For surgical residents presentation

1. METABOLIC RESPONSE TO
TRAUMA
By
Dr. Olofin.K.E

2. Outline
• Introduction
• Historical Perspectives
• Triggers of metabolic response to trauma
• Components of metabolic response to trauma
• Sequelae of metabolic response to trauma in the
surgical patient
• Factors affecting severity of response
• Attenuation of metabolic responses to trauma
• Conclusion

3. Introduction
• Metabolic response to trauma (MRT) refers to
adaptive defensive changes aimed at
maintaining homeostasis after a traumatic
event.
• Core objectives of these changes include
maintaining circulation, providing energy,
repair of wound and restoration of normal
function.

4. • Responses to trauma can however have
adverse effects on the patient if prolonged
and accentuated.
• Control of these responses can improve the
overall outcome in surgical patients.

5. Historical Perspectives
• 1932- Cuthbertson described in detail the
metabolic response of four patients with
lower limb injuries
• 2 phases were described-the ebb and flow
phases

6. Triggers of Metabolic response to
Trauma
1. Pain from damaged tissues
2. Hypovolemia/Heamorrhage/Hypoxia
3. Infection
4. Inflammatory reaction
5. Acidosis
6. Starvation
7. Hypothermia
8. Anxiety

7. Components of Metabolic Response to
Trauma
• Sympathetic Nervous System Activation
• Endocrine reponse
• Cytokine response

8. Sympathetic Nervous System response
Response
• Rise in norepinephrine
release from adrenal
medulla and presynaptic
nerve endinngs
Effects
• Cardiovascular effects –
tachycardia, hypertension,
redistribution of blood flow,
activation of the renin-
angiotensin system
• GIT-Reduced intestinal motility
• Respiratory System-
Bronchodilation
• Pancreas- Reduces insulin
secretion and raises glucagon
secretion

9. Endocrine Responses
Endocrine organ changes
• Hypothalamic-pituitary-
adrenal system- Rise in
ACTH and Growth hormone
secretion
• Posterior Pituitary gland-
arginine vasopressin
secretion
• Adrenal Cortex-Rise in
cortisol and aldosterone
• Pancreas-increase in insulin
and glucagon secretion
Effects
• Rise in plasma cortisol, GH
increases lipolysis,
gluconeogenesis and
decreased cellular glucose
uptake
• AVP- Increases water
reabsorbtion in the collecting
ducts
• Aldosterone increases Na
reabsorbtion
• Cortisol and glucagon-Insulin
antagonism

10. Cytokine Mediated Responses
Cytokine Effects
TNF-alpha Neutrophil activation, upregulation of adhesion molecules, increased
capillary permeability, fever
IL-1 Neutrophil and T-lymphocyte proliferation, increased capillary
permeability, proteolysis and fever
IL-2 Increases antibody-dependent cell mediated toxicity, proliferation of
activated T4 cells
IL-4 Increases B-cell and T4 type 2 cells
IL-6 Stimulates acute phase protein production in the liver- C-reactive
protein, serum amyloid A protein, Factor VIII, vWF, Fibrinogen
IL-10 Anti-inflammatory
IL-12 Increases production of IL-2, TNF-b, INF-g

11. Sequelae of metabolic response to
trauma/Relevance to surgical patient
• Increased energy requirement
• Reduced immunity
• Increase susceptibility to venous
thromboembolism
• Impaired wound healing
• Weight loss
• Fatigue

12. Factors Influencing Response
• Nature and severity of injury
• Nutritional status of patient
• Age
• Sex
• Environmental temperature

13. Attenuation of Metabolic Response
Pre/Per-operative measures
• Allaying of fear and anxiety
• Prompt replacement of blood
and fluid loss
• Regional anaesthesia
(epidural) when appropriate
• Adequate analgesia
• Minimally invasive surgeries
(laparoscopic surgeries)
• Pre-operative nutritional
support (arginine, glutamine,
fish oil)
• Antibiotic prophylaxis
Post operative measures
• Fluid and electrolyte
balance
• Adequate analgesia
• Early enteral feeding
• Perenteral nutritional
support
• Prompt treatment of
infections

14. Conclusion
• Metabolic response to trauma aims to restore
homeostasis after a traumatic event, it also
has the propensity of causing unwanted
effects.
• Measures that reduce its intensity should be
taken to reduce morbidity and mortality, and
of course improve treatment outcome.

15. Thank you!

16. References
• Principles and Practice of Surgery, 4th Edition
• The Stress Response to Trauma and Surgery by
JP Desborom, British Journal of
Anaesthesia,2000. 85(107-109)
• Textbook of anaesthesia, Aitkenhead 4th
Edition
• Physiological response to Trauma, Infection
and Surgery, www.surgical-trauma.co.uk