What occurs w/ the anticipatory response (cognitive anticipation of stress or trauma)?
Limbic system influences (via amygdala):
Brainstem (locus coeruleus)-> ↑d catecholamines
Prefrontal cortex signals the hypothalamus to ↑ secretion of CRH-> ↑ pituitary secretion of ACTH.
What factors are involved in the sequential physiology of pain (processes involved in pain).
Granulation & healing
Describe induction/transduction in regards to sequential physiology of pain.
Conversion of physical stimulus to nociceptive action potential via peripheral sensory neurons.
Describe inflammation in regards to sequential physiology of pain.
Leukocyte adhesion, diapedesis, mediator release
Complement, kinin, & coagulation activation
Arachidonic acid metabolites
Describe conduction/transmission in regards to sequential physiology of pain.
Nociceptive impulses are carried to CNS
Describe the nociceptive response to stress.
Arrival (in CNS) of nociceptive signals from PNS:
Pain impulses (c-fiber) ascend (via lateral spinothalamic tract) to thalamus triggers:
↑ hypothalamus release of CRH->release of pituitary hormones.
Hypothalamic signals to locus coeruleus-> ↑ production & release of NE.
Describe the inflammatory response to stress.
Tissue damage incites immediate production & release of inflammatory mediators:
Initiation of plasma defense systems: kinin, complement, coagulation
Leukocyte adhesion, diapedisis, & release of chemotactic factors & inflammatory mediators
Production & release of arachidonic acid metabolites.
Describe the endocrine response to stress.
↑ catabolic hormones
∆ in anabolic hormones
Describe what occurs w/ carbohydrate metabolism d/t the stress response.
Hyperglycemia, glucose intolerance, insulin resistance d/t
↑d glycogenolysis & gluconeogenesis
↓d insulin secretion & responsiveness
Describe what occurs w/ protein metabolism d/t the stress response.
Muscle protein catabolism, ↑d synthesis of acute-phase proteins
Describe what occurs w/ fat metabolism d/t the stress response.
↑d lipolysis & oxidation
Describe what occurs w/ fluid & e-lyte flux d/t the stress response.
H20 & Na retention, K excretion, ↓d functional ECF
Describe when & why hypercoagulability occurs d/t the stress response.
Throughout the peri-operative period-Virchow's Triad
How does pain and anxiety affect the surgical stress response?
What are the adverse effects of post-op pain on the pulmonary system?
Atelectasis, V/Q mismatch, arterial hypoxemia, hypercapnia, pneumonia
What are the adverse effects of post-op pain on the CV system?
HTN, tachycardia, myocardial ischemia, dysrhythmias
What are the adverse effects of post-op pain on the endocrine system?
Hyperglycemia, Na & H20 retention, protein catabolism, K wasting
What are the adverse effects of post-op pain on the coagulation system?
↑d platelet adhesiveness, ↓d fibrinolysis, hypercoagulability, DVT
What are the adverse effects of post-op pain on the GI/GU system?
Ileus (d/t ↑d sympathetic output), urinary retention
How do spinals & epidural affect the response to surgical stress?
Blunts peri-op stress hormones
Blunts metabolic response
How do spinals & epidural affect the fluid e-lyte shifts d/t surgical stress?
Complex relationship-↓ GFR; blunts stress hormones that cause Na & H20 retention & K excretion
How do spinals & epidural affect thermoregulation d/t surgical stress?
Vasodilation predisposes to hypothermia
How do spinals & epidural affect platelet aggregation d/t surgical stress?
Platelets-blunts ↑d aggregation (direct effects of LAs-inhibit ADP induced aggregation)
How do spinals & epidural affect factor VIII activity d/t surgical stress?
Inhibits increased activity.
How do spinals & epidural affect fibrinolytic activity d/t surgical stress?
Inhibits post-op inhibition
How do spinals & epidural affect plasminogen activity d/t surgical stress?
How do spinals & epidural affect inhibition of leukocyte adhesion d/t surgical stress?
Preservation of endothelial structure ↓ the inflammatory phase.
Degree of post-op immunodepression is correlated w/ the amount of surgical trauma rather than type of anesthetic (exception-thermoregulation)
What is the primary stress hormone?
What are the inflammatory mediators?
Interleukins (IL) & tumor necrosis factor (TNF)
What does the Virchow triad include?
2) Endothelial damage
3) Venous stasis
What are the catabolic hormones that are released by the endocrine system?
ACTH, cortisol, ADH, GH, catecholamines, renin, angiotensin II, aldosterone, glucagon, IL-1, IL-6
What are the anabolic hormone changes caused by the stress response?
insulin ↓s, testosterone ↑s
What factors are involved in glyogenolysis?
What factors are involved in gluconeogenesis?
Cortisol, glucagon, GH, epi, free fatty acids
What causes the ↑d synthesis of acute-phase proteins?
↑d cortisol, epi, glucagon, IL-1, IL-6, TNF.
What causes ↑d lipolysis & oxidation?
↑d catecholamines, cortisol, glucagon, GH
What causes H20 & Na retention, K excretion, ↓d functional ECF known as 3rd spacing & intracellular shift?
↑d catecholamines, aldosterone, ADH, cortisol, angiotensin II, prostaglandins
What is Virchow's Triad and what is involved?
Risk of thromboembolism & DVT
Fibrinolysis- ↑d intra-op, ↓d post-op
↑d platelet aggregation
What are the stress hormones that are blunted by spinals and epidurals?
Cortisol, RAAS, epi/NE, GH
What metabolic responses are blunted by spinals and epidurals?
What causes shivering?
Not necessarily d/t hypothermia:
Protective reaction to cold environment (vasodilated pt)
What is the locus coeruleus
A nucleus in the brainstem involved w/ physiologic responses to stree & panic.
With the anticipatory response to stress, how doe the prefrontal cortex signal the hypothalamus?
Via the thalamus.
What is ↓d functional ECF known as?
3rd spacing & intracellular shift
What innervates the kidneys?
In regards to perception, where is nociceptive info processed?
In the cerebral cortex prefrontal gyrus/cingulate gyrus.
In regards to modulation, where do interneurons modulate ascending impulses?
In the substantial gelatinosa/periaqueductal grey matter.
In regards to modulation how does descending modulation occur?
Via the corticospinal tract