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The metabolic effects of thermal injury

  • World Progress In Surgery
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Abstract

Major thermal injury is associated with extreme hypermetabolism and catabolism as the principal metabolic manifestations encountered following successful resuscitation from the shock phase of the burn injury. Substrate and hormonal measurements, indirect calorimetry, and nitrogen balance are biochemical metabolic parameters which are useful and more readily available biochemical parameters worthy of serial assessment for the metabolic management of burn patients. However, the application of stable isotopes with gas chromatography/mass spectroscopy and more recently, new immunoassays for growth factors and cytokines has increased our understanding of the metabolic manifestations of severe trauma.

The metabolic response to injury in burn patients is biphasic wherein the initialebb phase is followed by a hypermetabolic and catabolicflow phase of injury. The increased oxygen consumption/metabolic rate is in part fuelled by evaporative heat loss from wounds of trauma victims, but likely also by a direct central effect of inflammation upon the hypothalamus. Although carbohydrates in the form of glucose appear to be an important fuel source following injury, a maximum of 5–6 mg/kg/min only is beneficial. Burn patients have accelerated gluconeogenesis, glucose oxidation, and plasma clearance of glucose. Additionally, considerable futile cycling of carbohydrate intermediates occurs which includes anaerobic lactate metabolism and Cori cycle activity arising from wound metabolism of glucose and other substrates. Similarly, accelerated lipolysis and futile fatty acid cycling occurs following burn injury. However, recent evidence suggests that lipids in the diet of burned and other injured patients serve not only as an energy source, but also as an important immunomodulator of prostaglandin metabolism and other immune responses.

Amino acid metabolism in burn patients is characterized by increased oxidation, urea synthesis, and protein breakdown which is prolonged and difficult to reduce with current nutritional therapy. However, the current goal of nutritional support is to optimize protein synthesis. Specific unique requirements may exist for supplemental glutamine and arginine following burn injury but further research is needed before enhanced branched chain amino acids supplements can be recommended for burn patients. Recent research investigations have revealed the importance of enteral feeding to enhance mucosal defense against gut bacteria and endotoxin. Similarly, research has demonstrated that many of the metabolic perturbations of burns and sepsis may be due, at least in part, to inflammatory cytokines. Investigation of their pathogenesis and mechanism of action both at a tissue and a cellular level offer important prospects for improved understanding and therapeutic control of the metabolic disorders of burn patients.

Résumé

Après récupération de la première phase de choc survient un hypercatabolisme majeur. Des paramètres de surveillance de l'évolution et d'évaluation de l'efficacité du traitement sont facilement disponibles: dosages hormonaux et de différents subtats, calorimétrie indirecte et bilan azoté devraient être dosés de façon régulière chez les brûlés. Notre compréhension des perturbations métaboliques chez le blessé et chez la grand brûlé s'est améliorée ces dernières années en raison de l'application de techniques isotopiques avec des dosages par la chromatographie gazeuse et la spectrophotométrie de masse et plus récemment encore les dosages immunologiques des facteurs de croissance et des cytokines. La réponse métabolique à l'agression chez le brûlé est biphasique. La phase initiale est descendante, suivie d'une phase ascendante d'hypercatabolisme. L'augmentation de la consommation en oxygène et du métabolisme est en partie provoquée par la perte en chaleur au niveau des plaies, mais aussi, par un effet direct central, liée à l'inflammation qui agit sur l'hypothalamus. Bien que des hydrates de carbone, sous forme de glucose, semblent être une source importante d'énergie après un traumatisme, l'apport de seulement 5–6 mg/kg/min est suffisant. La néoglucogénèse, l'oxydation du glucose et la clairance plasmatique du glucose du brûlé sont accélérées. Les cycles métaboliques des hydrates de carbone, y compris le métabolisme anaérobie des lactates et le cycle de Cori sont inefficaces. De même, la lipolyse est accélérée et le cycle des acides gras est inefficace. Cependant, il est évident que les lipides chez le brûlé et d'autres patients victimes du traumatisme ne sont pas seulement une source d'énergie mais aussi un immunomodulateur du métabolisme des prostaglandines et d'autres voies de réponse immune. Le métabolisme des acides aminés chez le brûlé est caractérisé par une oxydation, une synthèse d'urée et un catabolisme protéique accrus, phénomènes prolongés et difficiles à réduire avec les moyens actuels de nutrition artificielle. Le but du soutien nutritionnel est cependant d'optimiser la synthèse protéique. Des besoins spécifiques peuvent nécessiter une supplémentation en glutamine et arginine après brûlures mais d'autres recherches sont nécessaires avant de pouvoir dire qu'une supplémentation en acides aminés branchés peut être utile. La recherche moderne a démontré l'importance de l'alimentation entérale qui empêche la traversée de la barrière muqueuse par les germes et les endotoxines. De même, il a été démontré que beaucoup des perturbations métaboliques dans les suites de brûlures et dans les états septiques sont dues, du moins en partie, aux cytokines inflammatoires. L'analyse de leur pathogénèse et leur mécanisme d'action à la fois au niveau tissulaire et cellulaire offrent d'importantes perspectives pour améliorer la compréhension et le contrôle thérapeutique des désordres métaboliques du brûlé.

