1.

Measure of metabolic rate after laparoscopy: Objective The aim of the research was to

compare local and systemic reactions of the body to laparotomy and laparoscopy. Design In a prospective randomized study the operative trauma and metabolic changes in 40 patients were investigated and compared in laparoscopy and laparotomy. Main outcome measures Metabolic changes were registered by indirect calorimetry. In order to quantify intraperitoneal trauma, short-term and medium-term pH measurements of the peritoneal surface were made. Results In the case of laparoscopy a severe intraoperative chemical acidosis occurred that disappeared a short time after operation. As a result, a short-term increase of metabolic rate was observed. Following laparotomy an increase in metabolic acidosis was registered during the first postoperative hours and had not returned to normal after 24 h. A prolonged catabolism lasted over 48 h. Conclusion In patients undergoing laparotomy the intraperitoneal trauma is more marked than in laparoscopy. Long-term metabolic intra-abdominal acidosis with resulting catabolism may cause increased impairment of the organism. Physiological Changes during Laparoscopic Surgery

Additionally. People who are otherwise healthy will tolerate laparoscopy well. CARDIOVASCULAR RESPONSE The cardiovascular response to increased intra abdominal pressure appears to be phasic. Although higher pressures are sometimes used transiently to optimize visualization. A physiologic effects seen with CO2 insufflation are transient and derive from the body's reaction to increases in intra abdominal pressure and CO2 absorption as it tries to achieve a new state of homeostasis. patient positioning. The working space developed by CO2 pneumoperitoneum or pneumoretroperitoneum would depend about the pressure of gas presentedto the patient. Typically. while individuals with underlying cardiopulmonary or renal diseases may not tolerate prolonged CO2 insufflation. and pressures more than 25 mm Hg could be associated with abdominal compartment syndrome. It begins with an early transient phase where venous return and cardiac filling pressures increase due to upward mechanical pressure about the dintra abdominal pressurehragm. in turn. an intra abdominal pressure of 20 mm Hg or greater for any prolonged period is considered unsafe. can exacerbate cardiovascular alterations in laparoscopy. for example steep Trendelenburg in prostatectomy. increases intrathoracic pressure as well as intra-abdominal compression about the splanchnic . This particular.Laparoscopic surgeries are commonly carried out through transperitoneal or retroperitoneal approaches with insufflation of CO2 and fewer commonly with another inert gas such as helium or argon. intra-abdominal pressures (intra abdominal pressure) of Ten to fifteen mm Hg are sufficient for visualization and dissection.

bradycardia and asystole can occur during CO2 insufflation and pneumoperitoneum. Following the transient rise in venous return with the initiation of pneumoperitoneum or pneumoretroperitoneum. A lot more specifically. Attention to patient positioning and its impact on cardiovascular response ought not to be neglected. although stroke volume and cardiac output decrease. Although the exact mechanism for this response and why only certain patients experience bradycardia remain topics of continued research. hemodynamic changes are magnified. and gas embolisms of those insoluble gases aren't well tolerated and can rapidly lead to death. ejection fraction. however. Those with underlying cardiac disease will likely have a lower intra abdominal pressure threshold. with higher pressures associated with more significant changes than lower pressures.venous bed and vena cava. generating decreased venous return. venous pooling in the lower extremity occurs. extremely soluble. some authors have recommended invasive hemodynamic monitoring with repetitive blood gas analysis. RESPIRATORY RESPONSE CO2 may be the gas of choice for laparoscopic surgeries because it is noncombustible. and right. but most studies have reported no significant long-term changes in heartbeat with laparoscopy. Nitrous oxide can result in bowel distension and decreased working space and is also combustible. systemic vascular resistance (SVR). In a tiny subset (0. . pulmonary capillary wedge pressure. In Trendelenburg position. The compressive effects on the arterial vasculature and capillaries increase afterload. Pneumothorax caused by helium and argon resolves much slower than CO2 pneumothorax. a steady state of decreased blood circulation with the inferior vena cava comes after due to the compressive effects of continued intra-abdominal cava pressure. Backwards Trendelenburg position.5%) of otherwise healthy patients. Helium and argon. are a lesser amount of soluble than CO2 and therefore are hard to eliminate through ventilation. and readily eliminated with the lungs. the threshold intra abdominal pressure that led to hemodynamic changes was 12 mm Hg. Due to the growing complexity of laparoscopic urologic cases and the increased duration of pneumoperitoneum required. Heart rate may rise transiently in response to increases in SVR and arterial blood pressure level to maintain cardiac output. it is believed that direct pressure about the vagus nerve leads to a stimulatory parasympathetic effect that leads to a decline in heart rate. and arterial pressure. which increases venous return. Other gases for example nitrous oxide have fallen out of favor. In cases where steep or reverse Trendelenburg positions are required. In in any other case healthy patients undergoing laparoscopy. although inert and nonflammable. Cardiovascular changes vary with intra abdominal pressure. venous return is improved with subsequent increases in cardiac filling pressures. with drops within the cardiac index (CI) of as much as 50% in certain reports.and left-side cardiac filling pressures. mechanical pressures on the venous vasculature result in increases in central venous pressure.

