What is the Systemic Inflammatory Response Syndrome (SIRS)?
A systemic inflammatory response activated by traumatic injury to produce a systemic inflammatory response in an attempt to limit damage.
What are the two phases of the stress response?
The stress response follows extensive tissue damage or systemic insult and is mediated by a complex signaling system and systemic washout of locally produced substances.
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Systemic Inflammatory Response Syndrome (SIRS)

What is the Systemic Inflammatory Response Syndrome (SIRS)?

A systemic inflammatory response activated by traumatic injury to produce a systemic inflammatory response in an attempt to limit damage.

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Neuroendocrine Response to Injury

What are the two phases of the stress response?

The stress response follows extensive tissue damage or systemic insult and is mediated by a complex signaling system and systemic washout of locally produced substances.

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Systemic Inflammatory Response Syndrome (SIRS)

What is the first response to traumatic injury?

Acute proinflammatory response resulting in the activation of the innate immune system.

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Systemic Inflammatory Response Syndrome (SIRS)

What is the purpose of the innate immune response in traumatic injury?

To produce a systemic inflammatory response in an attempt to limit damage.

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Systemic Inflammatory Response Syndrome (SIRS)

What is the body's response to injury or overwhelming infection?

Activating the innate immune response to stimulate the proinflammatory phase.

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Systemic Inflammatory Response Syndrome (SIRS)

What is the role of the anti-inflammatory response in the body?

To modulate the pro-inflammatory phase to return to homeostasis.

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Metabolism During Fasting

What is the relationship between the magnitude of metabolic expenditure and the severity of insult?

It appears to be directly proportional.

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Parenteral Nutrition

What is the dextrose content used in Peripheral Parenteral Nutrition?

5-10%.

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Surgical Nutrition

What is the goal of surgical nutrition?

To prevent or reverse the catabolic effects of the injury and to give adequate nutritional support.

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Systemic Inflammatory Response Syndrome (SIRS)

What can happen if there is an imbalance between pro-inflammatory and anti-inflammatory responses?

It can result in multiple organ failure and/or early death.

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Enteral Nutrition

What are the advantages of enteral nutrition?

Preserves gut integrity, decreases likelihood of bacterial translocation, preserves immunologic function of gut, increases compliance with intake, cost-effective vs parenteral, prevents intestinal villi atrophy.

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Metabolism During Fasting

What has the highest energy demands in terms of thermal injuries and severe infections?

Thermal injuries and severe infections.

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Parenteral Nutrition

For how long is Peripheral Parenteral Nutrition typically used?

Shorter periods of time (<2 weeks).

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Surgical Nutrition

What are the objectives of nutritional support?

To meet the energy requirements for essential metabolic and tissue repair, and to meet the substrate requirement for protein synthesis.

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Systemic Inflammatory Response Syndrome (SIRS)

What is the clinical definition of SIRS (Systemic Inflammatory Response Syndrome)?

Presence of 2 or more of the following: fever, tachycardia, tachypnea, abnormal WBC count.

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Enteral Nutrition

What are the disadvantages of enteral nutrition?

Mechanical complications (e.g. tube migration and obstruction), labor-intensive assessment (e.g. site care), risk of aspiration, applicable for nasogastric.

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Metabolism During Fasting

What happens to muscle protein in severe injury or trauma?

It gives more, leading to muscle wasting.

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Parenteral Nutrition

What type of patients is Peripheral Parenteral Nutrition not appropriate for?

Patients with severe malnutrition.

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Enteral Nutrition

What are the components of enteral nutrition?

Carbohydrates (49-53%), Fat (29-30%).

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Systemic Inflammatory Response Syndrome (SIRS)

What is the clinical definition of sepsis?

Identifiable source of infection + SIRS.

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Cellular Stress Response

What is the Unfolded Protein Response (UPR)?

A cellular response to stress that aims to reestablish appropriate protein folding through signaling proteins in the endoplasmic reticulum (ER).

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Enteral Nutrition

What are some types of enteral formulas?

Immunonutrients, standard polymeric formula, fiber-containing, immune enhancing, calorie dense formulas, high protein/bariatric, elemental, renal failure formula, hepatic failure formula.

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Apoptosis

What is pyroptosis?

