Systemic Response to Injury and Metabolic Support

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1. Systemic characterized by exaggerated immune responses to either a sterile or infectious process

inflammation
2. Cell migration Inflammatory response to injury or infection involves cell signaling, mediator release, and _____
3. Severe trauma Systemic inflammation is a central feature of both sepsis and ______.
4. Trauma leading cause of mortality and morbidity for individuals under 50
5. Sepsis Identifiable source of infection + SIRS
6. Severe sepsis sepsis + organ dysfunction
7. Septic shock sepsis + cardiovascular collapse
8. Vagus The ____ nerve exerts several homeostatic influences, including enhancing gut motility, reducing heart rate,
and regulating inflammation
9. Nicotine shown to reduce cytokine release after endotoxemia in animal models
10. Polypeptides cytokines, glucagon, insulin
11. Amino acids epinephrine, serotonin, histamine
12. Fatty acids glucocorticoids, prostaglandins, leukotrienes
13. Glucocorticoid Prototype of the intracellular hormone receptor
receptor
14. Glucocorticoid Receptor regulated by the stress-induced protein known as heat shock protein (HSP)
receptor
15. Fat Principal source of fuel for short fasting in healthy adults are derived from muscle protein and body ____.
16. Glycogenolysis Glucagon, norepinephrine, vasopressin, and angiotensin II can promote ______ during fasting.
17. Lactate Precursors for hepatic gluconeogenesis include ___, glycerol, and amino acids, such as alanine and
glutamine.
18. Cori cycle The recycling of lactate and pyruvate for gluconeogenesis is commonly referred to as the ________ _____.
19. Liver Normal adult body contains 300-400 g of carbohydrates in the form of glycogen. 75-100 g are stored in
the ____.
20. Cortisol Effective immunosuppressive agent, which causes thymic involution and depressed cell-mediated immune
responses.
21. Insulin Proteolysis during starvation, which results from decreased ____ and increased cortisol release is associated
with elevated urinary nitrogen excretion.
22. Skeletal Proteolysis during starvation occurs mainly within ____ ____.
muscles
23. Catabolic Phase characterized with hyperglycemia, increase secretion of urinary nitrogen
24. Early anabolic Phase with restored tissue perfusion, sharp decline in nitrogen excretion
25. Catabolic Ebb, Adrenergic-Corticoid
26. Early anabolic Flow, Corticoid-withdrawal
27. Early anabolic Phase with rapid and progressive gain in weight and muscular strength
28. Late anabolic Phase several months after injury once volume deficit has been restored
29. Late anabolic Metabolic phase of the injured patient in which body fat re-accumulates
30. Phospholipase Dietary lipids are not readily absorbable in the gut but require pancreatic lipase and ___ within the
duodenum to hydrolyze triglyceride to free fatty acids and monoglycerides.
31. Stress Hepatocytes use free fatty acids as fuel sources in stress
32. Lipoprotein Trauma or sepsis suppresses ___ activity in both adipose tissue and muscle, mediated by TNF-a
lipase (LPL)