Resumen

La lesión térmica mayor está relacionada con grados extremos de hipermetabolismo y catabolismo como las manifestaciones metabólicas principales que ocurren una vez cumplida exitosamente la resucitación de la fase de shock. Las determinaciones de sustratos y niveles hormonales, la calorimetría indirecta y el balance de nitrógeno son parámetros metabólicos de carácter bioquímico que son útiles y fácilmente disponibles, los cuales merecen estudios seriados para el manejo metabólico de los pacientes quemados. Sin embargo, la aplicación de isótopos estables con cromatografía de gas/espectrometría de masa y, más recientemente, nuevas inmunodeterminaciones para factores de crecimiento y citocinas, ha incrementado nuestro conocimiento y comprensión de las manifestaciones metabólicas del trauma severo.

La respuesta metabólica en los pacientes quemados es bifásica, en tanto que lafase ebb inicial es seguida de unafase flow hipermetabólica y catabólica. El aumento en el consumo de oxígeno/tasa metabólica se debe en parte a la pérdida evaporativa de calor a partir de las heridas de las víctimas de trauma, pero posiblemente también a un efecto central de la inflamación sobre el hipotálamo. Aunque los carbohidratos en forma de glucosa parecen ser una fuente energética importante, sólo hasta un máximo de 5–6 mg/kg/min son de beneficio. Los pacientes quemados exhiben aceleradas ratas de gluconeogénesis, oxidación de glucosa y depuración plasmática de glucosa. Además, se presenta considerable ciclaje futil de intermediarios de carbohidratos, lo cual incluye metabolismo anaeróbico de lactato y actividad del ciclo de Cori originados en el metabolismo de la glucosa y de otros sustratos a nivel de la herida. También se presenta lipolisis acelerada y ciclaje futil de ácidos grasos. Sin embargo, evidencias recientes sugieren que los lípidos en la dieta de los pacientes con quemaduras y otras formas de trauma sirven no sólo como fuentes energéticas, sino también como un factor importante de modulación del metabolismo de las prostaglandinas y de otras respuestas inmunitarias.

El metabolismo de aminoácidos en el paciente quemado se caracteriza por una oxidación incrementada, síntesis de urea y degradación proteica prolongada y difícil de controlar mediante la terapia nutricional actual. Sin embargo, el propósito actual del soporte nutricional es optimizar la síntesis proteica. Pueden existir requerimientos específicos de glutamina arginina suplementarias en las quemaduras, pero se requieren investigaciones adicionales antes de poder recomendar suplementos enriquecidos con aminoácidos racémicos en los pacientes quemados. Recientes investigaciones han revelado la importancia de la alimentación enteral para estimular las defensas de la mucosa intestinal contra bacterias y endotoxinas. También hay investigaciones que han demostrado que muchas de las alteraciones metabólicas de las quemaduras y las sepsis pueden ser debidas, por lo menos en parte, a las citocinas inflamatorias. La investigación de su patogénesis y mecanismo de acción, tanto al nivel tisular como celular, ofrece perspectivas importantes de una mejor comprensión y de superior control terapéutico de las alteraciones metabólicas de los pacientes quemados.

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  1. Firefighters' Burn Treatment Unit, University of Alberta Hospital, Alberta, Canada

    Edward E. Tredget M.Sc., M.D. & Yong Ming Yu M.D., Ph.D.

  2. Massachusetts General Hospital, Boston, Massachusetts, USA

    Edward E. Tredget M.Sc., M.D. & Yong Ming Yu M.D., Ph.D.

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Tredget, E.E., Yu, Y.M. The metabolic effects of thermal injury. World J. Surg. 16, 68–79 (1992). https://doi.org/10.1007/BF02067117

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