FirstRanker Logo

FirstRanker.com - FirstRanker's Choice is a hub of Question Papers & Study Materials for B-Tech, B.E, M-Tech, MCA, M.Sc, MBBS, BDS, MBA, B.Sc, Degree, B.Sc Nursing, B-Pharmacy, D-Pharmacy, MD, Medical, Dental, Engineering students. All services of FirstRanker.com are FREE

📱

Get the MBBS Question Bank Android App

Access previous years' papers, solved question papers, notes, and more on the go!

Install From Play Store

Download MBBS General Surgery PPT 5 Homeostasis Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) General Surgery PPT 5 Homeostasis Lecture Notes

This post was last modified on 07 April 2022


HOMEOSTASIS

Concepts of Homeostasis

--- Content provided by FirstRanker.com ---

? Claude Bernard:

? Stability of the "milieu int?rieur" is the primary condition for freedom and independence of

existence.

--- Content provided by FirstRanker.com ---


? i.e. body systems act to maintain internal constancy.

? Walter Cannon:

--- Content provided by FirstRanker.com ---

? Term "Homeostasis".
? Coordinated physiological process which maintains most of the steady states of the organism.
? i.e. complex homeostatic responses involving the brain, nerves, heart, lungs, kidneys and spleen

work to maintain body constancy.

--- Content provided by FirstRanker.com ---


? Responses to injury are beneficial to the host and al ow healing/survival.
Concepts of Homeostasis......

? Classical homeostatic control system:

--- Content provided by FirstRanker.com ---


? Signal detector
? Processor
? Effector
? Negative feedback loop

--- Content provided by FirstRanker.com ---


? Open loop system:

? Also referred to as non-feedback system
? Type of continuous control system in which the output has no influence or effect on the control

--- Content provided by FirstRanker.com ---


action of the input signal.

? Only with medical/surgical resolution of the primary abnormality results in classical homeostasis.

--- Content provided by FirstRanker.com ---

Concepts of Homeostasis......
? Elective surgical practice:

? Reduce the need for a homeostatic response by minimizing the primary insult
? e.g. minimal access surgery and `stress-free' perioperative care.

--- Content provided by FirstRanker.com ---


? Emergency surgery:

? Presence of tissue trauma/ sepsis/ hypovolaemia often compounds the primary problem.
? It requires:

--- Content provided by FirstRanker.com ---


? To augment artificial y homeostatic responses (e.g. resuscitation)

? And to close the `open' loop by intervening to resolve the primary insult (e.g. surgical treatment of major abdominal sepsis)
? And provide organ support (critical care)

--- Content provided by FirstRanker.com ---


? While the patient comes back to a situation in which homeostasis can achieve a return to normality.
Graded Nature of the Injury Response
? Response to injury:

--- Content provided by FirstRanker.com ---

? More severe the injury- Greater the response.

? Applies to Physiological/ Metabolic/ Immunological changes.
? Following elective surgery of intermediate severity-

--- Content provided by FirstRanker.com ---

? Changes may be a transient and modest.
? Mild rise in temp./ heart rate/ respiratory rate/ energy expenditure and white cel count.

? Following major trauma/sepsis-

--- Content provided by FirstRanker.com ---

? Changes are accentuated.
? Resulting in SIRS/ hyper metabolism/ marked catabolism/ shock and even multiple organ dysfunction (MODS).

? Genetic variability plays a key role in determining the intensity of the inflammatory response.

--- Content provided by FirstRanker.com ---

Graded Nature of the Injury Response....

Response to injury:

Hypermetabolism and increased nitrogen excretion are closely related to the magnitude of the initial injury and show a gradedresponse.

--- Content provided by FirstRanker.com ---

Graded Nature of the Injury Response....

? Immunological sequelae of major injury:

? Evolve from a Pro-inflammatory State

--- Content provided by FirstRanker.com ---


? Driven primarily by the innate immune system (macrophages, neutrophils, dendritic cel s).

? Finally- Compensatory Anti-Inflammatory Response Syndrome (CARS)

--- Content provided by FirstRanker.com ---

? Characterized by suppressed immunity- diminished resistance to infection.

? Patients who develop infective complications-

? CARS leads to ongoing systemic inflammation/ acute phase response and continued

--- Content provided by FirstRanker.com ---


catabolism.

Mediators of the Metabolic Response to

--- Content provided by FirstRanker.com ---

Injury
? `Classical Neuroendocrine

Pathways' of the stress
response consist of:

--- Content provided by FirstRanker.com ---


? Afferent nociceptive neurons

? Spinal cord

--- Content provided by FirstRanker.com ---

? Thalamus

? Hypothalamus

? and pituitary

--- Content provided by FirstRanker.com ---

Mediators of the Metabolic Response to

Injury.....
? Corticotrophin- Releasing Factor (CRF)- released from the hypothalamus

--- Content provided by FirstRanker.com ---

? Increases ACTH release- from the anterior pituitary.
? ACTH acts on the adrenals- increase the secretion of cortisol.

