Surgical Metabolism: The Metabolic Care of the Surgical Patient

Preface
Contents
Contributors
Abbreviations
Part I: Normal Metabolism
	1: Introduction to Metabolism
		Introduction
		History of Metabolism
		The Hierarchy of Metabolism
			The Mitochondrial Level
			The Cellular Level
			The Organ Level
				Metabolic States at the Organism Level
			Energy Requirements
				Normal Energy Requirements
				Abnormal Energy Requirements
			The Measurement of Energy Requirements
				Direct Calorimetry
				Indirect Calorimetry
				Equations to Calculate REE
			Sources of Energy
				Carbohydrates
				Proteins
				Lipids
				Alternate Sources of Energy
			Normal Metabolic Processes
				Cofactors and Enzymes
				Therapeutic Interventions
			Normal Metabolism
			Perturbations of Metabolism
				Starvation
				Obesity
				Metabolic Stressors
			Genomics Impacting Metabolism
				Metabolomics
				Inborn Errors in Metabolism
		References
	2: Fluid and Electrolytes
		Introduction
		Total Body Water and the Fluid Compartments
		Volume Control Mechanisms
		Baseline Water and Electrolyte Requirements
		Parenteral Solutions
		Maintenance Fluid Therapy
		Resuscitative Fluid Therapy
		The Relationship Between Disorders of Water Balance and Sodium Balance
		Disorders of Sodium Metabolism
		Disorders of Potassium Metabolism
		Disorders of Calcium Metabolism
		Disorders of Magnesium Metabolism
		Disorders of Phosphorous Metabolism
		References
	3: Acid–Base Physiology
		General Principles
			Physiologic Basis for Acid–Base Disorders and Their Compensation
			Chemical Buffering Systems
			Physiologic Determinants of Acid–Base Maintenance
			Renal System
			Renal Reabsorption of Bicarbonate and Excretion of Acid
			Kidney–Liver Interaction
			Gastrointestinal Tract
			Respiratory Regulation of Carbon Dioxide
			Description and Classification of Acid–Base Disorders
			Assessment of Acid–Base Balance
			Metabolic Acid–Base Disorders
		Metabolic Acidoses
			Pathophysiology
		Anion Gap Acidoses
			Determination of Anion Gap
			Clinical Utility of Anion Gap
			Strong Ion Gap
			Lactate
			Sodium Bicarbonate
			Ketoacidosis
			Acidosis Secondary to Toxin Ingestion
				Salicylates
				Alcohols
				Ethylene Glycol
				Methanol
				Isopropyl Alcohol
			Renal Failure
			Acidosis Secondary to Rhabdomyolysis
			Acidosis of Unknown Origin
			Prognostic Significance of Positive-AG Metabolic Acidosis
			Non-anion Gap Acidosis (Hyperchloremic)
			Gastrointestinal Tract Loss
			Renal Tubular Acidosis
			Iatrogenic Acidosis
			Unexplained Hyperchloremic Acidosis
		Metabolic Alkaloses
			Pathogenesis and Differential Diagnosis
			Chloride-Sensitive Metabolic Alkaloses
			Chloride-Resistant Metabolic Alkaloses
			Other Causes of Metabolic Alkalosis
		Diagnostic Evaluation and Management
			Metabolic Acidosis
			Respiratory Acid–Base Disorders
			Pathophysiology
		Respiratory Acidosis
			Mechanism
			Management
				Treatment of Underlying Ventilatory Impairment
			Control of Hypoxemia
			Permissive Hypercapnia
			Respiratory Alkalosis
			Pseudorespiratory Alkalosis
		References
