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Osteosynthesis and Trauma Care 2003; 11(3): 131-136
DOI: 10.1055/s-2003-42608
Original Article

© Georg Thieme Verlag Stuttgart · New York

Metabolic Response and Nutritional Support in Trauma Care

P. A. M. van Leeuwen1 , N. ter Wengel1 , I. P. Oñorbe Genovesi2 , M. P. C. Siroen1
  • 1Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands
  • 2Department of Surgery, De Heel Zaans Medical Center, Zaandam, The Netherlands
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Publikationsverlauf

Publikationsdatum:
29. September 2003 (online)

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Abstract

After stabilisation and fracture treatment of the trauma patient, adequate nutritional support becomes very important. Traumatic injury induces a stress response that requires large amounts of nutrients. When the provision of substrates is inadequate, endogenous sources like muscle tissue and visceral structures are consumed. This hypercatabolic state makes the trauma patient prone for developing complications. Ultimately, multiple organ failure may develop and the patient becomes critically ill. The metabolic response during critical illness consists of protein catabolism to mobilise amino acids that are needed as substrate for healing tissues, synthesis of acute phase proteins and glucose in the liver. This protein breakdown results in a loss of nitrogen. In addition, glucose production in critically ill patients increases, whereas the ability to utilise glucose is decreased because of insulin resistance. These metabolic responses are necessary for recovery of the trauma patient. In order to prevent “auto-consumption” of protein sources and thereby the development of critical illness, exogenous provision of substrates is necessary. This manuscript summarises important issues like the metabolic response to trauma, early enteral feeding and the role of the gut during critical illness.