33. 12 Number of ATP molecules produced in TCA cycle
34. Ketogenesis Excess acetyl-CoA serves as precursors for ____
35. Carnitine shuttle transport of fatty acyl-CoA from the outer mitochondrial membrane occurs via the ___ ___.
36. Fatty acid RQ of 0.7 means greater ___ ___oxidation
37. Carbohydrate RQ of 1 means greater ___ oxidation
38. 0.85 RQ = __ suggests the oxidation of equal amounts of fatty acids and glucose
39. Carbohydrate ___ depletion slows acetyl-CoA entry into the TCA cycle secondary to depleted TCA
intermediates and enzyme activity
40. Leucine Essential amino acid for ketogenesis
41. Gluconeogenesis Arginine is an essential amino acid for ____
42. Gluconeogenesis Histidine is an essential amino acid for ____
43. infection identifiable source of microbial insult
44. SIRS criteria Temp <36 or >38
HR >90 BPM
RR >20 BPM
PaCO2 <32mmHg
WBC <4000 or >12000
>10% bands
45. 3 major intercellular hormone -receptor kinases
pathways -G-protein receptors
-ligand-gated ion channels
46. hormones regulated by -corticotropin releasing hormone
hypothalamus -thyrotropin releasing hormone
-luteinizing hormone releasing hormone
47. hormones regulated by anterior -adrenocorticotropic hormone
pituitary -cortisol
-TSH
-thyroxine
-triiodothyronine
-GH
-gonadotropins
-sec hormones
-IGF
-somatostatin
-prolactin
-endorphins
48. hormones regulated by -vasopressin
posterior pituitary -oxytocin
49. hormones regulated by -NE
autonomic system -epinephrine
-aldosterone
50. hormones regulated by RAAS -insulin
-glucagon
-enkephalins
51. ACTH -polypeptide hormone
-regulates release of cortisol from zona fasciulata
52. stimuli for ACTH release -CRH
-pain
-anxiety
-vasopressin
-angiotensin II
-vasoactive intestinal
polypeptide
-proinflammatory
cytokines
53. potentiates the actions of glucagon and epinephrine that manifest as hyperglycemia cortisol
54. signs of adrenal insufficiency -tachycardia
-hypotension
-weakness
-nausea
-vomiting
-fever
-hypoglycemia
-hyponatremia
-hyperkalemia
55. neurohormone that modulates the inflammatory response by inhibiting the immunosuppressive Macrophage migration
effect of cortisol on immunocytes and thereby increasing their activity against foreign pathogens inhibiting factor (MIF)
56. neurohormone that promotes protein synthesis and insulin resistance, and enhances the mobilization GH
of fat stores.
57. In the liver, stimulates protein synthesis and glycogenesis; in adipose tissue, it increases glucose IGF
uptake and lipid utilization; and in skeletal muscles, it mediates glucose uptake and protein synthesis
58. 1. enhances phagocytic activity of immunocytes through increased lysosomal superoxide GH
production.
2. increases the proliferation of T-cell populations.
59. associated with worse outcomes, including increased mortality, prolonged ventilator dependence, exogenous GH
and increased susceptibility to administration in
infection. critically ill pts.
60. hormones secreted by the chromaffin cells of the adrenal medulla that function as neurotransmitters catecholamines
in the CNS
61. 1. shown to induce a catabolic state and hyperglycemia through hepatic gluconeogenesis and epinephrine
glycogenolysis by peripheral lipolysis and proteolysis.
2. promotes insulin resistance
in skeletal muscle.
3. increases the secretion of thyroid hormone, parathyroid hormones, and renin, but inhibits the
release of
aldosterone.
62. manifested by edema, hypertension, hypokalemia, and metabolic alkalosis aldosterone excess
63. manifested by aldosterone deficiency
hypotension and hyperkalemia
64. has immunosuppressive effects, including glycosylation of immunoglobulins and decreased hyperglycemia
phagocytosis and
respiratory burst of monocytes, and thus is associated with an increased risk for infection
65. class of proteins produced by the liver that manifest either increased or decreased plasma acute phase proteins
concentration in response
to inflammatory stimuli such as traumatic injury and infection
66. Among earliest responders after injury; half-life <20 min; activates TNF receptors 1 and 2; induces TNF
significant shock and catabolism
67. similar physiologic effects as TNF; induces fevers through prostaglandin activity in anterior hypothalamus; IL-1
promotes -endorphin release from pituitary; half-life <6 min
68. Promotes lymphocyte proliferation, immunoglobulin production, gut barrier integrity; half-life <10 min; IL-2
attenuated production after major blood loss leads to immunocompromise; regulates lymphocyte
apoptosis
69. Induces B-lymphocyte production of IgG4 and IgE, mediators of allergic and anthelmintic response; IL-4
downregulates TNF, IL-1, IL-6, IL-8
70. Promotes eosinophil proliferation and airway inflammation IL-5
71. Elicited by virtually all immunogenic cells; long half-life; circulating levels proportional to injury severity; IL-6
prolongs activated neutrophil survival
72. Chemoattractant for neutrophils, basophils, eosinophils, lymphocytes IL-8
73. Prominent anti-inflammatory cytokine; reduces mortality in animal sepsis and ARDS models IL-10
74. Promotes TH1 differentiation; synergistic activity with IL-2 IL-12
75. Promotes B-lymphocyte function; structurally similar to IL-4; inhibits nitric oxide and endothelial IL-13
activation
76. Anti-inflammatory effect; promotes lymphocyte activation; promotes neutrophil phagocytosis in fungal IL-15
infections
77. Similar to IL-12 in function; levels elevated in sepsis, particularly gram-positive infections; high levels IL-18
found in cardiac deaths
78. Mediates IL-12 and IL-18 function; half-life of days; found in wounds 5-7 d after injury; promotes ARDS IFN-γ
79. Promotes wound healing and inflammation through activation of leukocytes GM-CSF
80. Preferentially secreted by TH2 cells; structurally similar to IL-2 and IL-15; activates NK cells, B and T IL-21
lymphocytes; influences adaptive immunity
81. High mobility group box chromosomal protein; DNA transcription factor; late (downstream) mediator of HMGB1
inflammation (ARDS, gut barrier disruption); induces "sickness behavior"
82. -anti-inflammatory effects, Omega-3 FAs
including inhibition of NF- B activity, TNF release from hepatic Kupffer cells, as well as leukocyte
adhesion and migration.