A form of cellular response where the cell death is dependent on the activity of caspase enzyme.

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Metabolism During Fasting

What is the primary stimulus for hypoglycemia?

Hypoglycemia is the primary stimulus.

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Parenteral Nutrition

What type of veins are used for the administration of Peripheral Parenteral Nutrition?

Peripheral veins.

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Enteral Nutrition

Why is early enteral feeding preferred over late enteral feeding?

It is protective of the enteral epithelial barrier function and helps to maintain the diversity of the microbiome.

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Systemic Inflammatory Response Syndrome (SIRS)

What is the clinical definition of severe sepsis?

Sepsis + Organ dysfunction.

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Systemic Inflammatory Response Syndrome (SIRS)

What are the mediators of inflammation?

Cytokines, eicosanoids, plasma contact system, serotonin, histamine.

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Systemic Inflammatory Response Syndrome (SIRS)

What is the clinical definition of septic shock?

Sepsis + Cardiovascular collapse (requiring vasopressor support).

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Parenteral Nutrition

What are the contents of parenteral nutrition?

Electrolytes, amino acids, intravenous vitamin preparation.

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Systemic Inflammatory Response Syndrome (SIRS)

What syndrome is characterized by fever, tachypnea, tachycardia, and leukocytes as the initial reaction of the body to injury?

Systemic Inflammatory Response Syndrome (SIRS).

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Neuroendocrine Response to Injury

What are the effects of epinephrine and norepinephrine release in the sympathetic nervous system?

They increase heart rate, myocardial activity, blood pressure, cellular metabolism, and promote glycogenolysis, gluconeogenesis, lipolysis, and ketogenesis.

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Enteral Nutrition

What is the new guideline for early resumption of feeding after surgery?

ERAS (Early Resumption of feeding After Surgery) recommends early feeding as early as Day 2-3 with general liquids, and on day 3-4, food is given.

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Apoptosis

What is apoptosis?

Apoptosis is programmed cell death, an energy-dependent, organized mechanism for clearing senescent or dysfunctional cells without promoting an inflammatory response.

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Metabolism During Fasting

What are the sources of fuel during short term fasting?

Muscle protein, body fat, and hepatic glycogen, with fat being the most abundant source of energy.

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Systemic Inflammatory Response Syndrome (SIRS)

What differentiates septic shock from sepsis?

Cardiovascular collapse.

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Parenteral Nutrition

What are the indications for total parenteral nutrition?

Non-functioning GI tract, NPO for more than 5 days, GI fistula, acute pancreatitis, short bowel syndrome, malnutrition with more than 15% weight loss.

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Parenteral Nutrition

What type of vein access is required for Total Parenteral Nutrition?

Large veins.

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Metabolism During Fasting

What is the approximate basal energy expenditure during short term fasting for a 70 kg man?

22 to 25 kcal/kg per day.

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Necroptosis

What are the examples of conditions that can lead to necroptosis?

Ischemia, inflammation, and trauma.

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Surgical Metabolism

What happens to total body energy expenditure and urinary nitrogen wasting in the initial hours after surgical or traumatic injury?

They are reduced.

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Autophagy

What is autophagy and when does it occur?

Autophagy is the process of disposing of damaged organelles and debris aggregates, induced during hypoxia and stress to provide energy.

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Metabolism During Fasting

What are the hormonal changes that occur during starvation?

Increased cortisol, catecholamines, glucagon, and growth hormone.

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Autophagy

What are the steps of autophagy?

The steps include the engulfment of cytoplasm/organelle by a phagophore, fusion of the phagophore edges to form the autophagosome, and fusion of the autophagosome with a lysosome to form an autolysosome for degradation.

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Systemic Inflammatory Response Syndrome (SIRS)

What is the function of cytokines in the immune response?

Essential for both innate and adaptive immune responses, mediate cellular responses, eradicate invading microorganisms, and promote wound healing.

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Systemic Inflammatory Response Syndrome (SIRS)

How is organ failure identified in the context of septic shock?

Anuria (no urine output) and no response to fluid resuscitation resulting in cardiovascular collapse.

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Parenteral Nutrition

What are the technical complications associated with parenteral nutrition?

Contamination of central venous catheter, contamination of solution, complications of catheter placement.