there's a pressure-dependent decrease in the glomerular filtration rate (GFR). but as intra abdominal pressure reaches and exceeds 15 mm Hg. and peak airway and plateau pressures can enhance up to 50% and 81%. Endtidal CO2 measurements are difficult to rely on and tend to underestimate the real PCO2 on this population due to impaired gas swap. In otherwise. and renal venous outflow. urinary output decreases by as much as 63% to . the renal parenchyma. and pulmonary compliance drop with boosts in intra abdominal pressure. the dintra abdominal pressurehragm is pushed cephalad into the thoracic cavity. The renal effects are mild to negligible once the intra abdominal pressure is under 10 mm Hg. In a typical intra abdominal pressure of 15 mm Hg. Periodic arterial blood gas measurements ought to be obtained as well as in the big event that CO2 cannot be quickly eliminated. affected individuals with underlying chronic obstructive pulmonary disease (COPD) or morbid obesity are at high risk for pulmonary decompensation and could require positive end expiratory pressure for adequate gas exchange. cortical and medullary perfusion. CO2 absorption in the peritoneal cavity or retroperitoneal space will result in hypercapnia and respiratory acidosis. vital capacity. and exacerbation of congestive heart failure. pneumoperitoneum or pneumoretroperitoneum should be relieved immediately. Effects are transient and reversible upon desufflation. RENAL RESPONSE Oliguria is often seen otherwise expected with increases in intra abdominal pressure during laparoscopy and really should be described as a normal physiologic response. creatinine clearance. the respiratory response to mechanical improves in intra abdominal pressure as well as hypercapnia from absorption should be considered. fluid overload. ERBF. All round functional respiratory capacity. as intra abdominal pressure increases. CO2 is eliminated efficiently through respiration by increases in minute ventilation (increases in respiratory rate and/or tidal volume). respectively. poor CO2 diffusion and elimination can lead to significant and catastrophic increases of PCO2 if blood gases are not supervised. sodium excretion. constraining downward dintra abdominal pressurehragmatic excursion with respiration.Despite the proven effectiveness and protection of CO2 for insufflation in laparoscopy. pulmonary edema. and urinary output. CO2 excretion rises acutely. In procedures for example prostatectomy and cystectomy. within approximately Quarter-hour of pneumoperitoneum then plateaus thereafter. The greater concern would be to avoid overresuscitation. With CO2 insufflation and increases in intra abdominal pressure. and the IVC will reduce effective renal blood circulation (ERBF). Despite the fact that laparoscopy is usually well tolerated. healthy individuals without having pulmonary disease. CO2 insufflation could be resumed and also the laparoscopic procedure continuing. its compressive effects on the renal vasculature. from the typical baseline degree of 125 mL/min to 200 mL/min. Mechanistically. In patients with interstitial pulmonary disease or COPD. where steep Trendelenburg positioning may be required. In addition to the mechanical consequences of pneumoperitoneum. Similar to the phasic cardiac response. Once PCO2 has fallen to the acceptable range. pulmonary compliance and dintra abdominal pressurehragmatic movement are further limited.

causing them to are afflicted by more major and extended derangements in acid-base balance. resulting in systemic vasoconstriction and fluid retention. PEDIATRIC CONSIDERATIONS Laparoscopy within the pediatric population is generally nicely tolerated. an increase in minute ventilation is enough. tumor necrosis factora. optimizing ERBF during laparoscopy would seem reasonable. and antidiuretic hormone are elevated. Among them. Despite animal model data that suggest no adverse renal histologic changes with prolonged pneumoperitoneum. Cortisol. and pneumoperitoneum-induced renal failure does not occur. some investigators have suggested using isotonic and hypertonic intravascular volume expansion for transplant cases.64%. An alternative choice to volume expansion is to decrease intra abdominal pressure around visualization will allow. Along with renal compression and decreased ERBF. a similar intra abdominal pressure-dependent physiologic response could be anticipated. volume expansion and slight fluid overload in the course of surgery might not be unreasonable as long as the surgical team understands the possible unwanted effects. As donors are typically healthy and at safe for cardiopulmonary complications. there are no long-term renal sequelae. METABOLIC RESPONSE Metabolic acidosis from CO2 absorption is the primary derangement with laparoscopy. The optimal fluid managing of physiologic oliguria is much more controversial in laparoscopic live donor nephrectomy. but for individuals with COPD. along with a post-desufflation diuresis is usually noted in the following hours. a host of neurohormonal factors are freed. granulocytic elastase. Together with desufflation. Despite this drop. GFR by 21%. even in patients with pre-existing renal disease. these mediators return to baseline levels. C-reactive protein. Even though clinical implications might be minimal. and ERBF by 26%. clinically . endothelin. aldosterone. renin. removal of CO2 is less capable. From a cardiac perspective. immune and cytokine responses to laparoscopic surgery have been noted. As stated earlier. interleukin (IL)-6. desufflation might be necessary during a long laparoscopic procedure in patients with COPD or interstitial lung condition. catecholamines. and leukocytes are one of the factors released during laparoscopy that could impact your body's metabolic demand and rest energy expenditure within the postoperative setting. however. Systemic CO2 absorption and resultant metabolic consequences differ depending on the patient's underlying respiratory status since the lung eliminates absorbed CO2 buffered by the blood. In order to preserve renal perfusion and minimize possible deleterious effects on graft function. IL-10. When intra abdominal pressure is maintained at 10 to 12 mm Hg or less. Renal homeostasis is re-established within Twenty four hours after surgery with normalization of serum and urinary creatinine and electrolytes. In otherwise healthy patients.

