1. Systemic characterized by exaggerated immune responses to either a sterile or infectious process
inflammation 2. Cell migration Inflammatory response to injury or infection involves cell signaling, mediator release, and _____ 3. Severe trauma Systemic inflammation is a central feature of both sepsis and ______. 4. Trauma leading cause of mortality and morbidity for individuals under 50 5. Sepsis Identifiable source of infection + SIRS 6. Severe sepsis sepsis + organ dysfunction 7. Septic shock sepsis + cardiovascular collapse 8. Vagus The ____ nerve exerts several homeostatic influences, including enhancing gut motility, reducing heart rate, and regulating inflammation 9. Nicotine shown to reduce cytokine release after endotoxemia in animal models 10. Polypeptides cytokines, glucagon, insulin 11. Amino acids epinephrine, serotonin, histamine 12. Fatty acids glucocorticoids, prostaglandins, leukotrienes 13. Glucocorticoid Prototype of the intracellular hormone receptor receptor 14. Glucocorticoid Receptor regulated by the stress-induced protein known as heat shock protein (HSP) receptor 15. Fat Principal source of fuel for short fasting in healthy adults are derived from muscle protein and body ____. 16. Glycogenolysis Glucagon, norepinephrine, vasopressin, and angiotensin II can promote ______ during fasting. 17. Lactate Precursors for hepatic gluconeogenesis include ___, glycerol, and amino acids, such as alanine and glutamine. 18. Cori cycle The recycling of lactate and pyruvate for gluconeogenesis is commonly referred to as the ________ _____. 19. Liver Normal adult body contains 300-400 g of carbohydrates in the form of glycogen. 75-100 g are stored in the ____. 20. Cortisol Effective immunosuppressive agent, which causes thymic involution and depressed cell-mediated immune responses. 21. Insulin Proteolysis during starvation, which results from decreased ____ and increased cortisol release is associated with elevated urinary nitrogen excretion. 22. Skeletal Proteolysis during starvation occurs mainly within ____ ____. muscles 23. Catabolic Phase characterized with hyperglycemia, increase secretion of urinary nitrogen 24. Early anabolic Phase with restored tissue perfusion, sharp decline in nitrogen excretion 25. Catabolic Ebb, Adrenergic-Corticoid 26. Early anabolic Flow, Corticoid-withdrawal 27. Early anabolic Phase with rapid and progressive gain in weight and muscular strength 28. Late anabolic Phase several months after injury once volume deficit has been restored 29. Late anabolic Metabolic phase of the injured patient in which body fat re-accumulates 30. Phospholipase Dietary lipids are not readily absorbable in the gut but require pancreatic lipase and ___ within the duodenum to hydrolyze triglyceride to free fatty acids and monoglycerides. 31. Stress Hepatocytes use free fatty acids as fuel sources in stress 32. Lipoprotein Trauma or sepsis suppresses ___ activity in both adipose tissue and muscle, mediated by TNF-a lipase (LPL) 33. 12 Number of ATP molecules produced in TCA cycle 34. Ketogenesis Excess acetyl-CoA serves as precursors for ____ 35. Carnitine shuttle transport of fatty acyl-CoA from the outer mitochondrial membrane occurs via the ___ ___. 36. Fatty acid RQ of 0.7 means greater ___ ___oxidation 37. Carbohydrate RQ of 1 means greater ___ oxidation 38. 0.85 RQ = __ suggests the oxidation of equal amounts of fatty acids and glucose 39. Carbohydrate ___ depletion slows acetyl-CoA entry into the TCA cycle secondary to depleted TCA intermediates and enzyme activity 40. Leucine Essential amino acid for ketogenesis 41. Gluconeogenesis Arginine is an essential amino acid for ____ 42. Gluconeogenesis Histidine is an essential amino acid for ____ 43. infection identifiable source of microbial insult 44. SIRS criteria Temp <36 or >38 HR >90 BPM RR >20 BPM PaCO2 <32mmHg WBC <4000 or >12000 >10% bands 45. 