Surgery SGD

Question #3
3.1 Objective of Inflammation
The inflammatory response is an attempt by the body to restore and maintain homeostasis after injury
and is an integral part of body defense. Most of the body defense elements are located in the blood and
inflammation is the means by which body defense cells and defense chemicals leave the blood and enter the
tissue around the injured or infected site. Inflammation is essentially beneficial, however, excess or prolonged
inflammation can cause harm.
3.2 What are the key events in Inflammation?
Esentially, four occurrences make up the inflammatory mechanism which are triggered and enhanced by a
variety of chemical inflammatory mediators:
a. Smooth muscles around larger blood vessels contract to slow the flow of blood through the capillary
beds at the infected or injured site. This gives more opportunity for leukocytes to adhere to the walls of the
capillary and squeeze out into the surrounding tissue.
b. The endothelial cells that make up the wall of the smaller blood vessels contract. This increases the
space between the endothelial cells resulting in increased capillary permeability. Since these blood vessels get
larger in diameter as a result of this, the process is called vasodilation.
c. Adhesion molecules are activated on the surface of the endothelial cells on the inner wall of the
capillaries. Corresponding molecules on the surface of leukocytes called integrins attach to these adhesion
molecules allowing the leukocytes to flatten and squeeze through the space between the endothelial cells. This
process is called diapedesis or extravasation.
d. Activation of the coagulation pathway causes fibrin clots to physically trap the infectious microbes
and prevent their entry into the bloodstream. This also triggers blood clotting within the surrounding small
blood vessels to both stop bleeding and further prevent the microorganisms from entering the bloodstream.

3.3 Signs and symptoms of inflammation

Dolor (pain)
Calor (heat)
Rubor (redness)
Tumor (swelling)
Functio laesa (loss of function)
Redness and heat are due to increased blood flow at body core temperature to the inflamed site;
swelling is caused by accumulation of fluid; pain is due to release of chemicals that stimulate nerve endings;
while Loss of function has multiple causes but most probably the result of a neurological reflex in response to
pain.

Question #4
4. Metabolic response of the body to injury
4.1. Discuss the metabolic response of the body to pure starvation without injury. Differentiate this from
what happens in the body in response to injury.
Starvation

Injury

Body Fuels

Conserved

Wasted

Body Proteins

Conserved

Wasted

Slow

Rapid

Metabolic Rate

Urinary Nitrogen
Weight Loss

4.2. Explain why during injury, inspite of hyperglycemia, the body cannot use glucose as body fuel and has
to resort to other sources- hence, severe body wasting.
Injury and severe infections acutely induce a state of peripheral glucose intolerance
despite ample insulin production. This may occur due to the reduction in the skeletal muscle
pyruvate dehydrogenase activity after injury. Thus, there is a decrease in the conversion of
pyruvate to Acetyl CoA and entry into the TCA Cycle and (accumulated) pyruvate is shunted to
the liver for gluconeogenesis.
This shunting of the glucose away from nonessential organs is mediated by
catecholamine which causes increased hepatic gluconeogenesis and peripheral insulin
resistance.
4.3. Compute for the caloric requirement of the above victim prior to injury. Distribute the caloric
requirements for carbohydrates, fats, and proteins respectively.
Computation
Caloric Requirement= 25- 30 kcal/ kg BW/ day

Calorie Requirement
Carbohydrates (60%)

1,440 kcal

= 30 kcal x 80 kg

Proteins (15%)

360 kcal

=2400 kcal

Fats (25%)

600 kcal

4.4 Compute for the caloric requirement of the above victim after injury. Distribute the caloric requirement
from Carbohydrates, Fats, and Proteins respectively.
Male, 176lbs, athlete
176lbs * 1kg/2.2lbs= 80 kg
a.) Harris benedict method: (not applicable. Height not given)
BEE (men) 66.47 +13.75 (W) + 5.0 (H) 6.76 (A) kcal/d
b.) 25-30 kcal/kg b0dy weight per day
25*80kg
30*80kg