bradycardia and asystole may appear during gas insufflation from vagal nerve stimulation. for a longer time durations of CO2 insufflation and elevated intra abdominal pressure are required. and metabolic response in laparoscopy. thereby decreasing functional respiratory capacity. In youngsters. Thus. From the mechanical standpoint. As the complexity of urologic cases performed laparoscopically increases. TNM Classification for Malignant Melanoma (Open Table in a new window) . renal. Adequacy of ventilation should be assessed by serial arterial blood unwanted gas in affected individuals with pulmonary condition. CO2 absorption is a lot more efficient in youngsters due to a relatively greater absorptive surface-to-weight ratio. As with adults.[1. With increases in intra-abdominal pressure. the laparoscopist must be mindful from the each patient's fundamental cardiopulmonary status and anticipate the hemodynamic reaction to non-invasive surgery.significant hemodynamic compromise is generally not observed. similar pharmacokinetics 3. surgeons should view the basic physiologic principles of the cardiac. inhaling the pediatric population is more determined by diphragmatic movement than on expansion from the thoracic cavity as in adults. thoracic compliance is higher in the immature chest cavity. and initiating pneumoperitoneum in a lower insufflation rate might be warranted. respiratory. and also the respiratory changes appear to be more significant with intraperitoneal than extraperitoneal insufflation. In addition. minute ventilation ought to be increased. Staging of malignant melanoma leg TNM Classification for Malignant Melanoma The TNM classification for malignant melanoma is provided below. with close monitoring of endtidal CO2 and arterial oxygenation in longer cases. although increases in SVR (162%) and decreases in cardiac performance (67%) have been reported at pressures of 10 mm Hg. Bacteria production most potent exotoxins = Clostridium botulinum 2. the respiratory reaction to increased intra abdominal pressure and CO2 insufflation are magnified compared with adults. 1. Thus. Ropivicaine vs bupivacaine: ropivicaine has least CV toxicity. 2] Table. CONCLUSION With increasing laparoscopic applications. the diaphragm is pushed relatively more cephalad. and prevention of overhydration for physiologic oliguria is essential for patient safe practices. further magnifying physiologic modifications in patients. Children routinely have a higher resting vagal tone. Equally respiratory rate and peak airway pressures increases. it is advisable to minimize intra abdominal pressure if visibility allows just because a lower intra abdominal pressure is associated with fewer cardiac effects. From a metabolic standpoint. To avoid hypercarbia.

01-4. or matted lymph nodes.Regional metastases based upon number of metastatic nodes and presence or absence of 3 intralymphatic metastases (in transit or satellite metastases) N1 1 lymph node y y N1a: Micrometastases N1b: Macrometastases N2 2 or 3 lymph nodes y y y N2a: Micrometastases N2b: Macrometastases N2c: In-transit met(s)/satellite(s) without metastatic lymph nodes N3 • 4 metastatic lymph nodes. curettaged or severely regressed melanoma) T0 No evidence of primary tumor Tis Melanoma in situ T1 Melanoma ” 1.Primary tumor (T) TX Primary tumor cannot be assessed (ie.0 mm in thickness y y T2a: Without ulceration T2b: With ulceration T3 Melanomas 2.0 mm in thickness y y T3a: Without ulceration T3b: With ulceration T4 Melanomas > 4. or in-transit met(s)/satellite(s) with metastatic lymph node(s) . previously removed for another reason) N0 No regional metastases detected N1.0 mm in thickness y y T4a: Without ulceration T4b: With ulceration Regional lymph nodes (N) NX Patients in whom the regional nodes cannot be assessed (ie.01-2.0 mm in thickness y y T1a: Without ulceration and mitoses < 1/mm2 T1b: With ulceration or mitoses • 1/mm2 T2 Melanomas 1.