3 major intercellular hormone -receptor kinases pathways -G-protein receptors -ligand-gated ion channels 46. hormones regulated by -corticotropin releasing hormone hypothalamus -thyrotropin releasing hormone -luteinizing hormone releasing hormone 47. hormones regulated by anterior -adrenocorticotropic hormone pituitary -cortisol -TSH -thyroxine -triiodothyronine -GH -gonadotropins -sec hormones -IGF -somatostatin -prolactin -endorphins 48. hormones regulated by -vasopressin posterior pituitary -oxytocin 49. hormones regulated by -NE autonomic system -epinephrine -aldosterone 50. hormones regulated by RAAS -insulin -glucagon -enkephalins 51. ACTH -polypeptide hormone -regulates release of cortisol from zona fasciulata 52. stimuli for ACTH release -CRH -pain -anxiety -vasopressin -angiotensin II -vasoactive intestinal polypeptide -proinflammatory cytokines 53. potentiates the actions of glucagon and epinephrine that manifest as hyperglycemia cortisol 54. signs of adrenal insufficiency -tachycardia -hypotension -weakness -nausea -vomiting -fever -hypoglycemia -hyponatremia -hyperkalemia 55. neurohormone that modulates the inflammatory response by inhibiting the immunosuppressive Macrophage migration effect of cortisol on immunocytes and thereby increasing their activity against foreign pathogens inhibiting factor (MIF) 56. neurohormone that promotes protein synthesis and insulin resistance, and enhances the mobilization GH of fat stores. 57. In the liver, stimulates protein synthesis and glycogenesis; in adipose tissue, it increases glucose IGF uptake and lipid utilization; and in skeletal muscles, it mediates glucose uptake and protein synthesis 58. 1. enhances phagocytic activity of immunocytes through increased lysosomal superoxide GH production. 2. increases the proliferation of T-cell populations. 59. associated with worse outcomes, including increased mortality, prolonged ventilator dependence, exogenous GH and increased susceptibility to administration in infection. critically ill pts. 60. hormones secreted by the chromaffin cells of the adrenal medulla that function as neurotransmitters catecholamines in the CNS 61. 1. shown to induce a catabolic state and hyperglycemia through hepatic gluconeogenesis and epinephrine glycogenolysis by peripheral lipolysis and proteolysis. 2. promotes insulin resistance in skeletal muscle. 3. increases the secretion of thyroid hormone, parathyroid hormones, and renin, but inhibits the release of aldosterone. 62. manifested by edema, hypertension, hypokalemia, and metabolic alkalosis aldosterone excess 63. manifested by aldosterone deficiency hypotension and hyperkalemia 64. has immunosuppressive effects, including glycosylation of immunoglobulins and decreased hyperglycemia phagocytosis and respiratory burst of monocytes, and thus is associated with an increased risk for infection 65. class of proteins produced by the liver that manifest either increased or decreased plasma acute phase proteins concentration in response to inflammatory stimuli such as traumatic injury and infection 66. Among earliest responders after injury; half-life <20 min; activates TNF receptors 1 and 2; induces TNF significant shock and catabolism 67. similar physiologic effects as TNF; induces fevers through prostaglandin activity in anterior hypothalamus; IL-1 promotes -endorphin release from pituitary; half-life <6 min 68. Promotes lymphocyte proliferation, immunoglobulin production, gut barrier integrity; half-life <10 min; IL-2 attenuated production after major blood loss leads to immunocompromise; regulates lymphocyte apoptosis 69. Induces B-lymphocyte production of IgG4 and IgE, mediators of allergic and anthelmintic response; IL-4 downregulates TNF, IL-1, IL-6, IL-8 70. Promotes eosinophil proliferation and airway inflammation IL-5 71. Elicited by virtually all immunogenic cells; long half-life; circulating levels proportional to injury severity; IL-6 prolongs activated neutrophil survival 72. Chemoattractant for neutrophils, basophils, eosinophils, lymphocytes IL-8 73. Prominent anti-inflammatory cytokine; reduces mortality in animal sepsis and ARDS models IL-10 74. Promotes TH1 differentiation; synergistic activity with IL-2 IL-12 75. Promotes B-lymphocyte function; structurally similar to IL-4; inhibits nitric oxide and endothelial IL-13 activation 76. Anti-inflammatory effect; promotes lymphocyte activation; promotes neutrophil phagocytosis in fungal IL-15 infections 77. Similar to IL-12 in function; levels elevated in sepsis, particularly gram-positive infections; high levels IL-18 found in cardiac deaths 78. Mediates IL-12 and IL-18 function; half-life of days; found in wounds 5-7 d after injury; promotes ARDS IFN-γ 