-inhibit inflammation, ameliorate weight loss, increase small-bowel
perfusion, and may increase gut barrier protection.
83. group of proteins that contribute to inflammation, blood pressure control, coagulation, and pain Kallikrein-Kinin
responses. System
84. -mediate several physiologic processes, including vasodilation, increased capillary permeability, tissue kinins
edema, pain pathway activation, inhibition of gluconeogenesis, and increased bronchoconstriction. - also
increase renal vasodilation and consequently reduce renal perfusion
pressure
85. s-timulates vasoconstriction, bronchoconstriction, and platelet aggregation. serotonin
- also increases cardiac inotropy and chronotropy through nonadrenergic cyclic adenosine
monophosphate (cAMP) pathways.
86. two major second messengers of the G-protein pathway (1) cAMP
(2) calcium,
released from the
endoplasmic
reticulum
87. transmembrane receptors that are involved in cell signaling for several growth factors, including Receptor tyrosine
plateletderived kinases (RTKs)
growth factor, insulin-like growth factor, epidermal growth factor, and vascular endothelial growth factor
88. energy-dependent, organized mechanism for clearing senescent or dysfunctional cells, including Apoptosis (regulated
macrophages, neutrophils, and lymphocytes, without promoting an inflammatory response cell death)
89. activated through extrinsic pathway
the binding of death receptors which leads to the recruitment of Fas-associated death domain protein
and subsequent
activation of caspase 3
90. activated through protein mediators (Bcl-2) influence mitochondrial membrane permeability. Increased intrinsic pathway
membrane permeability leads to the release of mitochondrial cytochrome C, which activates caspase 3
and thus induces apoptosis
91. normal metabolism 22 to 25 kcal/kg per
day
92. metabolism during stress as high as 40
kcal/kg per
day
93. Body Fuel Reserves in a 70-kg Man Water and minerals
→ 49kg 0kcal 0days
Protein → 6.0kg
24,000kcal 13.0days
Glycogen → 0.2kg
800kcal 0.4days
Fat → 15.0kg
140,000kcal
78.0days
Total → 70.2kg
164,800kcal
91.4days
94. Recommended Daily Requirement glucose glucose 7.2 g/kg per day
95. Recommended Daily Requirement lipid 1.0 g/kg per day
96. Recommended Daily Requirement protein 0.8 g/kg per day
97. GLUT1 Major Expression Sites Placenta, brain,
kidney, colon
98. GLUT2 Major Expression Sites Liver, pancreatic β-
cells, kidney, small
intestine
99. GLUT3 Major Expression Sites Brain, testis
100. GLUT4 Major Expression Sites Skeletal muscle,
heart muscle, brown
and white fat
101. GLUT5 Major Expression Sites Small intestine,
sperm
102. primary source of energy during stressed state lipid metabolism
103. percent of energy provided by lipolysis during stress 50-80%
104. calories provided by oxidation of 1g of fat 9 kcal
105. transport of fatty acyl-CoA from the outer mitochondrial carnitine shuttle
membrane across the inner mitochondrial membrane
106. can cross mitochondrial membranes without carnitine shuttle Medium chain
triglycerides
107. represents a state in which hepatic ketone production ketosis
exceeds extrahepatic ketone utilization
108. calories provided by oxidation of 1g of 4 kcal
carbohydrate
109. calories provided by oxidation of 1g of 3.4 kcal
dextrose
110. facilitates fat entry into the TCA cycle and exogenous administration of small amounts of glucose (approximately 50
reduces ketosis g/d
111. RQs >1.0 indicates over feeding
-can result in conditions such as glucosuria, thermogenesis, and
conversion to fat (lipogenesis).