Key words

Metabolism - nutritional support - trauma - critical illness

References

  • 1 Alexander J W, MacMillan B G, Stinnett J D, Ogle C K, Bozian R C, Fischer J E, Oakes J B, Morris M J, Krummel R. Beneficial effects of aggressive protein feeding in severely burned children.  Ann Surg. 1980;  192 505-517
    PubMedGoogle Scholar
  • 2 Askanazi J, Carpentier Y A, Michelsen C B, Elwyn D H, Furst P, Kantrowitz L R, Gump F E, Kinney J M. Muscle and plasma amino acids following injury. Influence of intercurrent infection.  Ann Surg. 1980;  192 78-85
    PubMedGoogle Scholar
  • 3 Askanazi J, Elwyn D H, Kinney J M, Gump F E, Michelsen C B, Stinchfield F E, Furst P, Vinnars E, Bergstrom J. Muscle and plasma amino acids after injury: the role of inactivity.  Ann Surg. 1978;  188 797-803
    PubMedGoogle Scholar
  • 4 Askanazi J, Furst P, Michelsen C B, Elwyn D H, Vinnars E, Gump F E, Stinchfield F E, Kinney J M. Muscle and plasma amino acids after injury: hypocaloric glucose vs. amino acid infusion.  Ann Surg. 1980;  191 465-472
    CrossrefPubMedGoogle Scholar
  • 5 Aulick L H, McManus A T, Mason A D, Pruitt B A. Effects of infection on oxygen consumption and core temperature in experimental thermal injury.  Ann Surg. 1986;  204 48-52
    PubMedGoogle Scholar
  • 6 Berg R D. Translocation of indigenous bacteria from the intestinal tract. In: Hentges DJ (ed). Human Intestinal Microflora in Health and Disease. Academic Press Inc, New York 1983
    Google Scholar
  • 7 Black P R, Brooks D C, Bessey P Q, Wolfe R R, Wilmore D W. Mechanisms of insulin resistance following injury.  Ann Surg. 1982;  196 420-435
    CrossrefPubMedGoogle Scholar
  • 8 Bleichrodt R P, Mourik J B. Enterale Voeding. Uitgeverij Universiteit Twente, Enschede 1995
    Google Scholar
  • 9 Braunschweig C L, Levy P, Sheean P M, Wang X. Enteral compared with parenteral nutrition: a meta-analysis.  Am J Clin Nutr. 2001;  74 534-542
    CrossrefPubMedGoogle Scholar
  • 10 Cerra F B, McPherson J P, Konstantinides F N, Konstantinides N N, Teasley K M. Enteral nutrition does not prevent multiple organ failure syndrome (MOFS) after sepsis.  Surgery. 1988;  104 727-733
    PubMedGoogle Scholar
  • 11 Chiarelli A, Enzi G, Casadei A, Baggio B, Valerio A, Mazzoleni F. Very early nutrition supplementation in burned patients.  Am J Clin Nutr. 1990;  51 1035-1039
    CrossrefPubMedGoogle Scholar
  • 12 Chuntrasakul C, Siltharm S, Chinswangwatanakul V, Pongprasobchai T, Chockvivatanavanit S, Bunnak A. Early nutritional support in severe traumatic patients.  J Med Assoc Thai. 1996;  79 21-26
    PubMedGoogle Scholar
  • 13 Cuthbertson D P. Observations on disturbance of metabolism produced by injury to the limbs.  Q J Med. 1932;  25 233
    PubMedGoogle Scholar
  • 14 Cuthbertson D P, McGirr J L, Robertson J SM. The effect of fracture of bone on the metabolism of the rat.  Q J Exp Physiol. 1939;  29 13
    PubMedGoogle Scholar
  • 15 Dobbins W O. Gut immunophysiology: a gastroenterologist's view with emphasis on pathophysiology.  Am J Physiol. 1982;  242 G1-G8
    PubMedGoogle Scholar
  • 16 Douglas R G, Shaw J H. Metabolic response to sepsis and trauma.  Br J Surg. 1989;  76 115-122
    PubMedGoogle Scholar
  • 17 Enrione E B, Gelfand M J, Morgan D, Sperling M, Wagner S C, Popp M B. The effects of rate and route of nutrient intake on protein metabolism.  J Surg Res. 1986;  40 320-325
    CrossrefPubMedGoogle Scholar
  • 18 Golden S H, Peart-Vigilance C, Kao W H, Brancati F L. Perioperative glycemic control and the risk of infectious complications in a cohort of adults with diabetes.  Diabetes Care. 1999;  22 1408-1414
    CrossrefPubMedGoogle Scholar
  • 19 Howard J M. Studies of the absorption and metabolism of glucose following injury: the systemic response to sepsis and trauma.  Ann Surg. 1955;  141 311
    PubMedGoogle Scholar
  • 20 Jacobs D O, Evans D A, O'Dwyer S T. Trophic effects of glutamine-enriched parenteral nutrition on colonic mucosa.  J Parenter Enteral Nutr. 1988;  12 6
    PubMedGoogle Scholar
  • 21 Johnson L R, Lichtenberger L M, Copeland E M, Dudrick S J, Castro G A. Action of gastrin on gastrointestinal structure and function.  Gastroenterology. 1975;  68 1184-1192
    PubMedGoogle Scholar
  • 22 Kompan L, Kremzar B, Gadzijev E, Prosek M. Effects of early enteral nutrition on intestinal permeability and the development of multiple organ failure after multiple injury.  Intensive Care Med. 1999;  25 157-161
    CrossrefPubMedGoogle Scholar
  • 23 LeVoyer T, Cioffi WG J r, Pratt L, Shippee R, McManus W F, Mason A D, Pruitt B A. Alterations in intestinal permeability after thermal injury.  Arch Surg. 1992;  127 26-29
    PubMedGoogle Scholar
  • 24 Lewis S J, Egger M, Sylvester P A, Thomas S. Early enteral feeding versus “nil by mouth” after gastrointestinal surgery: systematic review and meta-analysis of controlled trials.  BMJ. 2001;  323 773-776