normal serum lactate dehydrogenase (LDH) level Lung metastases. subcutaneous. Pathologic staging (Open Table in a new window) Stage T N 0 Tis N0 IA T1a N0 IB T1b N0 T2a N0 IIA T2b N0 T3a N0 IIB T3b N0 T4a N0 IIC T4b N0 IIIA T(1-4)a N1a T(1-4)a N2a IIIB T(1-4)b N1a T(1-4)b N2a M M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 . Clinical staging (Open Table in a new window) Stage T N M 0 Tis N0 M0 IA T1a N0 M0 IB T1b N0 M0 T2a N0 M0 IIA T2b N0 M0 T3a N0 M0 IIB T3b N0 M0 T4a N0 M0 IIC T4b N0 M0 III Any T N1. or N3 M0 IV Any T Any N M1 Table. or distant lymph nodes. N2.M0 M1a M1b M1c Distant metastasis (M) No detectable evidence of distant metastases Metastases to skin. normal LDH level Metastases to all other visceral sites or distant metastases to any site combined with an elevated serum LDH level Anatomic stage/prognostic groups Table.

and 1 positive (micrometastatic) lymph node (T1-4aN1aM0) have a 5-y survival rate of 70% T1-4aN2aM0 lesions (any-depth lesion. no ulceration. no ulceration.T(1-4)a N1b M0 T(1-4)a N2b M0 T(1-4)a N2c M0 IIIC T(1-4)b N1b M0 T(1-4)b N2b M0 T(1-4)b N2c M0 Any T N3 M0 IV Any T Any N M1 Stage IA: y Lesions ” 1 mm in thickness with no evidence of ulceration or metastases (T1aN0M0) are associated with a 5-y survival rate of 95% Stage IB: y Lesions ” 1 mm in thickness with ulceration noted but without lymph node involvement (T1bN0M0) or lesions 1.01-4 mm in thickness with ulceration but no lymph node involvement (T3bN0M0) or lesions > 4 mm in thickness without ulceration or lymph node involvement (T4aN0M0) are associated with a 5-y survival rate of 63-67% Stage IIC: y Lesions > 4 mm in thickness with ulceration but no lymph node involvement (T4bN0M0) are associated with a 5-y survival rate of 45% Stage IIIA: y y Patients with any-depth lesion.0 mm in thickness without ulceration or lymph node involvement (T3aN0M0) are associated with an overall 5-y survival rate of 77-79% Stage IIB: y Melanomas 2. but 2-3 nodes positive for micrometastasis) are associated with a 5-y survival rate of 63% .01-4.01-2 mm in thickness without ulceration or lymph node involvement (T2aN0M0) are associated with a 5-y survival rate of approximately 91% Stage IIA: y Melanomas > 1 mm but ” 2 mm in thickness with no evidence of metastases but with evidence of ulceration (T2bN0M0) or lesions 2.

The incidence of SSI in hernia surgery is more frequent then it is assumed. is more frequently followed by the infection. The mesh infection (type I) never involves its body but it is present around sutures and bended edges. Comparing to inguinal hernia repair. and 1 lymph node positive for micrometastasis (T1-4bN1aM0) or 2-3 nodes positive for micrometastasis (T14bN2aM0) have a 5-y survival rate of 50-53% Patients with any-depth lesion. operative approach (open . incisional). The mesh infection Type II involves entire prosthesis while in the case of Type III it is present in its peripheral part. 2-3 nodes positive for macrometastasis (T1-4bN2bM0). positive ulceration. no ulceration. while prosthesis Type II must be removed completely. low incidence of infection. matted lymph nodes. or in-transit met(s)/satellite(s) have a 5-y survival rate of 24-29% Stage IV: y y y Melanoma metastatic to skin. or • 4 metastatic lymph nodes. N1b. A type I of the prosthesis is more resistant to the infection then prosthesis II and III. a prosthesis Type I is possible to be saved.laparoscopic). although the consequences of the mesh infection may be severe. If the infection is present the nontension . The laparoscopic operations are followed with the lower incidence of SSI then in the case of open operations. and 1 lymph node positive for macrometastasis (T1-4bN1bM0). The usage of the mesh does not increase the incidence of SSI. subcutaneous tissue. usage of the prosthetic material and drainage. In regard to the position of the mesh. on the spot of surgical work (SSI). Etiology of wound infection inguinal hernia Traditionally. The defect that remained after excision of non-resorptive prosthesis is a long-term and very complicated surgical problem.Stage IIIB: y y Patients with any-depth lesion. and the same is for the Type III (the partial removal is rarely suggested). positive ulceration. the operation of hernia is considered as a clean operation due to expected. or lymph nodes with normal LDH level (M1a) is associated with a 5-y survival rate of 19% M1b disease (metastatic disease to lungs with normal LDH level) has a 5-y survival rate of 7% M1c disease (metastatic disease to all other visceral organs and normal LDH level or any distant disease with elevated LDH level) is associated with a 5-y survival rate of 10% 4. and 1 lymph node positive for macrometastasis (T1-4a. incisional hernia repair. preaponeurotic retromuscular or pre-peritoneal mesh placemen. SSI is more common if the mesh is placed subcutaneously then in the case of sub-aponeurotic premuscular. The important risk factors for SSI are the following: type of hernia (inguinal. M0) or 2-3 nodes positive for macrometastasis (T14aN2bM0) have a 5-y survival rate of 46-59% Stage IIIC: y Patients with any-depth lesion. In the case of SSI.