- results in elevated carbon dioxide production, which may be harmful in
patients with suboptimal pulmonary function, as well as hyperglycemia,
which may contribute to infectious risk and immune suppression.
112. transports glucose molecules against Na+/glucose secondary active transport system
concentration gradients by active transport.
113. calories provided by oxidation of 1g of protein 4 kcal
114. Harris-Benedict equations used to calculate basal energy expenditure
115. will adequately meet energy requirements in 30 kcal/kg/day
most postsurgical patients, with a
low risk of overfeeding
116. protein requirements in burn patients 2.5 g/kg/day
117. type nutrition with associated reduced enteral
infectious complications and acute phase
protein production
118. associated with underfeeding and calorie early gastric feeding after closed-head injury
deficiency due to the difficulties in overcoming
gastroparesis and the high risk of aspiration
119. requires cessation of feeding and adjustment Gastric residuals of 200 mL or more in a 4- to 6-hour period or abdominal
of the infusion rate distention
120. patient groups for 1. Newborn infants with catastrophic gastrointestinal anomalies, such as
whom parenteral nutrition has been tracheoesophageal fistula, gastroschisis, omphalocele, or massive intestinal
used in an effort to achieve these goals: atresia
2. Infants who fail to thrive due to gastrointestinal insufficiency associated with
short-bowel syndrome, malabsorption, enzyme
deficiency, meconium ileus, or idiopathic diarrhea
3. Adult patients with short-bowel syndrome secondary to massive small-bowel
resection (<100 cm without colon or ileocecal valve, or
<50 cm with intact ileocecal valve and colon)
4. Patients with enteroenteric, enterocolic, enterovesical, or high-output
enterocutaneous fistulas (>500 mL/d)
5. Surgical patients with prolonged paralytic ileus after major operations (>7 to 10
days), multiple injuries, or blunt or open abdominal
trauma, or patients with reflex ileus complicating various medical diseases
6. Patients with normal bowel length but with malabsorption secondary to sprue,
hypoproteinemia, enzyme or pancreatic insufficiency,
regional enteritis, or ulcerative colitis
7. Adult patients with functional gastrointestinal disorders such as esophageal
dyskinesia after cerebrovascular accident, idiopathic
diarrhea, psychogenic vomiting, or anorexia nervosa
8. Patients with granulomatous colitis, ulcerative colitis, or tuberculous enteritis in
which major portions of the absorptive mucosa are diseased
9. Patients with malignancy, with or without cachexia, in whom malnutrition might
jeopardize successful use of a therapeutic option
10. Patients in whom attempts to provide adequate calories by enteral tube
feedings or high residuals have failed
11. Critically ill patients who are hypermetabolic for >5 days or for whom enteral
nutrition is not feasible
121. Patients in whom hyperalimentation is 1. Patients for whom a specific goal for patient management is lacking or for
contraindicated include the following: whom, instead of extending a meaningful life, inevitable
dying would be delayed
2. Patients experiencing hemodynamic instability or severe metabolic
derangement (e.g., severe hyperglycemia, azotemia,
encephalopathy, hyperosmolality, and fluid-electrolyte disturbances) requiring
control or correction before hypertonic intravenous feeding is attempted
3. Patients for whom gastrointestinal tract feeding is feasible; in the vast majority
of instances, this is the best route by which to provide nutrition
4. Patients with good nutritional status
5. Infants with <8 cm of small bowel, because virtually all have been unable to
adapt sufficiently despite prolonged periods of parenteral nutrition
6. Patients who are irreversibly decerebrate or otherwise dehumanized
122. TPN -requires large bore access
-15-25% dextrose
-all nutrients are deliverable by this route
123. peripheral parenteral nutrition -5-10% dextrose
-3% protein
-not appropriate for malnourished patients because some nutrients not
deliverable
124. essential fatty acid deficiency manifests as dry, scaly dermatitis and loss of hair
125. complications of parenteral nutrition -sepsis 2/2 contamination of central venous catheter
-PNX
-hemothoraz
-subclavian artery injury
-thoracic duct injury
-arrythmia
-air embolism
-cardiac perforation
-hyperglycemia
-hepatic steatosis 2/2 overfeeding
-cholestasis and gallstones
-intestinal atrophy