? Hypothalamic activation of the Sympathetic Nervous System-

--- Content provided by FirstRanker.com ---

? Release of Adrenaline and Glucagon.

? Intravenous infusion of a cocktail of these `counter-regulatory' hormones (glucagon,

glucocorticoids and catecholamine)-

--- Content provided by FirstRanker.com ---


? Results in many aspects of the metabolic response.

Mediators of the Metabolic Response to

--- Content provided by FirstRanker.com ---

Injury....
? Other mediators:

? Alterations in insulin release and sensitivity.

--- Content provided by FirstRanker.com ---

? Hypersecretion of prolactin and growth hormone (GH) in the presence of low circulatory

insulin-like growth factor-1 (IGF-1).

? Inactivation of peripheral thyroid hormones and gonadal function.

--- Content provided by FirstRanker.com ---

Neuroendocrine response to injury/critical

il ness
? Neuroendocrine response to severe injury/critical il ness is biphasic:

--- Content provided by FirstRanker.com ---

? Acute phase:

? Actively secreting pituitary and elevated counter-regulatory hormones (cortisol, glucagon,

adrenaline).

--- Content provided by FirstRanker.com ---


? Changes are thought to be beneficial for short term survival.

? Chronic phase:

--- Content provided by FirstRanker.com ---

? Hypothalamic suppression and low serum levels of the respective target organ hormones.

? Changes contribute to chronic wasting.

Immunological changes to injury/critical

--- Content provided by FirstRanker.com ---


il ness
? Innate immune system (principally macrophages) interacts in a complex manner with the

adaptive immune system (T cells, B cells):

--- Content provided by FirstRanker.com ---


? Also affects the metabolic response to injury.

? Pro-inflammatory cytokines (IL-1/ TNF/ IL-6 and IL-8):

--- Content provided by FirstRanker.com ---

? Produced within the first 24 hours of injury.
? Act directly on the Hypothalamus-

? Cause pyrexia.
? Augment the hypothalamic stress response.

--- Content provided by FirstRanker.com ---


? Act directly on skeletal muscle- induce proteolysis.
? Act on liver- Induce acute phase protein production.
? A complex role in the development of peripheral insulin resistance.
Immunological changes to injury/critical

--- Content provided by FirstRanker.com ---


il ness.....
? Endogenous Cytokine Antagonists enter the circulation:

? Within hours of the Upregulation of Pro-inflammatory Cytokines.

--- Content provided by FirstRanker.com ---

? e.g. interleukin-1 receptor antagonist [IL-1Ra] and TNF-soluble receptors [TNF-sR-55 and 75].
? Act to control the pro-inflammatory response.
? A complex adaptive changes includes:

? Development of a Th2-type counter-inflammatory response.

--- Content provided by FirstRanker.com ---


? Regulated by IL-4, -5, -9 and -13 and transforming growth factor beta [TGF].

? If accentuated and prolonged in critical illness- characterized as the CARS.

--- Content provided by FirstRanker.com ---

? Results in immunosuppression- increased susceptibility to nosocomial infection.

Immunological changes to injury/critical

il ness....

--- Content provided by FirstRanker.com ---

? Duration and magnitude of acute inflammation as wel as the return to

homeostasis are influenced by-

? Specialized proresolving mediators (SPM)- include essential fatty acid-derived

--- Content provided by FirstRanker.com ---


lipoxins, resolvins, protectins and maresins.

? Uptake and clearance- of apoptotic polymorphonuclear neutrophils and microbial

--- Content provided by FirstRanker.com ---

particles

? Reduce- proinflammatory cytokines and lipid mediators
? Enhance the removal of cel ular debris.
Immunological changes to injury/critical

--- Content provided by FirstRanker.com ---


il ness.....
? Systemic inflammatory response syndrome following major injury:

? Is driven initially by proinflammatory cytokines (e.g. IL-1, IL-6 and TNF).

--- Content provided by FirstRanker.com ---

? Is fol owed rapidly by increased plasma levels of cytokine antagonists and

soluble receptors (e.g. IL-1Ra, TNF-sR).

? If prolonged or excessive may evolve into a counterinflammatory response

--- Content provided by FirstRanker.com ---


syndrome.

