1.
Basic concepts of homeostasis, metabolic changes in injury and their
mediators
Introduction:
Homeostasis is the ability of the body to maintain a stable internal environment despite external stress.
Injury and surgery disrupt this balance, leading to metabolic and endocrine changes aimed at survival.
Phases of response:
- Ebb phase (0–48 hrs): ↓ metabolism, ↓ O2 use, hypothermia.
- Flow phase (>48 hrs): hypermetabolism, ↑ O2 consumption, catabolism.
Mediators:
- Catecholamines, cortisol, glucagon → hyperglycemia, lipolysis.
- Cytokines (IL-1, TNF-α) → inflammation, fever.
- ADH, aldosterone → water & sodium retention.
Clinical relevance:
- ↑ calorie & protein needs.
- Risk of infection, poor healing.
- Management: resuscitation, nutrition, glycemic control.
2. Factors affecting metabolic response to injury
Introduction:
The magnitude of metabolic response to injury varies depending on several host and external factors.
Factors:
- Age: Children & elderly have exaggerated response.
- Nutritional status: Malnutrition worsens catabolism.
- Severity/type of injury: Burns > trauma > elective surgery.
- Comorbidities: Diabetes, renal, hepatic disease alter response.
- Medications: Steroids blunt response, β-blockers reduce catecholamine surge.
- Anesthesia/analgesia: Adequate pain control reduces stress.
Clinical significance:
- Tailor fluid & nutrition to patient’s profile.
- Anticipate complications in high-risk patients.
3. Basic concepts of perioperative care
Introduction:
Perioperative care covers pre-, intra-, and post-operative management to ensure safe surgical
outcomes.
Preoperative care:
- History, exam, investigations.
- ASA risk assessment.
- Optimization of comorbidities.
- Informed consent.
Intraoperative care:
- Monitoring: ECG, BP, O2 sat.
- Fluid balance.
- Asepsis & anesthesia safety.
Postoperative care:
- Pain control (NSAIDs, opioids, epidural).
- Fluids/electrolytes balance.
- Prevention of complications: DVT, pneumonia, wound infection.
Summary: Good perioperative care reduces morbidity and improves recovery.
4. Pathophysiology of shock, types, principles of resuscitation
Introduction:
Shock = state of inadequate tissue perfusion → anaerobic metabolism → lactic acidosis.
Types:
- Hypovolemic (hemorrhage, dehydration).
- Cardiogenic (MI, arrhythmias).
- Distributive (septic, anaphylactic, neurogenic).
- Obstructive (PE, tamponade).
Pathophysiology:
- ↓ perfusion → cellular hypoxia.
- Anaerobic glycolysis → lactate accumulation.
- Cellular failure → MODS.
Resuscitation principles (ABC):
- Airway: ensure patency.
- Breathing: oxygen, ventilation.
- Circulation: IV fluids (crystalloids), blood transfusion.
- Monitor urine output, lactate.
- Use vasopressors if fluid refractory.
5. Clinical features and treatment of shock
Clinical features:
- General: hypotension, tachycardia, tachypnea.
- Skin: cold, clammy (except septic – warm).
- CNS: confusion, restlessness.
- Renal: oliguria.
- Lab: metabolic acidosis, ↑ lactate.
Treatment:
- Rapid recognition & ABC management.
- Oxygen supplementation.
- IV fluids: crystalloids first-line.
- Blood transfusion if hemorrhagic.
- Vasopressors: norepinephrine in septic shock.
- Treat underlying cause (e.g., antibiotics in sepsis, surgery for bleeding).
Summary: Shock is life-threatening but reversible if treated early with fluids, oxygen, and
cause-specific therapy.