxane

Fatty Acid metabolites

Kallikrien-Kinen system

Serotonin

histamine

Cytokine Response to Injury

Lots of cytokines

Most potent mediators of inflammatory response

Pro- and anti-inflammatory

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

Impt Eicosanoids

Prostacyclin (PGI2)

From endothelium

Decreases platelet aggregation

Promotes vasodilation

Thromboxane (TXA2)

From platelets

Increases platelet aggregation

Promotes vasoconstriction

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

Surgical Metabolism

Basic metabolic needs = 25 kcal/kg/day

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

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

Gluconeogenesis

Occurs in the liver

Precursors include:

Amino acids

(alanine)

Lactate

Pyruvate

Glycerol

Cori cycle

In late starvation gluconeogenesis occurs in kidney

Metabolism following Injury

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

Protein Metabolism

6 g protein = 1 g N

Provides substrates for gluconeogenesis and acute phase proteins

1g protein=4kcal

Protein metabolism

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

Schwartz's Principles of Surgery, Ninth Edition

REFRENCE ;

تشکر از توجه شما