The physiologic recovery trajectory as the organizing principle for the quantification of hormonometabolic adaptation to surgical stress and severe sepsis.
Preoperative and serial postoperative clinical, cardiovascular, physiologic, and metabolic studies were carried out on 86 patients undergoing coronary artery bypass surgery (CABG); and 48 patients undergoing abdominal general surgical procedures (GSEL). Multivariable statistical analysis of these data showed the patients to be in different physiologic states and to manifest several types of recovery trajectories that could not be discerned on clinical grounds alone. The CABG patients followed one of three types of cardiogenic recovery trajectories. In contrast, GSEL patients show a normal recovery trajectory different from all CABG types. When sepsis develops, and exaggerated stress response (A state) occurs, with increased oxygen consumption and a pattern of amino acids, fat, and glucose breakdown products, which is heightened but similar to the response of nonseptic GSEL patients. With progression of sepsis severity, an unbalanced hyperdynamic recovery trajectory (B state) develops in which a decrease in oxygen consumption is associated with increases in the aromatic amino acids tyrosine, tryptophane, and phenylalanine; and decreases in the branched-chain amino acids, leucine and isoleucine. Triglycerides rise as keto acids fall, but both lactate and pyruvate rise. Glucagon is persistently high, regardless of insulin levels. The quantifiably different physiologic recovery trajectories reflect altered hormone and metabolic states and imply different responses to therapy.