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SURGERY 081606

METABOLISM
IN= ingested nitrogen
I. REVIEW
UN= 24-hr urine nitrogen
Nutrients RNL= remaining nitrogen loss
- Proteins = 3.1 (constant)
o 4 kcal/ g
- Carbohydrates 0 NB= normal
o 4 kcal/g (oral) + NB= pregnant women
o 3.4kcal/g (parenteral) - NB = stressed individuals
- Lipids
o 9 kcal/g
- water Respiratory Quotient (RQ)
- vitamins
- minerals RQ = VC02 / V02

Glucose Metabolism VC02= C02 produced


V02= 02 produced
Glucose in circulation
↓ Glucose Oxidation
Glucose goes into the cytoplasm 1 glucose + 6O2 = 6CO2 + 6H2  RQ = 6/6 = 1

Glucose is converted into Pyruvate Fat Oxidation
↓ 1 palmitate + 23O2 = 16CO2 +16H20  RQ= 16/23 =
Pyruvate can be converted to AcetylCoa in the 0.7
mitochondria and enter Kreb’s Cycle
Or Protein Oxidation
Pyruvate can be converted to Lactate to enter Cori’s 1 AA + 5.1 O2 = 4.1 CO2 + 2.8 H20
Cycle  RQ= 4.1/5.1 = 0.8

Lipogenesis
Fatty Acid Metabolism - RQ > 1.0 – 8.0
- Should be avoided in nutrition
Triglycerides in circulation

Fatty Acid + glycerol Nutrient Utilization

Can enter cell for metabolism Regulation
OR - nutrient availability
Remain in circulation (hypertriglyceredemia) - stress

Amino Acids Excess Glucose Supply

Essential ↑ glucose  pyruvate  AcetylCoa  ↑ ATP (Kreb’s


- body cannot synthesize Cycle)  negative feedback  AcetylCoa  ↑
- have to provide in the diet Triglycerides and CO2

Conditionally Essential An increased glucose level in circulation triggers cellular


- glutamine take-up of glucose. Glucose is converted to pruvate and
- arginine pyruvate is converted to AcetylCoa to complete the
Non-essential Kreb’s cycle resulting in the generation of ATP. However,
- NH3 – R- COOH increased ATP levels provides negative feedback,
- used for protein synthesis inhibiting AcetylCoa from completeing the Kreb’s cycle.
AcetylCoa consequently moves out of the cell where it
undergoes lipogenesis producing CO2 and triglycerides.
Nitrogen Balance

NB = IN – (UN + RNL)

SURGERY METABOLISM 1
 will yield approximately same
Excess Fatty Acids value

↑ Free Fatty Acid  Beta oxidation  Acetyl Coa 


↑Ketones (if low insulin) or ↑Triglycerides (if high insulin) Protein Requirement

Fatty acids in the circulation go inside the mitochondria For Healthy individuals = 0.8- 1.0
where it undergoes beta oxidation. AcetylCoa is For Stressed = 1.0- 2.0
produced which moves into the cytoplasm. It is
converted to Ketones during low insulin states or
Triglycerides during high insulin states. Carbohydrate Requirements

- Must provide 50% to 60% of total calories


Inflammatory Response (Glucose) - Necessary for CHON metabolism

Glucose  Pyruvate  Lactate  Cori Cycle


Fat Recommendations
TNF- alpha, IL- 6 and IL- 1 prevent the conversion of
pyruvate into AcetylCoa in the mitochindria, thus - source of energy + essential FA
pyruvate is converted to lactate instead. o linoleic acid: 2-7 g/day
- 20% - 30% of total calories
↑TNF-alpha, ↑IL-6, ↑IL1 =
↑lactate production
Calorie Distribution

Inflammatory Response (Fatty Acids) Normal


CHO = 60%
Triglyceride  FA + glycerol  FA  triglyceride  Fat = 25%
circulation CHON= 15%

TNF and IL-1 inhibit carnitine, which metabolizes fatty Catabolic State
acids in the mitochondria. Thus FA are converted back to CHO= 45%
triglycerides and are brought back into the circulation. Fat = 30%
CHON= 25%
↑TNF, ↑IL-1 = ↓carnitine = hypertriglyceridemia
Vitamins and Minerals

Malnutrition Fat Soluble Vitamins


- A, D, E, K
- energy expenditure must be
calculated based on ABW, not Water Soluble Vitamins
- using IBW will over-feed the patient resulting in
↑triglycerides, ↑FA II. METABOLIC RESPONSE TO TRAUMA AND
STARVATION

