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40 Exogenous
Glycogen
Gluconeogenesis
30
20
10
LEGEND I II III IV V
FUEL FOR GLUCOSE, GLUCOSE,
BRAIN
GLUCOSE GLUCOSE GLUCOSE
KETONES KETONES
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.
Respon Stress
Instabilitas hemodinamik,
ekstremitas dingin, hipometabolik
Waktu: bervariasi, 12-24 jam, paling
lama 2 hari
Tergantung cukupnya resusitasi
cairan
Cardiac output menurun
Konsumsi oksigen berkurang
Penggunaan substrat menurun
Penurunan fungsi sel
Metabolic Response to Trauma:
Ebb Phase
Characterized by hypovolemic shock
Priority is to maintain life/homeostasis
Cardiac output
Oxygen consumption
Blood pressure
Tissue perfusion
Body temperature
Metabolic rate
Fatty Acids
Fatty Deposits
Muscle
(amino acids) Amino Acids
Metabolic Response to Trauma
28
Nitrogen Excretion (g/day)
24
20
16
12
8
4
0
10 20 30 40
Days
Long CL, et al. JPEN 1979;3:452-456
Severity of Trauma: Effects on
Nitrogen Losses and Metabolic
Rate
Major
Ciruga
Surgery
mayor
Moderate
Quemadurato Severe
moderadaBurn
a grave
Nitrogen Loss in Urine
Severe
Sepsis
grave
Sepsis
Infeccin
Infection
Elective
Ciruga
electiva
Surgery
From Simmons RL, Steed DL: Basic science review for surgeons, Philadelphia, 1992, WB Saunders.
Starvation vs. Stress
Respon Metabolik terhadap stress
berbeda dg respon terhadap kelaparan.
Starvation = penurunan energi
expenditure, menggunakan energi
alternatif, penurunan protein wasting,
penggunaan cadangan glikogen pada 24
jam pertama
Late starvation = fatty acids, ketones, and
glycerol provide energy for all tissues
except brain, nervous system, and RBCs
Energy Expenditure in Starvation
12
Nitrogen Excretion (g/day)
8 Normal Range
4 Partial Starvation
Total Starvation
0
10 20 30 40
Days
Long CL et al. JPEN 1979;3:452-456
Metabolic Response to Trauma
Ebb
Ebb Flow
Flow
Phase Phase
Energy Expenditure
Phase Phase
Time
Aldosteronecorticosteroid
menyebabkan retensi sodium
Antidiuretic hormone (ADH)
merangsang absorpsi air di
tubular renal
Mempertahankan air dan
garan untuk menunjang
sirkulasi volume darah
Hormonal Stress
Responsecontd
Interleukin-1, interleukin-6,
and tumor necrosis factor
(TNF)
Released by phagocytes in
response to tissue damage,
infection, inflammation, and
some drugs and chemicals
Pemakaian energi
Peningkatan hormon
glukokortikoid, katekolamin,
dan glukagon
Metabolisme Protein
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000. Updated by Maion F. Winkler and
Ainsley Malone, 2002.
Metabolic Response to Surgical Trauma
Alanine / Pyruvate
Glucose Brain
Glutamine
Glycerol Gluconeogenesis
Ketones Urea
NH3
Kidney
Intestine
Determining Calorie
Requirements
Indirect calorimetry
Harris-Benedict x stress factor x activity factor
25-30 kcal/kg body weight/day
Metabolic Response to Starvation
and Trauma: Nutritional
Requirements
Injury Stress Factor Example:
Minor surgery 1.00 1.10 Energy requirements for
Long bone fracture 1.15 1.30 patient with cancer in bed
Cancer 1.10 1.30
Peritonitis/sepsis 1.10 1.30 = BEE x 1.10 x 1.2
Severe infection/multiple trauma 1.20 1.40
Multi-organ failure syndrome 1.20 1.40
Burns 1.20 2.00
Activity Activity Factor
Confined to bed 1.2
Out of bed 1.3
ADA: Manual Of Clinical Dietetics. 5th ed. Chicago: American Dietetic Association; 1996
Long CL, et al. JPEN 1979;3:452-456
Metabolic Response to
Overfeeding
Hyperglycemia
Hypertriglyceridemia
Hypercapnia
Fatty liver
Hypophosphatemia, hypomagnesemia, hypokalemia
Protein
Requirements range from 1.2-2.0 g/kg/day during stress
Comprise 20%-30% of total calories during stress
Smith RJ, et al. JPEN 1990;14(4 Suppl):94S-99S; Pastores SM, et al. Nutrition 1994;10:385-391
Calder PC. Clin Nutr 1994;13:2-8; Furst P. Eur J Clin Nutr 1994;48:607-616
Standen J, Bihari D. Curr Opin Clin Nutr Metab Care 2000;3:149-157
Role of Arginine in Metabolic
Stress
Provides substrates to immune system
Increases nitrogen retention after metabolic stress
Improves wound healing in animal models
Stimulates secretion of growth hormone and is a precursor
for polyamines and nitric oxide
Not appropriate for septic or inflammatory patients.