lactate. Non carbohydrate sources such as alanine. When glucose was administered at 200 g. glycerol. After glucose administration. Protein-sparing effect of glc administration What is Protein-Sparing effect? Protein sparing is the process by which the body derives energy from sources other than protein. while in the case of opening of various organs dominant bacteria's originate from them. Such sources can include fatty tissues. . Leucine. If there is an indication for drainage it should be as short as possible. the concept of protein-sparing effect was introduced by Gamble. There are no prospective studies that justify the usage of antibiotic prophylaxes in hernia surgery. or approximately 400 g for six days. This indicates that administration of glucose. and are conserved in the body in a greater ratio. alone cannot fully inhibit the catabolism of body proteins. acetate.techniques using non-resorptive prosthetic implants are not recommended. a branched-chain amino acid has been recently known also to have protein-sparing effect. Protein sparing conserves muscle tissue. Decreasing dietary DP/DE ratio results in an increase of protein conservation. 5. approximately 80 g/day. 100 g/day of glucose is required at minimum. In clinical nutrition. dietary fats and carbohydrates. branched-chain ketoacids are also known to exert protein-sparing effects.. This is equivalent to approximately 2 kg of muscle. 1. For this purpose.3 During starvation in a 70 kg man. and the total quantity of protein fed to the body. The degree of protein catabolism was similar to that at 100 g. The appearance of SSI increases the price of treatment and may lead to the recurrence. The superficial infection does not lead to the recurrence. The antibiotic prophylaxis is indicated for the clean operations when placing the implants and when severe complication is expected. The amino acids are not catabolized for energy. Using alternate energy sources lessens the amount of amino acids that will be metabolized for energy. Approximately 40 g of proteins at minimum is necessary as a daily average intake to maintenance N-balances under no stress conditions.e. The cause of SSI for elective operations are bacteria's that arrives from the skin.2 The amount of protein used in the body is influenced by the percentage that is digestible by the body. glucose administration inhibited the protein loss to approximately 50% of that during starvation. It is more common for incisional hernioplasty then for inguinal hernia repair. The balance between digestible protein (DP) and digestible energy (DE) in the diet is a key factor. while it is very possible in the case for deep infection. i. Bodybuilding and other strength training promotes the utilization and conservation of protein's amino acids in the body. The protein loss at a glucose dose of 100 g/day was approximately 40 g/day or approximately 200 g for six days. an energy source. This means. the protein catabolism was inhibited. The presence of drainage and its duration increases the incidence of SSI. of proteins was lost due to the catabolism of body proteins.

and glucose production were assessed by stable isotope tracer kinetics using leucine and glucose isotops. with or without glucose at 4 mg · kg 1 · min 1) on the second day after colorectal surgery. The provision of small amounts of glucose was associated with a decrease in amino acid oxidation during colorectal surgery. They randomly allocated 14 patients to receive intravenous glucose at 2 mg·kg 1·min 1 (glucose group) starting with the surgical incision or an equivalent amount of normal saline 0.05). protein oxidation. supplementation of not only energy sources (carbohydrates and fats) but also amino acids that are used for protein synthesis is important to improve N-balance and protein metabolism and then inhibit the catabolism of body proteins. The administration of amino acids increased protein balance from 16 ± 4 mol · kg 1 · h 1 in the fasted state to 16 ± 3 mol · kg 1 · h 1. an estimate of protein breakdown. including glucose. the energy demand is increased and protein catabolism is further enhanced. Combined infusion of amino acids and glucose increased protein balance from 17 ± 7 to 7 ± 5 mol· kg 1 · h 1. secondary endpoints were leucine rate of appearance and nonoxidative leucine disposal as determined by a stable isotope tracer technique. 14 patients with colonic cancer were randomly assigned to undergo a 6-hour stable isotope infusion study (3 hours of fasting followed by 3-hour infusions of 10 % amino acids 10% at 0. A group of japanese investigators showed that combination of amino acids. .001) and stimulated insulin secretion (P = . spare protein while preventing hyperglycemia. In this case.9% (control group).05 vs. Leucine rate of appearance. Thomas Schricker et al examined the hypothesis that amino acids.. The primary endpoint was whole body leucine oxidation.02 mL · kg 1 · min 1.6 In this prospective study. lactate. and cortisol were measured before and after 2 h of surgery. Even moderate increases in blood glucose are associated with poor surgical outcome. decreased in both groups during surgery (P < 0. control group) whereas it remained unchanged in the control group. glucose and electrolytes is more effective than exclusive amino acids or electrolyte plus 10% glucose solution in minimizing weight loss and negative nitrogen balance 4 Intraoperative protein sparing with glucose Schricker et al examined the hypothesis that glucose infusion inhibits amino acid oxidation during colorectal surgery 5. glucagon. and nonoxidative leucine disposal. insulin. and glucagon were determined. Combined administration of amino acids and glucose decreased endogenous glucose production (P = . It becomes more difficult to inhibit protein catabolism by glucose administration alone.07). The increase in protein balance during nutrition was comparable in the 2 groups (P = . Circulating concentrations of glucose. Circulating concentrations of glucose. Leucine oxidation intraoperatively decreased from 13 ± 3 to 4 ± 3 µmol·kg 1·h 1 in the glucose group (P < 0. in the absence of glucose supply. leads to hyperglycemia.001) to a greater extent than the administration of amino acids alone.Under stress conditions such as surgery. protein balance. cortisol. insulin. an estimate of protein synthesis. Parenteral nutrition and protein sparing after surgery Although capable of inducing an anabolic state after surgery. parenteral nutrition. Protein breakdown.