	4: Metabolomics and Other “-Omic” Approaches to Characterize Perioperative Trajectories
		Surgery and Critical Illness as a Model to Understand Vulnerability and Resilience to Physical Stressors at the Individual and Population Level
			The Host Response to Physical Stressors, Surgery, Trauma, and Injury
			Physical Resilience to Surgical Stressors
		The Role of Metabolic Phenotypes and Metabolic Trajectories in Precision Perioperative Medicine
			Metabolic Phenotyping for Risk Stratification in Surgical and Critically Ill Patients
				Applications in Cardiovascular Surgery
				Applications of Metabolic Phenotyping in Critically Ill Patients Requiring Extracorporeal Membrane Oxygenation (ECMO)
				Applications in Trauma and Acute Care Surgery
				Applications in Bariatric Surgery
				Applications in Transplant Surgery
				Applications in Surgical Oncology
				Metabolic Phenotyping for Intraoperative Patient Monitoring
		Metabolic Adaptations: Metabolic Arrest, Hypometabolism, and Other Lessons Learned from Hibernation Biology
		Linking Metabolic with Immunophenotyping and Other “-Omics” Information
			Contribution of Genomic Variation in Inflammatory and Metabolic Responses to Surgery
			The Relationship Between Gut Microbiome and Metabolic Phenotypes
			Pharmacogenomic and Pharmacometabonomics
			Challenges to Creating a Dynamic Analytical Environment that Allows for Real Decisions in Real Time
		Summary and Future Directions
		References
Part II: Global Perturbations of Metabolism
	5: Starvation
		Starvation and Surgery
		Short-Term Starvation: Metabolic Consequences
			Carbohydrate Metabolism
			Lipid Metabolism
			Insulin Resistance
			Protein Metabolism
			Bone Metabolism
			Energy Expenditure
			Hydration
			Weight Loss
			Hormonal Changes
		Prolonged Starvation: Metabolic Consequences
			Substrate Metabolism
			Vitamin Deficiencies
		Semistarvation
			Metabolic and Hormonal Changes
			Substrate Metabolism
		Long-Term Consequences of Semistarvation
			Marasmus
			Body Composition in Marasmus
			Minerals and Vitamins
		Kwashiorkor
			Carbohydrate Metabolism
			Lipid Metabolism
			Protein Metabolism
		Anorexia Nervosa
			Hormonal Responses
			Carbohydrate Metabolism
			Lipid Metabolism
			Energy Expenditure
			The Elderly: Cachexia and Sarcopenia
			The Refeeding Syndrome
		Conclusions
		References
	6: Metabolism in the Trauma Patient
		The Metabolic Response to Trauma
			Ebb and Flow
		Catabolic Response to Trauma
		The Cytokine Response to Trauma
		Gut Hypothesis of MOF
		Chronic Critical Illness and Persistent Inflammation, Catabolism, and Immune Suppression
		Neuroendocrine Response to Trauma
		Nutrition Support in the Trauma Patient
		Nutrition Assessment
		Estimating Nutrition Needs
		Potential Modulators of Metabolism
		Nutritional Challenges in the Trauma Patient
		Monitoring the Response to Nutritional Supplementation
		Critically Injured Elderly
		References
	7: Burns
		The Body’s Response to Burn Injury
		Historical Perspective to Nutrition and What Has Been Practiced
		Who Needs Nutritional Support
		How Much to Feed and How Soon?
