A BI - MONTHLY NEWSLETTER OF INDIAN SOCIETY OF CRITICAL ... · Dr. Deepak Govil, President - Elect, ISCCM, Chairman, Scientiﬁc Committee, Criticare 2021 Director Critical Care Medanta

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A BI - MONTHLY NEWSLETTER OF INDIAN SOCIETY OF CRITICAL CARE MEDICINE

VOLUME 15.3 MAY - JUNE 2020

www.isccm.org

th

ANNUAL CONFERENCE OF INDIAN SOCIETY OF CRITICAL CARE MEDICINE

CRITICARE 2021 - AHMEDABAD

CRITICAL CARECOMMUNICATIONS

WELCOME TO CRITICARE 2021

AHMEDABAD

TH THWORKSHOP: 24 - 25 FEB 2021TH TH

CONFERENCE: 26 - 28 FEB 2021VENUE: MAHATMA MANDIR CONVENTION AND EXHIBITION CENTRE

THEME SAFETY AND EFFICIENCY

AMIDST RESOURCE LIMITATION

CONTENTS Editorial Office

Dr. Deepak Govil, President - Elect, ISCCM,

Chairman, Scientific Committee, Criticare 2021

Director Critical Care Medanta The Medicity, Gurgaon

Mobile: + 91 9818056688

Email: [email protected] ,

[email protected]

Address: B-8/6137, Vasant Kunj, Delhi

Published By :

Indian Society of Critical Care Medicine

For Free Circulation Amongst Medical Professionals

Unit 13 & 14, First Floor, Hind Service Industries

Premises Co-operative Society, Near Chaitya

Bhoomi, Off Veer Savarkar Marg,

Dadar, Mumbai - 400028

Tel. 022-24444737, Telefax: 022 - 24460348 •

Email: [email protected]

1. Editorial

2. Message from the President

3. Message from the General Secretary

4. Editorial Board Critical Care Communications 2020 - 2021

5. Election Result 2020

6. ISCCM Activities

7. ISCCM Branch Activities

8. New Normal Intensive Care Unit - Learnings from COVID-19

9. Ethical and social issues related to COVID-19 Pandemic

10. Challenges of manpower planning during current COVID-19 pandemic

11. R and Re of COVID-19: Can we predict when the pandemic outbreak will be over?0

12. Lockdown exit: evolving practices for safe pregnancy and childhood

13. Dilemma of research in COVID era

14. Monitoring of COVID -19 patients at home

15. Risk factors and epidemiology of multidrug resistant acinetobacter infections

among critically ill adult patients admitted in medical intensive care unit

16. Journal Scan

17. Innovations in Critical Care

18. Quiz Section

19. Answer to the quiz March - April 2020

20. Ensuring safety at every stage for CRITICARE 2021, Ahmedabad

Editorial...TM

www. .orgisccm

Dear Friends

I sincerely thank everyone for the overwhelming response

and suggestions about previous two editions of Critical

care communication. As expected, the cases of COVID-19

are skyrocketing in many parts of the country. Situation is

particularly concerning in Metropolitan Cities where

authorities have resorted to open makeshift hospitals.

Despite this, situation concerning the bed availability is

grim in most of the hospitals. Additionally, limited

availability of Critical care beds and trained staffs can’t be

overemphasised. Despite of many limitations health care

workers are doing exemplary job under stress and deserve

standing ovation for their efforts. Intensivists are the shining light and backbone of healthcare force

in the management of this pandemic. Many healthcare workers including intensivists have

contracted the disease and sacriced their life while performing the seless duty. We are indebted

to them and shall never forget their contribution in service of nation.As most of the places have already opened for economic activities, it’s an extremely challenging

time for the government as well as common people. Opening the lockdown during the height of

pandemic can bring disastrous consequences if not managed properly. It’s extremely important for

the common public to follow the rules of social distancing and other preventive strategies.

Simultaneously government must escalate the test, trace and isolate strategy and ensure adequate

number of beds to curb the surge. In the present issue of critical care communication, we have focussed on many incumbent issues

related to COVID-19. Theses relevant topics can be extremely useful to health care workers for

their day to day management of patients. I would like to thank all of you again for your efforts.“The greater the obstacle, the more glory in overcoming it.”Jean-Baptiste Poquelin (Molière)

Dr. Deepak GovilMD, EDIC, FCCMPresident - Elect, ISCCM,Chairman, Scientic Committee, CRITICARE 2021Director, Critical Care, Medanta The Medicity, GurgaonEmail: [email protected] , [email protected]: +91 9818056688

THE CRITICAL CARE COMMUNICATIONS »

A BI-MONTHLY NEWSLETTER OF INDIAN SOCIETY OF CRITICAL CARE MEDICINE

President’s DeskTM

www. .orgisccm

Dear friends

Last few months have been roller coaster testing physical, mental &

emotional endurance of individuals irrespective of profession they are

in but more so of health care workers. COVID has proven to be

disrupter of old order be it social, economic or practice of medicine.