Obesity
Early Fasting
- energy expenditure must be calculated based on IBW - energy comes from muscles
- using ABW will over-feed the patient resulting in - ↑ gluconeogenesis
↑triglycerides, ↑FA
Late Fasting
- energy from ketones
Calculating Basal Energy Expenditure
Metabolic Reaction to Starvation
Harris Benedict Equation
 variables: age, weight, height, gender, activity levels, Hormone Source
etc Norepi Sympathetic ↓
NS
“Rule of Thumb” Method Norepi Adrenals ↑
 calorie requirement: Epi Adrenals ↑
25-30 kcal/ kg/ day T4 Thyroid ↓

SURGERY METABOLISM 2
↑ hyperglycemia
*There is less energy expenditure in starvation! ↑ gypertriglyceridemia
↑ hypercapnia
↑ fatty liver
Metabolic Response to Trauma ↑ hyperphosphatemia
↑ hypermagnesemia
Ebb Phase
- hypovolemic shock
- ↓ Cardiac output Macronutrients During Stress
- ↓ O2 consumption
- ↓ Blood pressure Carbohydrates
- ↓ Tissue perfusion - at least 100g/day to prevent
- ↓ Body temperature k-sis? (sorry can’t understand my
- ↓ Metabolic rate handwriting)
- CHO intake 30%- 90% of total
Flow Phase Calories
- ↑ catecholamines
- ↑ glucocorticoids Fat
- ↑ glucagon - provide 20%- 35% of total
- ↑ cytokines, lipid mediators calories
- ↑ acute CHON production from muscle = loss of - intravenous: 1.0- 1.5
body mass
Protein
Endocrine Response - 20%- 30% of total calories
- FA from FA deposits
- Glucose from liver/ muscle glycogen
- AA from muscle No Stress
Cal: Nitogen >150:1
*There is increased energy expenditure in trauma! %CHON/ total calories 45% CHON
CHON/ kg body weight 0.8g/kg/day

( - ) Nitrogen Balance in Patients Moderately Stressed


Cal: Nitogen 150-100:1
Burns – Most severe N loss %CHON/ total calories 15- 20% CHON
Severe sepsis CHON/ kg body weight 1.0-1.2/g/kg/day
Infection
Elective Surgery – Least severe Severely Stressed
Cal: Nitogen <100: 1
%CHON/ total calories >20%
Starvation Trauma CHON/ kg body weight 1.5-2.0g/kg/day
Metabolic ↓ ↑↑
Rate Conditionally Essential Amino Acids (in metabolic stress)
Body Fuel Conserved wasted
Body CHON conserved wasted Glutamine
Urinary ↓ ↑↑ - body cannot synthesize glutamine in stress
Nitrogen - depleted after trauma
Weight Loss Slow rapid - fuel for immune system and GIT

*Body adapts to starvation but not during disease or Arginine


trauma! - provides substrates for immune system
- ↑ Nitrogen retention
Injury Stress Factor - ↑ wound healing
Minor Surgery 1 – 1.10 - ↑ growth hormone
Long Bone 1.15 – 1.3 - Do not use for septic patients! Arginine ↑ activity
Fracture of immune system, giving it to patient might
Burns 1.2 – 2.00 exhaust him/her
 based on Harris Benedict equation
Vitamins

Metabolic Response to Over- feeding A – wound healing, tissue repair


B – metabolism, CHO utilization
SURGERY METABOLISM 3
C – collagen synthesis
E – antioxidant
Pyridoxine – CHON synthesis
Iron and B12 – oxygen delivery
Nutritional Assesment
Nutrient Requirements
- Medical History
- Physical Examination Short Method
- Anthropometric Measures

Nutrient Intervention
Nutritional Evaluation
- Nutrient counseling
SGA: Subjective Global - Oral supplements
Assessment - Enteral tube feeding
- Parenteral
History
- weight change in the past 3-6 months or 2 *Rule: if the patient’s GIT is functional, use oral
weeks supplements and enteral tube feeding. Only of the GIT is
- dietary intake compared to usual non-functional will parenteral methods be used!
- GI symptoms
- functional capacity * refer to Clinical Decision Making Algorithm for
- Metabolic needs of diseases Nutritional Support

Physical Examination
- loss of subcutaneous fat Summary
- muscle wasting
- ankle edema - nutrient utilization depends on availability
- sacral edema (fasting) and inflammatory response (stress)
- ascites - Nutritional requirements ↑ during trauma

SGA Grading System


A- well nourished (0)
B- moderately nourished with suspicion of
malnourishment (1)
C- severely malnourished (2)

Biochemical Markers for Nutrient Evaluation

- serum albumin (not <3.5)


- serum transferring
- prealbumin

Anthropometrics Measures

TSF
MAC

BMI Nomogram

Underweight <18.5
Normal 18.5-25
Overweight 25- 30
Obese >30

*based on American statistics, Asian classification much


less

SURGERY METABOLISM 4