79. Promotes wound healing and inflammation through activation of leukocytes GM-CSF 80. Preferentially secreted by TH2 cells; structurally similar to IL-2 and IL-15; activates NK cells, B and T IL-21 lymphocytes; influences adaptive immunity 81. High mobility group box chromosomal protein; DNA transcription factor; late (downstream) mediator of HMGB1 inflammation (ARDS, gut barrier disruption); induces "sickness behavior" 82. -anti-inflammatory effects, Omega-3 FAs including inhibition of NF- B activity, TNF release from hepatic Kupffer cells, as well as leukocyte adhesion and migration. -inhibit inflammation, ameliorate weight loss, increase small-bowel perfusion, and may increase gut barrier protection. 83. group of proteins that contribute to inflammation, blood pressure control, coagulation, and pain Kallikrein-Kinin responses. System 84. -mediate several physiologic processes, including vasodilation, increased capillary permeability, tissue kinins edema, pain pathway activation, inhibition of gluconeogenesis, and increased bronchoconstriction. - also increase renal vasodilation and consequently reduce renal perfusion pressure 85. s-timulates vasoconstriction, bronchoconstriction, and platelet aggregation. serotonin - also increases cardiac inotropy and chronotropy through nonadrenergic cyclic adenosine monophosphate (cAMP) pathways. 86. two major second messengers of the G-protein pathway (1) cAMP (2) calcium, released from the endoplasmic reticulum 87. transmembrane receptors that are involved in cell signaling for several growth factors, including Receptor tyrosine plateletderived kinases (RTKs) growth factor, insulin-like growth factor, epidermal growth factor, and vascular endothelial growth factor 88. energy-dependent, organized mechanism for clearing senescent or dysfunctional cells, including Apoptosis (regulated macrophages, neutrophils, and lymphocytes, without promoting an inflammatory response cell death) 89. activated through extrinsic pathway the binding of death receptors which leads to the recruitment of Fas-associated death domain protein and subsequent activation of caspase 3 90. activated through protein mediators (Bcl-2) influence mitochondrial membrane permeability. Increased intrinsic pathway membrane permeability leads to the release of mitochondrial cytochrome C, which activates caspase 3 and thus induces apoptosis 91. normal metabolism 22 to 25 kcal/kg per day 92. metabolism during stress as high as 40 kcal/kg per day 93. Body Fuel Reserves in a 70-kg Man Water and minerals → 49kg 0kcal 0days Protein → 6.0kg 24,000kcal 13.0days Glycogen → 0.2kg 800kcal 0.4days Fat → 15.0kg 140,000kcal 78.0days Total → 70.2kg 164,800kcal 91.4days 94. Recommended Daily Requirement glucose glucose 7.2 g/kg per day 95. Recommended Daily Requirement lipid 1.0 g/kg per day 96. Recommended Daily Requirement protein 0.8 g/kg per day 97. GLUT1 Major Expression Sites Placenta, brain, kidney, colon 98. GLUT2 Major Expression Sites Liver, pancreatic β- cells, kidney, small intestine 99. GLUT3 Major Expression Sites Brain, testis 100. GLUT4 Major Expression Sites Skeletal muscle, heart muscle, brown and white fat 101. GLUT5 Major Expression Sites Small intestine, sperm 102. primary source of energy during stressed state lipid metabolism 103. percent of energy provided by lipolysis during stress 50-80% 104. calories provided by oxidation of 1g of fat 9 kcal 105. transport of fatty acyl-CoA from the outer mitochondrial carnitine shuttle membrane across the inner mitochondrial membrane 106. can cross mitochondrial membranes without carnitine shuttle Medium chain triglycerides 107. represents a state in which hepatic ketone production ketosis exceeds extrahepatic ketone utilization 108. calories provided by oxidation of 1g of 4 kcal carbohydrate 109. calories provided by oxidation of 1g of 3.4 kcal dextrose 110. facilitates fat entry into the TCA cycle and exogenous administration of small amounts of glucose (approximately 50 reduces ketosis g/d 111. RQs >1.0 indicates over feeding -can result in conditions such as glucosuria, thermogenesis, and conversion to fat (lipogenesis). - results in elevated carbon dioxide production, which may be harmful in patients with suboptimal pulmonary function, as well as hyperglycemia, which may contribute to infectious risk and immune suppression. 