REMEMBERING PROF. N.N. MAHENDRA BY HIS LECTURE ON SEPSIS

 

 

Prof. N.N. Mahendra was a Reader in the Department of Surgery, when we were students and later residents in Surgery. He was a thorough gentleman, and was always smiling and encouraging students. His lectures were very well curated, researched and organized. His bed-side teaching too was meticulous and very thoughtfully crafted. He was a stickler of correct illustration of physical signs and always ensured that every student under his care understood the significance of the sign and elicited it correctly. He was a very good examiner and would go an extra mile to get the correct answer out of the students, encouraging them at every step.

Prof. Mahendra was a very compassionate surgeon and his patients loved him. He had a palatial home in Mahanagar on Mandir Marg and had a small operating theatre there. I have had the privilege of assisting him in many surgeries in the private and he would refer all his Plastic Surgery cases to me, so long as he was in active practice. He was a very calm and level headed surgeon and so Prof. P.C. Dubey, Prof. R.P. Sahi and Prof. G.P. Agarwal would often request him to assist them in their private practice. His sense of timing of surgical intervention was outstanding and not withstanding how socially or politically influential the patient is, he never hesitated to operate if indicated. I distinctly remember a young Congress leader of Amethi, near Lucknow, close to the then Prime Minister of India, was involved in a pre poll violence in 1989 and was shot in abdomen. He was brought in shock, pulseless and gasping. Any other surgeon would have thought twice before accepting to be his surgeon, but Prof. Mahendra did not hesitate for a moment. He immediately took him to the theatre, opened the abdomen and stopped the source of bleeding, thus saving the young politician’s life. He was later sent by the government to some N.H.S hospital in the U.K. for recuperation.

Prof. Mahendra was very helpful to his post graduates and thesis under him was most sought after. Residents in his team had the opportunity to treat a wide variety of surgical cases, and he saw to it that every resident was getting something to do in the O.T, depending on their proficiency and seniority. It was very easy to know how he was feeling about a student / resident / patient – if he was happy, he would address the person as ‘dear’ and if he was not then as ‘master’. So, it would be “Very nice, dear” or “No master, not like this”. Every surgeon has some peculiar choices of instruments, gadgets and procedures. Prof. Mahendra loved the Mallecot catheter. After a bladder or urethral surgery, he would never use the Foley catheter or the K-90; it was always the Mallecot catheter. The sight of the Mallecot being pulled out of the penis with a jerk, still sends shudder down my spine, but he always insisted that if it is prior lubricated with local anaesthetic Xylocaine jelly, it was a painless procedure!

I will now share with you a lecture, which he gave to our class in 1978 on Sepsis.

 

When we have an infection, our body works constantly to protect us from it. Antibiotic or anti-viral drugs are sometimes needed, but unfortunately, the fight against bacteria and viruses is not always simple. When the infection is not properly treated and is out of control, immune system activity can go awry, leading to sepsis - a life-threatening condition in which the body harms itself to protect its organs. As doctors, it is highly recommended that you familiarize yourself with the dangers of the condition and its symptoms so that you can offer  medical help right away as soon as you notice it, as this may be life saving

 

Definition

Sepsis is your body’s extreme reaction to an infection. When there is an infection, the immune system works to try to fight it. But sometimes the immune system stops fighting the infection and starts damaging your normal tissues and organs, leading to widespread inflammation throughout the body.

At the same time, an abnormal chain reaction in the clotting system can cause blood clots to form in the blood vessels. This reduces blood flow to the different organs of the body and can cause significant damage or even failure.

 

A typical patient

Though sepsis can affect anyone, but people with any kind of infection, especially bacteremia, are at a particularly high risk. These are

·        Age above 65

·        Pregnant

·        Co-morbidities – diabetes, cancer, obesity, kidney disease

·        Immuno-compromised – on Cortisone or chemotherapy

·        Hospitalized patients

·        Severe injuries / large burns

·        Have indwelling catheters, tubes

·        Have suppurative infections

 

 

Why is sepsis so dangerous?

If you don’t treat sepsis, it can cause septic shock, which is an advanced state of infection in the body that causes very low and dangerous blood pressure.  When the body is in a state of septic shock, it's very difficult to improve blood pressure with intravenous fluids alone. This in turn means that it is very difficult to regain proper blood flow to the organs needed to keep them functioning. The vital organs of the body, the brain, the heart, the liver and the kidneys are at grave risk. Sepsis soon leads to septic shock.

 

Causes of Sepsis

Sepsis can be the end result of any infective condition - pneumonia, appendicitis, urinary tract infections, and cellulitis. When an offending organism, a bacteria, invades the body, the immune system of the body, the lymphocytes from the Reticulo-endothelial system, challenge it. When the host immunity gets the better of bacteria the host is cured, but when the virulence of the organism gets the better of the host resistance we get infection and, if it still remains unchecked, then bacteremia, septicemia and sepsis.