The `Ebb and Flow ' model of metabolic

--- Content provided by FirstRanker.com ---

response
? Natural physiological response to injury includes:

? Immobility/rest

--- Content provided by FirstRanker.com ---

? Anorexia

? Catabolism

? Sir David Cuthbertson divided the metabolic response to injury:

--- Content provided by FirstRanker.com ---


? Into `ebb' and `flow' phases
Ebb phase
? Begins at the time of injury and lasts for approximately 24?48 hours.

--- Content provided by FirstRanker.com ---

? Characterized by-

? hypovolemia/ decreased BMR/ reduced cardiac output/ hypothermia and lactic acidosis.

? Predominant hormones regulating the ebb phase- catecholamines/ cortisol/ aldosterone.

--- Content provided by FirstRanker.com ---


? Magnitude of response depends on:

? Degree of blood loss.

--- Content provided by FirstRanker.com ---

? Stimulation of somatic afferent nerves at the site of injury.

? Main physiological role of the ebb phase:

? Conserve both circulating volume and energy stores for recovery and repair.

--- Content provided by FirstRanker.com ---


Flow phase

? Following resuscitation, ebb phase evolves into a hypermetabolic flow phase.

--- Content provided by FirstRanker.com ---

? This phase involves:

? Mobilization of body energy stores- for recovery and repair

? and subsequent replacement of lost or damaged tissue.

--- Content provided by FirstRanker.com ---


? Characterized by:

? Tissue edema (from vasodilatation and increased capil ary leakage)

--- Content provided by FirstRanker.com ---

? Increased basal metabolic rate (hyper metabolism)/ Increased cardiac output

? Raised body temperature/Leukocytosis

? Increased oxygen consumption

--- Content provided by FirstRanker.com ---


? And increased gluconeogenesis.
Flow phase.......
? Flow phase may be subdivided into:

--- Content provided by FirstRanker.com ---

? Catabolic phase

? lasting approximately 3?10 days.

? Increased production of counter-regulatory hormones (catecholamines, cortisol, insulin and glucagon) and

--- Content provided by FirstRanker.com ---


inflammatory cytokines(e.g. IL-1, IL-6 and TNF).

? Significant fat and protein mobilization- significant weight loss and increased urinary nitrogen excretion.

--- Content provided by FirstRanker.com ---

? Increased production of insulin- associated with significant insulin resistance and poor glycemic control.

? Increased risk of complications- further aggravate the neuroendocrine and inflammatory stress responses and creates

a vicious catabolic cycle.

--- Content provided by FirstRanker.com ---


? Anabolic phase

? may last for weeks if extensive recovery and repair are required fol owing serious injury.

--- Content provided by FirstRanker.com ---

Key Catabolic Elements of the Flow Phase

? During the response to injury, not al tissues are catabolic.

? Essence of coordinated response is-

--- Content provided by FirstRanker.com ---


? Reprioritise limited resources away from peripheral tissues towards key viscera and wound.
Key Catabolic Elements of the Flow Phase

? Hypermetabolism:

--- Content provided by FirstRanker.com ---


? Caused by an acceleration of energy-dependent metabolic cycles.
? limited in modern practice on account of elements of routine critical care.

? Skeletal muscle wasting:

--- Content provided by FirstRanker.com ---


? Provides amino acids for the metabolic support of central organs/tissues.
? Mediated at a molecular level- by activation of the ubiquitin?proteasome pathway.
? Can result in-

--- Content provided by FirstRanker.com ---

? Immobility
? Contribute to hypostatic pneumonia
? If prolonged and excessive- leads to death

Key Catabolic Elements of the Flow Phase

--- Content provided by FirstRanker.com ---


? Hepatic acute phase response:

? Represents a reprioritisation of body protein metabolism towards the liver and is characterised by:

--- Content provided by FirstRanker.com ---

? Positive reactants (e.g. CRP): plasma concentration
? Negative reactants (e.g. albumin): plasma concentration

? Insulin resistance

--- Content provided by FirstRanker.com ---

? Fol owing surgery or trauma- hyperglycemia develops as a result of

? Increased glucose production
? Combined with decreased glucose uptake in peripheral tissues.

--- Content provided by FirstRanker.com ---

? Decreased glucose uptake is a result of insulin resistance which is transiently induced.
CHANGES IN BODY COMPOSITION FOLLOWING

INJURY

--- Content provided by FirstRanker.com ---

? Catabolism:

? Decrease in fat mass and

skeletal muscle mass

--- Content provided by FirstRanker.com ---


? Body weight may

paradoxical y increase

--- Content provided by FirstRanker.com ---

? Expansion of extracellular

fluid space

Avoidable factors that compound the

--- Content provided by FirstRanker.com ---


response to injury
? Continuing haemorrhage
? Hypothermia
? Tissue oedema

--- Content provided by FirstRanker.com ---

? Tissue underperfusion
? Starvation
? Immobility