    CrossrefPubMedGoogle Scholar
  • 25 Long C L, Spencer J L, Kinney J M, Geiger J W. Carbohydrate metabolism in man: effect of elective operations and major injury.  J Appl Physiol. 1971;  31 110-116
    PubMedGoogle Scholar
  • 26 Long J M, Wilmore D W, Mason A D, Pruitt B A. Effect of carbohydrate and fat intake on nitrogen excretion during total intravenous feeding.  Ann Surg. 1977;  185 417-422
    PubMedGoogle Scholar
  • 27 Marin M L, Greenstein A J, Geller S A, Gordon R E, Aufses A H. A freeze fracture study of Crohn's disease of the terminal ileum: changes in epithelial tight junction organization.  Am J Gastroenterol. 1983;  78 537-547
    PubMedGoogle Scholar
  • 28 McArdle A H, Palmason C, Morency I, Brown R A. A rationale for enteral feeding as the preferable route for hyperalimentation.  Surgery. 1981;  90 616-623
    PubMedGoogle Scholar
  • 29 Moore E E, Jones T N. Benefits of immediate jejunostomy feeding after major abdominal trauma - a prospective, randomized study.  J Trauma. 1986;  26 874-881
    PubMedGoogle Scholar
  • 30 Moore F A, Feliciano D V, Andrassy R J, McArdle A H, Booth F V, Morgenstein-Wagner T B, Kellum J M, Welling R E, Moore E E. Early enteral feeding, compared with parenteral, reduces postoperative septic complications. The results of a meta-analysis.  Ann Surg. 1992;  216 172-183
    CrossrefPubMedGoogle Scholar
  • 31 Munro H N. Free Amino Acid Pools and Their Role in the Regulation. Academic Press Inc, New York 2003; 299
    Google Scholar
  • 32 O'Dwyer S T, Smith R J, Hwang T L, Wilmore D W. Maintenance of small bowel mucosa with glutamine-enriched parenteral nutrition.  J Parenter Enteral Nutr. 1989;  13 579-585
    PubMedGoogle Scholar
  • 33 O'Dwyer S T, Smith R J, Scott T. Glutamine enriched nutrition decreases intestinal injury and increases nitrogen retention.  Br J Surg. 1987;  74 1162
    PubMedGoogle Scholar
  • 34 Page C P, Edgar J. Poth lecture. The surgeon and gut maintenance.  Am J Surg. 1989;  158 485-490
    CrossrefPubMedGoogle Scholar
  • 35 Pape H C, Dwenger A, Regel G, Auf'm'Kolck M, Gollub F, Wisner D, Sturm J A, Tscherne H. Increased gut permeability after multiple trauma.  Br J Surg. 1994;  81 850-852
    PubMedGoogle Scholar
  • 36 Peng Y Z, Yuan Z Q, Xiao G X. Effects of early enteral feeding on the prevention of enterogenic infection in severely burned patients.  Burns. 2001;  27 145-149
    CrossrefPubMedGoogle Scholar
  • 37 Piccone V A, LeVeen H H, Glass P, Berlyne G, Lundin A P. Prehepatic hyperalimentation.  Surgery. 1980;  87 263-270
    PubMedGoogle Scholar
  • 38 Roumen R M, Hendriks T, Wevers R A, Goris J A. Intestinal permeability after severe trauma and hemorrhagic shock is increased without relation to septic complications.  Arch Surg. 1993;  128 453-457
    PubMedGoogle Scholar
  • 39 Sagor G R, Ghatei M A, Al Mukhtar M Y, Wright N A, Bloom S R. Evidence for a humoral mechanism after small intestinal resection. Exclusion of gastrin but not enteroglucagon.  Gastroenterology. 1983;  84 902-906
    PubMedGoogle Scholar
  • 40 Shangraw R E, Turinsky J. Local effect of burn injury on glucose and amino acid metabolism by skeletal muscle.  J Parenter Enteral Nutr. 1979;  3 323-327
    PubMedGoogle Scholar
  • 41 Stoutenbeek C P, van Saene H K, Miranda D R, Zandstra D F, Langrehr D. The effect of oropharyngeal decontamination using topical nonabsorbable antibiotics on the incidence of nosocomial respiratory tract infections in multiple trauma patients.  J Trauma. 1987;  27 357-364
    PubMedGoogle Scholar
  • 42 Van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, Vlasselaers D, Ferdinande P, Lauwers P, Bouillon R. Intensive insulin therapy in the critically ill patients.  N Engl J Med. 2001;  345 1359-1367
    CrossrefPubMedGoogle Scholar
  • 43 Wilmore D W, Black P R, Muhlbacher F. Injured man: trauma and sepsis. In: Winters RWGHL (ed). Nutritional Support of the Seriously Ill Patient. Academic Press Inc, New York 1983; 33
    Google Scholar
  • 44 Wilmore D W, Brennan M F, Harken A H, Holcroft J W, Meakins J L. Care of the Surgical Patient. Scientific American Inc, New York 1993
    Google Scholar
  • 45 Wilmore D W, Goodwin C W, Aulick L H, Powanda M C, Mason A D, Pruitt B A. Effect of injury and infection on visceral metabolism and circulation.  Ann Surg. 1980;  192 491-504
    PubMedGoogle Scholar
  • 46 Windmueller H G. Glutamine utilization by the small intestine.  Adv Enzymol Relat Areas Mol Biol. 1982;  53 201-237
    PubMedGoogle Scholar
  • 47 Wolfe R R, Durkot M J, Allsop J R, Burke J F. Glucose metabolism in severely burned patients.  Metabolism. 1979;  28 1031-1039
    CrossrefPubMedGoogle Scholar

Prof. Dr. P. A. M. van Leeuwen

Department of Surgery

VU University Medical Center · PO Box 70 57

1007 MB Amsterdam

The Netherlands

Telefon: +31/20/4 44 36 01

Fax: +31/20/4 44 36 20

eMail: pam.vleeuwen@vumc.nl