1.endocrine and Metabolic Response To Trauma

Kuliah Pra Bedah Dasar 11 Maret 2010
Trauma or injury cellular disruption caused by an

exchange with environmental energy that is beyond the
body's resilience
Remains the most common cause of death for all

individuals between the ages of 1 - 44 years
The third most common cause of death regardless of age
U.S. government classifies injury-related death into the

following categories: accidents (unintentional injuries),
intentional self-harm (suicide), assault (homicide), legal
intervention or war, and undetermined causes
Unintentional injuries 110,000 deaths per

year, with motor vehicle collisions 40%.
Homicides, suicides, and other causes50,000
deaths each year
Injury-related medical expenditures $117

billion each year in the United States
For these reasons, trauma must be considered

a major public health issue
Understanding the complex pathways that

regulate local and systemic inflammation is
necessary to develop therapies to intervene
during overwhelming sepsis or after severe
injury
Initiate the
Endocrine &
Metabolic
responses
To trauma
Hormones are chemical signals that are released to modulate the

function of target cells
Several chemical categories, including polypeptides (e.g.,

cytokines, glucagon, and insulin), amino acids (e.g., epinephrine,
serotonin, and histamine), and fatty acids (e.g., glucocorticoids,
prostaglandins, and leukotrienes)
Three major pathways: (1) receptor kinases such as insulin and

insulin-like growth factor (IGF) receptors, (2) guanine nucleotidebinding or G-protein receptors such as neurotransmitter and
prostaglandin receptors, and (3) ligand-gated ion channels that
permit ion transport when activated
The signal is then amplified through the action of

secondary signaling molecules
Intracellular signaling leads to downstream effects such

as protein synthesis and further mediator release
Together with the targeted DNA sequences, activate

transcription
The prototype of the intracellular hormone receptor is

the glucocorticoid receptor
Regulated by the stress-induced protein known as heat

shock protein (HSP), which maintains the glucocorticoid
receptor in the cytosol
HSP is released, and the receptor-ligand complex is

transported to the nucleus for DNA transcription
The initial hours after surgical or traumatic injury are metabolically

associated with a reduced total body energy expenditure and urinary
nitrogen wasting
A reprioritization of substrate use ensues to preserve vital organ

function and to support repair of injured tissue
Characterized by functions that participate in the restoration of

homeostasis, such as augmented metabolic rates and oxygen
consumption, enzymatic preference for readily oxidizable substrates
such as glucose, and stimulation of the immune system
Understanding alterations in amino acid (protein), carbohydrate, and

lipid metabolism characteristic lays the foundation upon which
metabolic and nutritional support can be implemented
To maintain basal metabolic needs (i.e., at

rest and fasting), a normal healthy adult
requires approximately 22 to 25 kcal/kg per
day drawn from carbohydrate, lipid, and
protein sources. This requirement can be as
high as 40 kcal/kg per day in severe stress
states, such as those seen in patients with
burn injuries
Injuries or infections induce unique

neuroendocrine and immunologic responses
that differentiate injury metabolism from that of
unstressed fasting
The magnitude of metabolic expenditure

appears to be directly proportional to the
severity of insult
The increase in energy expenditure is mediated

in part by sympathetic activation and
catecholamine release
Fuel sources that minimize protein catabolism in the injured patient
Lipid metabolism potentially influences the structural integrity of cell

membranes
Adipose stores within the body (triglycerides) are the predominant

energy source (50 to 80%)
Fat mobilization (lipolysis) occurs mainly in response to

catecholamine stimulus of the hormone-sensitive triglyceride lipase
Other hormonal include adrenocorticotropic hormone (ACTH),

catecholamines, thyroid hormone, cortisol, glucagon, growth hormone
release, reduction in insulin levels, and increased sympathetic
stimulus
Although the process is poorly understood,

adipose tissue provides fuel for the host in the
form of free fatty acids and glycerol during
critical illness and injury
Although the liver is capable of synthesizing

triglycerides from carbohydrates and amino
acids, dietary and exogenous sources provide
the major source of triglycerides
Dietary lipids are not readily absorbable in the

gut but require pancreatic lipase and
phospholipase
The average protein intake in healthy young adults

ranges from 80 to 120 g/d, and every 6 g of protein
yields approximately 1 g of nitrogen
After injury the initial systemic proteolysis, mediated

primarily by glucocorticoids, increases urinary
nitrogen excretion to levels in excess of 30 g/d
Protein catabolism after injury provides substrates

for gluconeogenesis and for the synthesis of acute
phase proteins
Cortisol, glucagon and catacholamines also play a

role in this reaction. The mobilised amino acids
are utilised for gluconeogenesis or oxidation in
the liver and other tissues, but also for synthesis
of acute-phase proteins required for immunocompetence, clotting, wound healing and
maintenance of cellular function
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Kuliah Pra Bedah Dasar 11 Maret 2010

Trauma or injury cellular disruption caused by an

Remains the most common cause of death for all

The third most common cause of death regardless of age

U.S. government classifies injury-related death into the

Unintentional injuries 110,000 deaths per

Injury-related medical expenditures $117

For these reasons, trauma must be considered

Understanding the complex pathways that

Hormones are chemical signals that are released to modulate the

Several chemical categories, including polypeptides (e.g.,

Three major pathways: (1) receptor kinases such as insulin and

The signal is then amplified through the action of

Intracellular signaling leads to downstream effects such

Together with the targeted DNA sequences, activate

The prototype of the intracellular hormone receptor is

Regulated by the stress-induced protein known as heat

HSP is released, and the receptor-ligand complex is

The initial hours after surgical or traumatic injury are metabolically

A reprioritization of substrate use ensues to preserve vital organ

Characterized by functions that participate in the restoration of

Understanding alterations in amino acid (protein), carbohydrate, and

To maintain basal metabolic needs (i.e., at

Injuries or infections induce unique

The magnitude of metabolic expenditure

The increase in energy expenditure is mediated

Fuel sources that minimize protein catabolism in the injured patient

Lipid metabolism potentially influences the structural integrity of cell

Adipose stores within the body (triglycerides) are the predominant

Fat mobilization (lipolysis) occurs mainly in response to

Other hormonal include adrenocorticotropic hormone (ACTH),

Although the process is poorly understood,

Although the liver is capable of synthesizing

Dietary lipids are not readily absorbable in the

The average protein intake in healthy young adults

After injury the initial systemic proteolysis, mediated

Protein catabolism after injury provides substrates

Cortisol, glucagon and catacholamines also play a

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