		Total Parenteral Nutrition Versus Enteral Nutrition: When to Use What and Why
		What Needs to Be Supplemented: Protein, Calories, Vitamins, and Minerals
		Modulation of the Stress Response to Burn Injury and Metabolically Altering Agents
		Non-pharmacologic Means (Early Operative Intervention and Thermoregulation of the Environment)
			Early Excision and Grafting
			Temperature Regulation
		Pharmacologic Means (Beta-Blockade, Oxandrolone, Insulin, Glutamine, Erythropoietin, Iron, and Probiotics)
			Beta-Blockade
			Oxandrolone
			Insulin
			Glutamine
			Erythropoietin
			Iron
			Probiotics
		Measuring Effectiveness of Nutritional Support
		Special Considerations (Children, Elderly, Morbidly Obese)
			Children
			Elderly
			Morbidly Obese
		Conclusions
		References
	8: Obesity
		Impact of Obesity Upon Clinical Outcomes
		The Obesity Paradox
		Metabolic and Physiologic Consequences of Obesity that Compound Critical Illness and Nutrition Therapy
		Defining Calorie and Protein Requirements for Surgical Patients with Obesity
		Interpreting Nitrogen Balance
		Relationship Between Calories and Protein and Its Influence on Nitrogen Balance and Body Composition
		Evidence for the Efficacy of Hypocaloric, High-Protein Nutrition Therapy for the Hospitalized Surgical Patient with Obesity
		Evaluation of Unique Patient Populations and Specialized Considerations for Hypocaloric, High-Protein Nutrition Therapy
		Metabolic Considerations Following Bariatric Surgery
		Technical Issues of Providing a Parenteral or Enteral Hypocaloric, High-Protein Nutrition Regimen
		Metabolic Monitoring of the Critically Ill Surgical Patient with Obesity
		Conclusions
		References
	9: Malignancy
		The Consequences of Nutrition in Cancer
		Undernutrition
		Quality of Life
		Overnutrition
		The Metabolic Milieu in Malignancy: Cancer Cachexia
		Energetics
		Intermediary Metabolism [49–51]
		Cytokine Milieu
		Surgery in Cancer Patients
		Effect of Surgery on Nutrition in Cancer Patients
		Nutrition Support in Surgical Patients with Cancer
		Perioperative Nutrition Support
		Immune-Enhancing Formulae
		Special Considerations
			Esophageal Cancer
			Gastric Cancer
			Small Bowel Resection
			Pancreatic Cancer
			Liver and Gallbladder Cancer
			Colon Cancer
		Practical Notes to the Perioperative Nutritional Support of Cancer Patients
		References
	10: Sepsis and Nutrition
		Introduction
			Defining Sepsis
		Sepsis Pathophysiology: A Brief Review
		Provision of Nutritional Support in Critical Illness: Initial Assessment
		Impact of Early Nutritional Therapy
			Enteral vs. Parenteral Nutrition
		Enteral Nutrition and Vasopressors
		Immunonutrition and Immune-Enhancing Diets: Is There a Role?
			Glutamine
			Arginine
			Omega-3 Fatty Acids
			Antioxidant Supplementation
		References
	11: Management of Intestinal Failure
		Introduction
		Functional Classification of Intestinal Failure
		Pathophysiology of Intestinal Failure
		Normal Digestion and Absorption of Nutrients
		Factors Influencing Intestinal Failure and Adaptation
		Site of Intestinal Resection
			Jejunum
			Ileum
			Presence of the Ileocecal Valve
			Colon
			Phases of Intestinal Adaptation Following Resection
			Diagnostic Method and Clinical Assessment
			Radiologic Evaluation of Gut Failure
			Medical Management of Intestinal Failure
			Fluid and Electrolytes
			Pharmacology
			Antisecretory Agents
			Antidiarrheals
			Glucagon-Like Peptide 2 Analogs
			Nutritional Management
			Dietary Management
			Micronutrient Supplementation
			Enteral Nutrition
			Parenteral Nutrition
		Complications of Long-Term Parenteral Nutrition
			Hepatic Complications
			Catheter-Related Complications
			Other Long-Term Parenteral Nutrition Complications
			Microbiome in Intestinal Failure
			Surgery in Intestinal Failure
		Conclusions
		References
Part III: Metabolic Support and Nutrition Repletion
	12: Enteral Nutrition
		Basic Science of Enteral Feeding
			Nutritional Assessment
			Feeding Access
			Nutritional Intervention
			Complications of Enteral Nutrition
				Aspiration
				Bowel Dysmotility
				Diarrhea
					Nonocclusive Mesenteric Ischemia
			Failure of Enteral Nutrition