112. transports glucose molecules against Na+/glucose secondary active transport system concentration gradients by active transport. 113. calories provided by oxidation of 1g of protein 4 kcal 114. Harris-Benedict equations used to calculate basal energy expenditure 115. will adequately meet energy requirements in 30 kcal/kg/day most postsurgical patients, with a low risk of overfeeding 116. protein requirements in burn patients 2.5 g/kg/day 117. type nutrition with associated reduced enteral infectious complications and acute phase protein production 118. associated with underfeeding and calorie early gastric feeding after closed-head injury deficiency due to the difficulties in overcoming gastroparesis and the high risk of aspiration 119. requires cessation of feeding and adjustment Gastric residuals of 200 mL or more in a 4- to 6-hour period or abdominal of the infusion rate distention 120. patient groups for 1. Newborn infants with catastrophic gastrointestinal anomalies, such as whom parenteral nutrition has been tracheoesophageal fistula, gastroschisis, omphalocele, or massive intestinal used in an effort to achieve these goals: atresia 2. Infants who fail to thrive due to gastrointestinal insufficiency associated with short-bowel syndrome, malabsorption, enzyme deficiency, meconium ileus, or idiopathic diarrhea 3. Adult patients with short-bowel syndrome secondary to massive small-bowel resection (<100 cm without colon or ileocecal valve, or <50 cm with intact ileocecal valve and colon) 4. Patients with enteroenteric, enterocolic, enterovesical, or high-output enterocutaneous fistulas (>500 mL/d) 5. Surgical patients with prolonged paralytic ileus after major operations (>7 to 10 days), multiple injuries, or blunt or open abdominal trauma, or patients with reflex ileus complicating various medical diseases 6. Patients with normal bowel length but with malabsorption secondary to sprue, hypoproteinemia, enzyme or pancreatic insufficiency, regional enteritis, or ulcerative colitis 7. Adult patients with functional gastrointestinal disorders such as esophageal dyskinesia after cerebrovascular accident, idiopathic diarrhea, psychogenic vomiting, or anorexia nervosa 8. Patients with granulomatous colitis, ulcerative colitis, or tuberculous enteritis in which major portions of the absorptive mucosa are diseased 9. Patients with malignancy, with or without cachexia, in whom malnutrition might jeopardize successful use of a therapeutic option 10. Patients in whom attempts to provide adequate calories by enteral tube feedings or high residuals have failed 11. Critically ill patients who are hypermetabolic for >5 days or for whom enteral nutrition is not feasible 121. Patients in whom hyperalimentation is 1. Patients for whom a specific goal for patient management is lacking or for contraindicated include the following: whom, instead of extending a meaningful life, inevitable dying would be delayed 2. Patients experiencing hemodynamic instability or severe metabolic derangement (e.g., severe hyperglycemia, azotemia, encephalopathy, hyperosmolality, and fluid-electrolyte disturbances) requiring control or correction before hypertonic intravenous feeding is attempted 3. Patients for whom gastrointestinal tract feeding is feasible; in the vast majority of instances, this is the best route by which to provide nutrition 4. Patients with good nutritional status 5. Infants with <8 cm of small bowel, because virtually all have been unable to adapt sufficiently despite prolonged periods of parenteral nutrition 6. Patients who are irreversibly decerebrate or otherwise dehumanized 122. TPN -requires large bore access -15-25% dextrose -all nutrients are deliverable by this route 123. peripheral parenteral nutrition -5-10% dextrose -3% protein -not appropriate for malnourished patients because some nutrients not deliverable 124. essential fatty acid deficiency manifests as dry, scaly dermatitis and loss of hair 125. complications of parenteral nutrition -sepsis 2/2 contamination of central venous catheter -PNX -hemothoraz -subclavian artery injury -thoracic duct injury -arrythmia -air embolism -cardiac perforation -hyperglycemia -hepatic steatosis 2/2 overfeeding -cholestasis and gallstones -intestinal atrophy