while microminerals and zinc facilitate cellular metabolism. Sp = TN/TN+FP 7. American Society for Nutrition J. Nutritional Biochemistry. it has been shown to contribute to hyperglycemia. Sn = TP/TP+FN b. February 2006 Mitchell JC. J Surg Res 2004. Volume 56. Yakuri To Chiryo 1994.Is Protein-Sparing Effect Considered in Formulation of Maintenance Solution ? New generation dual-chamber maintenance solutions like Aminofluid® contain combination of glucose and amino acids to prevent consumption of amino acids as energy source and thus have favourable profile on nitrogen balance. 121:311. Evenson AR. Lattermann R. Nutr. Higher infection rates have been found in patients receiving TPN versus enteral nutrition. 2005 (Schricker T Parenteral nutrition and protein sparing after surgery: do we need glucose?Original Research Article Metabolism. and Carli F Intraoperative protein sparing with glucose J Appl Physiol 99: 898 901. 2. 4. 3. however. the risk of hyperglycemia was substantially reduced in patients who received infusions at lower rates Hyperglycemia resulting from excess dextrose in TPN solutions elevates the respiratory quotient in ventilated patients and increases infectious complications. In contrast. August 2007. Etiology of hyperglycemia/TPN: Stress from illness induces a hyperglycemic state. Although total parenteral nutrition (TPN) provides necessary nutrients and calories to critically ill patients and lowers their risk of noninfectious complications.45% saline) are used 8. Issue 8. p 454 Urabe H. Choice of fluid in hypovolemia: Isotonic crystalloid solutions are typically given for intravascular repletion during shock and hypovolemia. emphasizing the importance of glucose control for TPN .) 6. D5 0. 6. and hypotonic solutions (eg. which can be further exacerbated with TPN. Second Edition. References: 1. Pages 1044-1050. 136:529S-532S. Patients (without diabetes) who received TPN and dextrose at rates >5 mg/kg/min had a 49% chance of developing hyperglycemia. the content of electrolytes is necessary for water and electrolyte homeostasis. Colloid solutions are generally not used. 5. Nutraceutical Effects of Branched-Chain Amino Acids on Skeletal Muscle. et al. Tawa NE: Leucine inhibits proteolysis by the mTOR kinase signaling pathway in skeletal muscle. In addition.22 (Supplement):S835 Schricker T. Brody T. the serum glucose concentrations in the former group have been consistently higher. Sensitivity vs Specificity a. Shimomura Y et al. Patients with dehydration and adequate circulatory volume typically have a free water deficit.

and a raised border around the affected area. Alternatively.2 g/kg-1. Etiology of shock s/p AAA repair: most commonly hemorrhagic shock PA Catheter tracing see pdf Process Measures SCIP Rx of high-voltage electrical injury fluid resuscitation. Incidence of hyperglycemia was significantly reduced in patients receiving a lipid-based admixture (80% nonprotein calories as lipid) compared with patients receiving a dextrose-based formulation (100% nonprotein calories as dextrose Insulin is very effective in managing hyperglycemia and should be considered a part of the TPN order. wide debridement with longitudinal flaps Dx finding sepsis see pdf Etiology of lymphangitis (red streaking up extremity) Lymphangitis is an inflammation of the lymphatic channels[1] that occurs as a result of infection at a site distal to the channel. TPN solutions can be formulated as 3-in-1 admixtures containing lipid emulsions as a source of calories. lymphadenitis.5 g/kg). 11. Thin red lines may be observed running along the course of the lymphatic vessels in the affected area. A person with lymphangitis should be hospitalized and closely monitored by medical professionals. Avoiding hyperglycemia during TPN administration can begin with gradual dextrose infusion. 13.patients.[2] Lymphangitis is the inflammation of the lymphatic vessels and channels. accompanied by painful enlargement of the nearby lymph nodes . starting with 100 g to 150 g dextrose and advancing toward goal only as glucose tolerance permits. Underfeeding will not result in impaired nitrogen balance when there is adequate protein in the TPN solution (>1. This is characterized by certain inflammatory conditions of the skin caused by bacterial infections. Lymphangitis is also sometimes called "blood poisoning". 12. 9. The most common cause of lymphangitis in humans is Streptococcus pyogenes (Group A strep). 14. The person may also have chills and a high fever along with moderate pain and swelling. warmth. 10. Signs and symptoms include a deep reddening of the skin.