			Pancreatitis
		Conclusion
		References
	13: Parenteral Nutrition
		Introduction
		Current Clinical Practice Guideline Overview
		Nutritional Assessment
		Nutrition Support Goals
		Timing of Parenteral Nutrition Support
		Indications
		Administration
		Supplemental Parenteral Nutrition
		Complications and Monitoring
		Home Parenteral Nutrition
		Conclusion
		References
	14: Immunonutrition and Supplementation: Pathways, Promise, and Pessimism
		Introduction
		L-Arginine
		L-Glutamine
		Omega-3 (n-3) Fatty Acids
		Nucleotides
		Antioxidants
		Probiotics
		Prebiotics
		Clinical Evidence
		Elective Surgery
		Critical Illness and Sepsis
		Cancer
		Trauma
		Traumatic Brain Injury
		Burns
		Obesity
		Pancreatitis
		Solid Organ Transplant
		Inflammatory Bowel Disease
		Pediatric Population
		Current Guidelines and Recommendations
		CCCPG 2015 Summarized Recommendations for Immunonutrition
		Conclusion
		References
	15: Special Considerations in Organ Failure
		Introduction
		Concept of MODS/MOF
		Epidemiology of MOF
		Outcomes
		Scoring Systems
		Pathophysiology
			General Mechanisms
			Neural Regulation
			Microvascular Milieu
			Mitochondrial Role
			Genomics
			Clinical Presentation
				Lung
				Kidney
				Cardiovascular System
				Nervous System
				Gastrointestinal Tract
				Liver
				Hematological System
				Metabolic Disturbances
		Treatment
			General Management
			Nutritional Interventions and Their Impact on MODS/MOF Pathogenesis
			Avoidance of Early Parenteral Nutrition
			Early Enteral Nutrition
			Tight Glucose Control
			Immune-Enhancing Enteral Formulas
			Arginine
			Glutamine
			Lipids
			Future Options
			Current Epidemic of PICS and the Nutritional Implications
		Conclusion
		References
	16: Endocrine Perturbations in Critical Illness
		Disorders of Glucose Control
			Diabetes Management in the Intensive Care Unit
				Background
				Evidence
				Guidelines
				Insulin Infusions
				Subcutaneous Insulin Regimens
				Transitioning the Patient to Discharge
				Diabetic Emergencies
					Epidemiology
					Definitions of DKA and HHS
					Pathophysiology
					Clinical Presentation
					Evaluation
					Management
					Complications
		Adrenal Disorders
			Adrenal Insufficiency
				Background
				Assessing Adrenal Function in the ICU
				Management of Established Adrenal Disease in the ICU
			Pheochromocytoma
				Preoperative Preparation
				Postoperative Management
			Cushing Syndrome
		Thyroid Disorders
			Hypothyroidism
				Epidemiology
				Definition and Clinical Presentation
			Thyrotoxicosis
				Epidemiology
				Definitions and Clinical Presentation
			Nonthyroidal Illness Syndrome
			Calcium Disorders
				Serum Calcium in Normal Conditions
				Hypercalcemia
					History and Physical Examination
					Laboratory Studies
					Causes of Hypercalcemia
					Treatment of Hypercalcemia
						Saline Hydration
						Bisphosphonate Therapy
						Other Treatments for Hypercalcemia
				Hypocalcemia
					Treatment of Hypocalcemia
		References
Part IV: Thyroid and Parathyroid Disturbances
	17: The Microbiome, Surgical Stress, and Infection
		Introduction
		Definitions
		Surveying the Biome
		Differences and Changes in the Biome
		Perturbations of the Biome: Trauma, Burn, and Sterile Inflammation
		Bowel Preparation
		Anatomic Changes
		The Biome and Cancer
		Function
		Effects of Changing the Biome on Outcome
		Anastomotic Breakdown
		The Future
		Bibliography
	18: Special Considerations at the Extremes of Age
		Introduction
			The Current State
		Metabolic Requirements
			Physiologic Changes of Aging
			Vitamin Deficiencies
			Nutritional Monitoring
		Diagnosis of Malnutrition
			Risk Factors for Malnutrition
			Screening Tools
			Biochemical Markers
			Nitrogen Balance
			Nutritional Requirements
				Carbohydrates
				Proteins
				Lipids
				Vitamins and Minerals
				Calcium
				Fluids
				Glutamine
			Indications for Nutritional Support
				Enteral Nutrition
				Parenteral Nutrition
			Nutrition in Palliative Care and the Terminally Ill
				Psychosocial Aspects
				Anorexia
				Cachexia
			Ethical Decision-Making Regarding Artificial Nutrition
		Conclusion
		References
Index