=2000-2400 kcal per day

Distribution at catabolic states:
45% carbohydrates *2000-2400kcal = 900-1080 kcal carbohydrates
30% fats*2000-2400kcal=600-720 kcal fats
25% proteins*2000-2400kcal= 500-600 proteins
For normal 60% carbohydrates, 15% proteins, 25% fats
=
4.5 What are the routes of delivery of the computed caloric requirement?
a.) Nasoenteric Tubes
-reserved for those with intact mentation and protective laryngeal reflexes to minimize risks of
aspiration.
b.) Percutaneous Endoscopic Gastrostomy
-most common indications for percutaneous endoscopic gastrostomy (PEG) include impaired swallowing
mechanisms, oropharyngeal or esophageal obstruction, and major facial trauma. It is frequently used for
debilitated patients requiring caloric supplementation, hydration, or frequent medication dosing. It is also
appropriate for patients requiring passive gastric decompression.
- Relative contraindications for PEG placement include ascites, coagulopathy, gastric varices, gastric neoplasm,
and lack of a suitable abdominal site.
c.) Percutaneous Endoscopic Gastrostomy-Jejunostomy
-for patients who cannot tolerate gastric feedings or who have significant aspiration risks are fed directly past
the pylorus through the percutaneous endoscopic gastrostomy-jejunostomy (PEG-J) method. In the
percutaneous endoscopic gastrostomy-jejunostomy (PEG-J) method, a 9F to 12F tube is passed through an
existing PEG tube, past the pylorus, and into the duodenum. This can be achieved by endoscopic or fluoroscopic
guidance. With weighted catheter tips and guidewires, the tube can be further advanced past the ligament of
Treitz.
d.) Direct Percutaneous Endoscopic Jejunostomy
-uses the same techniques as PEG tube placement but requires an enteroscope or colonoscope to reach the
jejunum. DPEJ tube malfunctions are probably less frequent than PEG-J tube malfunctions, and kinking or
clogging is usually averted by placement of larger-caliber catheters.
e.)Surgical Gastrostomy and Jejunostomy
- affords direct access to the stomach or small bowel.for a patient undergoing complex abdominal or trauma
surgery. The only absolute contraindication to feeding jejunostomy is distal intestinal obstruction. Relative
contraindications include severe edema of the intestinal wall, radiation enteritis, inflammatory bowel disease,
ascites, severe immunodeficiency, and bowel ischemia. Needle-catheter jejunostomies also can be done with a
minimal learning curve.
f.) Parenteral Nutrition
- is the continuous infusion of a hyperosmolar solution containing carbohydrates, proteins, fat, and other
necessary nutrients through an indwelling catheter inserted into the superior vena cava. To obtain the
maximum benefit, the calorie:protein ratio must be adequate (at least 100 to 150 kcal/g nitrogen), and both
carbohydrates and proteins must be infused simultaneously. When the sources of calories and nitrogen are
given at different times, there is a significant decrease in nitrogen utilization. These nutrients can be given in
quantities considerably greater than the basic caloric and nitrogen requirements, and this method has proved
to be highly successful in achieving growth and development, positive nitrogen balance, and weight gain in a
variety of clinical situations.

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4.6 Why is surgical nutrition important?
-to meet the energy requirements for metabolic processes, core temperature maintenance, and repair of
injured tissue. Failure to provide adequate nonprotein energy sources will lead to consumption of lean tissue
stores
-to prevent or reverse the catabolic effects of disease or injury. The ultimate validation for nutritional support in
surgical patients should be improvement in clinical outcome and restoration of function
-to preserve vital organ function
-for restoration of homeostasis through augmented metabolic rates and oxygen consumption, enzymatic
preference for readily oxidizable substrates such as glucose, and stimulation of the immune system.