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Metabolism During Fasting

What is the approximate energy yield from the oxidation of 1g of fat?

Approximately 9 kcal of energy.

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Reactive Oxygen Species (ROS) and Oxidative Stress

What are reactive oxygen species (ROS) and how are they formed?

ROS are highly reactive molecules formed as by-products of oxygen metabolism in mitochondria, peroxisomal fatty acid metabolism, cytochrome P450 reactions, and respiratory burst of phagocytic cells.

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Enteral Nutrition

What are the conditions that require enteral nutrition support?

Impaired ingestion, inability to consume adequate nutrition orally, patient is unable to eat, impaired digestion, absorption and metabolism, severe wasting.

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Apoptosis

What are the two pathways through which apoptosis proceeds?

The extrinsic pathway, activated through the binding of death receptors, and the intrinsic pathway, which proceeds through protein mediators that influence mitochondrial membrane permeability.

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Metabolism During Fasting

What happens to hepatic glycogen stores in the fasting state?

They are rapidly depleted.

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Cellular Stress Response

What is the unfolded protein response (UPR) and what triggers it?

The UPR is triggered by cellular stress that decreases calcium concentration in the endoplasmic reticulum (ER), leading to the accumulation of unfolded or misfolded proteins. It is a process to reestablish appropriate folding and decrease protein synthesis.

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Metabolism During Fasting

What does protein catabolism after injury provide substrate for?

Gluconeogenesis and for the synthesis of acute phase proteins.

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Metabolism During Fasting

What is the source of fuel during long term fasting?

Same as short term fasting plus ketone bodies, with ketone bodies being the principal fuel source.

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Surgical Metabolism

What occurs with substrate use after adequate resuscitation and stabilization of an injured patient?

A reprioritization of substrate use ensues to preserve vital organ function and support repair of injured tissue.

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Parenteral Nutrition

What is the principal indication for parenteral nutrition?

Sepsis or surgical or traumatic injury in seriously ill patients for whom use of the GI tract for feedings is not possible.

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Necroptosis

What is the expected cellular response upon examination of neurons in a patient diagnosed with ischemic stroke?

Necroptosis.

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Neuroendocrine Response to Injury

What is the role of cortisol in the neuroendocrine response to injury?

Cortisol is essential for survival during significant physiologic stress and results in a net anti-inflammatory effect when it binds to glucocorticoid receptors.

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Metabolism During Fasting

What is the predominant energy source during critical illness and after injury?

Adipose stores within the body (triglycerides).

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Autophagy

How is autophagy controlled?

Autophagy process is controlled by numerous autophagy-specific genes and by the specific kinase, mammalian target of rapamycin (mTOR).

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Systemic Inflammatory Response Syndrome (SIRS)

What is the role of the plasma contact system in the body?

It is activated almost immediately after a traumatic injury and acts as the required 'first line of defense' for the host against pathogens by binding and clearing them from the circulation.

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Systemic Inflammatory Response Syndrome (SIRS)

What differentiates sepsis from SIRS?

Identifiable bug.

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Parenteral Nutrition

What are the metabolic complications associated with parenteral nutrition?

Hyperglycemia, electrolyte abnormalities, CO2 retention and respiratory insufficiency, hepatic steatosis or marked glycogen deposition, cholestasis and formation of gallstones.

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Metabolism During Fasting

What is the approximate energy yield from the oxidation of 1g of carbohydrate?

4 kcal of energy.

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Reactive Oxygen Species (ROS) and Oxidative Stress

What are the consequences of too much reactive oxygen species (ROS) in the body?

Too much ROS can lead to cellular injury through the oxidation of cell membrane substrates, cellular proteins, and DNA, and can result in the death of host cells.

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Metabolism During Fasting

What is the primary goal for maintenance glucose administration in surgical patients?

To minimize muscle wasting.

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Necroptosis

What is necroptosis?

Necroptosis is the premature, uncontrolled death of cells in living tissue, typically caused by accidental exposure to external factors which result in extreme cellular stress.

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Necroptosis

What is necroptosis?

Premature uncontrolled death of cells in living tissue typically caused by accidental exposure to external factors which result in extreme cellular stress.

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Apoptosis

What is apoptosis?

A form of cellular response where the cell death is dependent on the activity of your caspase enzyme.

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