The methodology of an anti-factor Xa assay is that patient plasma is added to a known amount of excess factor Xa and excess antithrombin. Vessels supplying head of pancreas a. Sepsis. Superior & inferior pancreaticoduodenal arteries b. Remember.[5] Antithrombin deficiencies in the patient do not affect the assay. Rx for diffuse bleeding resuscitation and identification of bleeding source 18. one anterior and one posterior to head . Glomerulonephritides. Monitoring LMWH Rx .activated factor X assay LMWH therapy is monitored by the anti-factor Xa assay.[5] Results are given in anticoagulant concentration in units/mL of antifactor Xa. Arterial supply of head of pancreas .15. The amount of residual factor Xa is detected by adding a chromogenic substrate that mimics the natural substrate of factor Xa. etc Postrenal: Obstruction (BPH. such that high values indicate high levels of anticoagulation and low values indicate low levels of anticoagulation 17. Renal Artery Stenosis. etc. Both divide into two parallel vessels c. measuring anti-factor Xa activity. FENa calculation Fractional Excretion of Sodium (FENa) = (PCr * UNa ) / (PNa x UCr) % Prerenal UNa (mmol/L) FENa <20 <1% >40 >1% Intrinsic Renal >40 >4% Postrenal Prerenal: Anything that causes decreased effective renal perfusion: Hypovolemia. If heparin or LMWH is present in the patient plasma.[5] The amount of residual factor Xa is inversely proportional to the amount of heparin/LMWH in the plasma. AIN. it will bind to antithrombin and form a complex with factor Xa. releasing a colored compound that can be detected by a spectrophotometer. inhibiting it. bilateral ureter obstruction) 16. because excess amounts of antithrombin is provided in the reaction. contrast-induced nephropathy will often look prerenal. CHF. bladder stone. making residual factor Xa cleave it. Intrinsic Renal: ATN.

Once the acid is secreted. Bile Salts: These are sodium and potassium salts of the bile acids (primary bile acids cholic and chenodeoxycholic acid and secondary bile acids deoxycholic and lithocholic acid). Some of the components of bile are reabsorbed in the intestine and then excreted again by the liver (enterohepatic circulation). and other substances dissolved in an alkaline electrolyte solution that resembles pancreatic juice. As protein digestion occurs in the intestine. which initiates protein digestion. which in turn stimulate the acid-producing cells in the stomach to release acid. The second phase is the gastric phase. About 500ml of bile is secreted per day. bile pigments. signals are sent via molecules to the stomach to produce more acid. During this phase. which are conjugated to . chewing and swallowing stimulate the vagus nerve. Crohn¶s disease ± associated with granulomas and aphthous ulcers Table 2. 22. The last phase is the intestinal phase. The first is the cephalic phase. GI hormone enhance appetite ghrelin (decreased s/p RYGB) 20. Initiation of intestinal protein digestion: There are three mechanisms for gastric acid secretion. Decreased Chloride levels with increase in pancreatic exocrine secretion 21. Primary pigment of human bile PRIMARY PIGMENT OF HUMAN BILE Bile: Bile is made up of bile salts. which in turn signals cells in the stomach to release acid. Endoscopic Features of Crohn's Disease vs Ulcerative Colitis Crohn's disease Rectum often spared "Skip" areas Aphthous ulcers Cobblestoning from submucosal edema Linear or serpiginous ulcers Fistulas Ulceration of the terminal ileum Ulcerative colitis Rectum involved Continuous uniform involvement Loss of vascular markings Diffuse erythema Mucosal granularity ("wet sandpaper") Fistulas not seen Normal-appearing terminal ileum 23. it activates pepsin. Distension of the stomach as food enters sends a signal to the local nerves.19.

the free (unconjugated) bilirubin is conjugated to glucoronic acid in a reaction catalyzed by glucoronyl transferase. and various other hemoproteins. biliverdin reductase. to bilirubin. are responsible for the goldenyellow color of bile.g. the primary pigment of human bile. and absorption. spleen) is transported to the liver within the plasma where it is tightly bound to albumin. They serve many important functions that aid in fat emulsification. Most of the conjugated bilirubin is secreted into the bile and into the intestine. This bilirubin diglucoronide (conjugated bilirubin) is much more watersoluble than free (unconjugated) bilirubin. myoglobin. Biliverdin is then reduced by a second enzyme. In the liver hepatocytes. Bilirubin produced in the extrahepatic reticuloendothelial system (e. bilirubin and biliverdin.either glycine or taurine and secreted into intestines. resulting in the formation of the green tetrapyrrole biliverdin. 70-90% of bilirubin is derived from the degradation of hemoglobin of senescent or injured circulating red blood cells. digestion. Bilirubin. Bile Pigments: The glucoronides of the bile pigments. is the end-product of the metabolic degradation of heme. unlike the free (unconjugated) bilirubin that is never excreted in the urine regardless of how high the . the prosthetic group of hemoglobin. however. The conversion of heme to bilirubin first entails the oxidative opening of the heme molecule by the microsomal enzyme heme oxygenase. a small amount of conjugated bilirubin can escape into the blood and is filtered and excreted in the urine. the cytochrome P450s.