 

Symptoms

Symptoms of sepsis are very similar to those of septic shock and both go hand in hand, so if you come across a combination of the following symptoms in your patient, it is highly recommended that you diagnose sepsis and initiate lifesaving treatment.

1. Cold, clammy skin - When the body experiences sepsis, it focuses on sending blood to the most vital organs, such as the heart, kidneys, and brain, then to less important areas like the skin. However, remember that skin that feels cold and clammy to the touch is a symptom of many diseases, some of which are less dangerous - this is a sign of concern only if you also experience other symptoms of sepsis or you have a significant infection.

2. Decreased volume or dark colored urine - The kidneys are the most severely affected organs during sepsis because they are sensitive to any change in blood flow and pressure. Therefore, the effects of this condition can often be seen in the urine. When the body senses that its blood pressure is low, it tries to store as much fluid as possible, which leads to decreased urination or dark colored urine. So, oligurea in sepsis is more than just dehydration.

3. Changes in mental state - Confusion, low alertness, and dizziness or agitation can all be the result of too little blood in the brain, dehydration, and toxins that enter the body and contaminate it. If your patient experiences septic shock, all of these symptoms will appear, but by this time the diagnosis is very late. Sepsis is better prevented than treated. These symptoms must occur with infection for them to be treated as symptoms of sepsis, as these are also common symptoms of a stroke.

4. Increased heart rate - In the case of sepsis, your patient will not only experience an accelerated heart rate, such as after a morning run, but he/she will feel that his/her heart is pounding even while relaxed. The average pulse at rest is 60-90 beats per minute, and over 90, it may be a sign of sepsis. When afflicted with sepsis the body increases heart rate to improve circulation and prevent tissue damage.

5. Difficulty breathing - If your patient does not have a medical condition that causes breathing difficulties, he/she may have sepsis. Hyperventilation and shortness of breath are often encountered. As in the case of the previous symptom, this symptom is also caused by the body's need to pump more blood into its organs, in which case it is important to enrich the blood with oxygen. Because of this, the body tries to breathe faster, which causes unpleasant feelings such as difficulty breathing, or dyspnea. Some patients develop shortness of breath that makes it hard to keep a healthy breathing rate.

Other symptoms can be:

·        Small dark red spots o the skin

·        Oliguria

·        Hypotension

·        Fever or Hypothermia

·        Chills and rigor

·        Extreme pain and discomfort

 

Investigations

A combination of findings — from a physical exam, lab tests, X-rays and other tests — to identify the infection is necessary. Increased total count, above 10,000/cu mm and with more than 80% polymorphs gives a strong indication. Bacterial cultures from wound, blood, urine can diagnose both the offending organism and the antibiotics to which it may be best sensitive. X. Ray of Chest to rule our pneumonia and urine examination to diagnose urinary track infection is routinely done. Serum electrolytes, Serum Urea and Creatnine, and coagulation profile also assist in diagnosis.

 

Treatment

You shouldn't delay treatment as sepsis causes damage to the body that can develop and worsen over a few hours. The faster you treat it, the more your patient’s body will prevent injuries that will worsen his/her health later in life. While the treatment varies from person to person, it is usually an aggressive process because quick action is needed.

1.      Antibiotics – a broad spectrum one to start with to cover both gram positive and gram negative bacteria and anaerobes

2.      I.V. fluids – to maintain hydration and blood pressure so that vital organs are not starved of blood

3.      Vasopressors: These will prevent peripheral pooling of blood and help to maintain blood pressure

4.      Appropriate supportive care like Ventilation and Dialysis

5.      Surgery – If sepsis is caused by an infection that can be surgically addressed like incision and drainage of an abscess, putting an intercostal drainage catheter with under water seal to drain our empyema thoracis, or putting drains in abdomen to drain septic peritonitis, then the patient’s condition can rapidly improve.

6.      Blood transfusion – Fresh blood, rich in clotting factors and platelets can address the abnormal bleeding tendencies.

 

Treatment outcome

With timely and quick diagnosis and treatment, many people with mild sepsis survive. Without treatment, most people with more serious stages of sepsis will die. Even with treatment, 30% to 40% of people with septic shock, the most severe stage of sepsis, will die. Septic shock can cause death in as little as 12 hours.

With prompt treatment, many people with sepsis recover completely and return to leading normal lives. But others may experience long-term effects. They  may develop complications such as:

·        Insomnia

·        Nightmares and hallucinations

·        Panic attacks

·        Joint and muscle pain

·        Decreased cognitive functioning – learning, remembering, concentrating, decision making

·        Organ failure

 

Sepsis occurs when your patient’s immune system has a dangerous reaction to an infection. It causes extensive inflammation throughout the body that can lead to tissue damage, organ failure and even death. Many different kinds of infections can trigger sepsis, which is a medical emergency. The quicker you receive treatment, the better your outcome will be. When it comes to sepsis and septic shock, remember that early detection is the most important thing in order to get the best treatment for your patient.

Thus ended Prof. Mahendra’s lecture on Sepsis.