The metabolic response to surgery is a result of:

hypovoleia, stress, electrolyte losses, pain, starvation, heat losses, infection

and blood coagulation status.
The response is mediate by a variety of factors including:
Immunological- cytokines which induce vasodilaltation at the site and the influx
of inflammatory cells
Endocrine- increase in stress hormones (ACTH, ADH, adrenaline, cortisol, renin a
ngiotensin),
- decrease in anabolic hormones insulin, tetosterone, thyroid).
Sympathetic stimulation
Overall the endocrine response to trauma is as follows:
cortisol increases, thus increases glucose availability, there is gluconeogenesi
s, proteolysis, and lypolysis.
This provides essential amino acids and energy sources required for healing and
wound repair.
These responses occur due to the metabolic responses to trauma.
There is tissue breakdown which leads to potassium release, there is increased c
apillary permeability and fluid
loss (mostly third space). The body goes into a state of fluid retention. There
is increasing catabolism and
weight loss finally followed by an anabolic period.
In order to assist the body in its response to trauma/surgery, it is vital that
we maintain oxygen levels,
energy forms, water, electrolytes, maintain acid - base balance and overall main
tainenance of tissue perfusion.
daily fluid requirements are the first aspect to consider. Approx 60% of the bo
dy is composed of water.
Most of this is intracellular (50%). Extracellular water is further divided int
o interstitial and blood/plasma.
When assessing fluid status it is important to consider losses which occur. The
se are through the following routes:
urine- 1.5 L
feaceal - 0.2L
respiratory - 0.5L
skin loss - 0.5L
other (fever loss)
Overall it accounts for approx 2-3L over 24hrs.
The equation:
- 100 mL/kg for the first 10Kg
- 50 mL/kg for the next 10Kg
- 20mL/kg for every further kg.
Electrolyte requirements are also important to consider:
Na- 150Mmol/24hrs
K- 100Mmol/24hrs
Overall the follwing is a good plan:
3 L / 24 hours
1 L Normal saline together with (154Mmol Na)
2 L 5 % Dextrose (30Mmol Na/L),or
2 L 4 % Dextrose/ N/5 Saline
Add potassium after 48 hours
In post surgical management it is important that we consider nutritional require
ments:
protein - 100g
carbohydrates - 300g
lipids - 50g
When conisdering post operative management you must first consider the preoperat
ive assessment. Risk factors for
poor surgical outcomes include:
-age
-obesity
-multiple comorbidities, particularly repiratory and cardiac
-smoking
-malignancy
-malnutrition
-diabetes
-immunocompromisation
What to observe in post-operative management:
Patient appearance
Oxygen level
Pulse rate (tachycardia is an early warning sign that something is not quite rig
ht, e.g. sepsis)
Blood pressure
Breathing
Pain
Temperature (usually low immediately post-op)
Urine
Level of consciousness
Wound (problems may include haematoma, infection, breakdown).
Important parameters to measure in post-operative management:
Blood count Hb , white cell count
Electrolytes, urea, creatinine
Arterial blood gases
Liver function tests
Glucose, calcium, phosphate, magnesium,
lactate
Another aspect of post-operative management includes DVT prophylaxis. All patie
nts should be recommended for TED
stockings and should have been placed in calf commpressors during surgery (parti
cularly for long surgeries).
Patients should be encouraged to mobilise early. Should be given unfractioned o
r LMW heparin for 7 days.