The key advantage of pressure targeted ventilation is unlimited flow in inspiration to satisfy the patient¶s demands. Normally. Site of protein absorption 50% of the ingested protein is absorbed between the stomach and the jejunum and 90% is absorbed by the time the digested food reaches the ileum 25. 24. 28. conjugated bilirubin reaches the duodenum and passes down the gastrointestinal tract without reabsorption by intestinal mucosa. the greater the pressure gradient. Redistributes fluid within the alveoli and reducesintrapulmonary shunting2. Pathophysiology of atherosclerosis plaques. Although some reaches the feces unaltered. Gas exchange1. The trigger mechanism is the same as in volume control. urobilin and stercobilin by bacterial metabolism within the ileum and colon. Reduces FIO2 . Pathophysiology of pulse loss in claudication vasodilation and stealing of blood from areas distal to occlusion 27. The harder the patient draws in. an appreciable fraction is converted to urobilinogen (a colorless compound). Urobilinogen is reabsorbed from these sites. Urobilin and stercobilin are excreted in the feces with the stool and are primarily responsible for the brownish pigmentation of stool. Urobilinogen not taken up by the liver reaches the systemic circulation from which it is cleared by the kidneys. reaches the liver via the portal circulation.concentration gets because it is tightly bound by albumin and not filtered across the glomeruli. Following secretion into bile. Physiology of PEEP Positive end-expiratory pressure (PEEP) refers topressure in the airway at the end of passiveexpiration that exceeds atmospheric pressure. and re-excreted into bile. Advantage of pressure-control ventilation Patients can breath spontaneously on pressure control as long a the inspiratory time has not be unduly prolonged. and the higher the flow 26. Improves arterial oxygenation (PaO2)3. the gut does not see unconjugated (free) bilirubin because all of it would have been conjugated before it was excreted.

diarrhea or flushing will be the initial presenting complaint. Both occur particularly with liver metastasis. occasionally a patient will have flushing episodes. Indication for surgical tx of asymptomatic aneurysms see table 30. Characteristic of medullary cancer in MEN-2a . Improves lung compliance5. Shifts tidal deflections to the right along theinspiratory pressure-volume curve minimizing potentialfor ventilator-induced lung injury by preventingrepetitive collapse of lung units at end-expirationfollowed by re-openingduring inspiration6. Decreases left and right ventricular preload(end-diastolic volume)4.3 By the end of 2002. 35. Hypotension and organ hypoperfusion canoccur. and bone. Treatment of extraperitoneal bladder rupture foley drainage. lung.requirements and risk of oxygen toxicity Lung mechanics1. by increasing CVP 29. Role of vitamin C in collagen synthesis vit C cofactor for prolyl hydroxylase and lysyl hydroxylase 32. Stabilizes and recruits lung units3. Increases right ventricular afterload5. Nerve injury associated with flexor carpi radialis weakness median nerve 31. the use of hormone-replacement therapy had decreased by 38% in the United States. May decrease the inspiratory work of breathing dueto auto-PEEP in patients with obstructive airway diseaseHemodynamic effects of PEEP-induced increases inintrathoracic pressure1. Decreases cardiac output.b. Decreases left ventricular afterload7. The presumed cause of flushing and diarrhea is the excessive production of calcitonin gene products (calcitonin or calcitonin gene-related peptide) and differs from the causation of flushing and diarrhea in carcinoid syndrome. Increases intracranial pressure. lymph nodes in the central portion of the chest (mediastinum). Decreases ventricular compliance8. with approximately 20 million fewer prescriptions written in 2003 than in 2002. Etiology for decline of breast ca . Increases functional residual capacity4.6. Mechanism of inheritance of MEN syndromes = autosomal dominant . Occasionally.major clinical symptom of metastatic medullary thyroid carcinoma is diarrhea. Sites of spread of medullary thyroid carcinoma include local lymph nodes in the neck. Dx of sickle cell dz 36. which reported a significant increase in the risks of coronary heart disease and breast cancer associated with the use of estrogen progestin combination therapy. Spread to other sites such as skin or brain occurs but is uncommon 34. Reduction of both cardiac output and bloodpressure is particularly likely in the presenceof hypovolemia. Increases intraluminal central venous pressure2. as a result of theabove effectsa.decrease in breast-cancer incidence began in mid-2002 and occurred shortly after the highly publicized series of reports from the randomized trial of the Women's Health Initiative. repair later (immediate OR for intraperitoneal bladder rupture) 33. Decreases venous return3. liver. The flushing that occurs in medullary thyroid carcinoma is indistinguishable from that associated with carcinoid syndrome. Helps prevent alveolar collapse2.

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