COVID story in India is a mixed lot; affecting primarily urban India- the

areas where swine u caused havoc in the past & also states like Kerala

& Goa with minimal effect thanks to excellent public health response &

measures. It has re-emphasised the signicance of basics of hygiene,

practice of medicine including critical care & importance of uncertainty

of medicine & art of probability. COVID is as much saga of valour of men & women in white coats as is

of nurses. In-spite of grave personal threat, residents & younger

colleagues have led from the front. It’s the time when we from net

importers of PPE have become exporter of high-quality PPE; the

transition over weeks has been amazing testifying the strength & resilience of mankind. The diagnostic network

expanded to such an extent that today we are doing more than 2 lakh tests (RT PCR) a day. Biggest challenge

encountered has been of infection control both in COVID & Non COVID areas, however it is the latter which is a far

bigger challenge.Challenges continues to be enormous. We have to adapt to the change, develop new protocols & continue to be on

guard. We are still struggling to nd right treatment, right timing & right strategy for management. Reams of pages are

being published on COVID19, leading to information toxicity; we need wisdom to decipher right knowledge from this

ocean.Circulation & spread of negative news with half-baked information on social media has created an environment of fear

& despondency among medical professionals. I never saw this in my career spanning over 30 years, where otherwise

rational professionals just deserted or melt away. I saw & observed stigmatisation & social ostracisation of health care

workers & patients, adding to the misery leading to rise of emotional & psychological issues.However, the silver lining has been self-recovery of nearly 90% of patients & also of majority of rest, if we identied

the complications right at the onset & treat them aggressively. COVID epidemic has brought intensivist to the

centerstage. It has added to our responsibilities and role in clinical management to provide seamless care starting from

pre-emergency, emergency, intensive care, post ICU care & rehabilitation. To deliver, we need leadership, training,

team work & adaptation, all being the hall mark of Intensivist. In view of protean manifestations & to share

responsibility in decision making, we need multidisciplinary teams to improve outcomes. Latter is even desired by

Honourable Supreme Court.Friends, the biggest casualty during these 4 months has been the care of non COVID & of COVID suspect patients.

We have to nd ways to provide continuous care to them, without fear, following all infection control practices as this

is the area most vulnerable for spread.I salute you all for doing seless service to mankind in-spite of grave personal threat. We as an intensivist, must

continue to provide quality & safe critical care services to our patients. Stay safe, stay mentally strong & look after yourself

Best wishes & regards

Dhruva ChaudhryMD(Med.), DNB (Med.), DM(PCCM), FICP, FICCM, FNCCPPresident, ISCCMOrganizing Chairman, CRITICARE 2021 Professor & Head PCCM, PGIMS, RohtakDean Medical Super-SpecialtyPT.B.D.S University of Health Sciences, RohtakEmail: [email protected]: +91 94160 51616



General Secretary's DeskTM

www. .orgisccm



Dear Friends,Hope this message nd you in good health and spirit. The

pandemic has really stretched the resolve and the

resources of the Critical Care community. The preparations for the Criticare 2021 have been

hampered and slowed down by the pandemic and the

subsequent lockdowns. However, the organizing team is

quite optimistic and hopeful of going ahead with the

conference on schedule. Several meetings with the event

management team and the venue team have reinforced our

condence. All due precautions are being put in place and

several pro active steps are being taken to make it a safe

meeting.

In due course the scientic committee will be sketching out the agenda and the same will be

shared with all of you. The strength of the meeting has always been its scientic content and the knowledge of the faculty.

These core points will be kept in focus while designing the program. While it is a fact that several

international stalwarts might be unable to travel due to local restrictions, the conference will not

be deprived of their knowledge and contribution. Parallel work on a hybrid conference where

online talks will be interspersed with platform lectures is also on.

The organizing team is working hard to ensure that the commitment of a good CRITICARE is

fullled and delivered to the members. With all your support, we hope to overcome the pandemic

and the obstacles it has created. We are sure of coming out successful and with ying colours.

CheersBe Safe

Dr. Srinivas SamavedamMD, DNB, FRCP, FNB, EDIC, FICCM, DMLE, MBAGeneral Secretary, ISCCMOrganising Secretary, CRITICARE 2021Head, Critical Care, Medical Director Virinchi Hospitals, HyderabadEmail: [email protected]: +91 98663 43632

EDITORIAL BOARD CRITICAL CARE COMMUNICATIONS 2020 - 2021

Dr. Anuj ClerkMD,IDCCM,FNB Critical Care EDIC,FIECMO

Head, Intensive Care Services

Sunshine Global Hospital, Surat


Mob: 7574851424

Dr. Mozammil ShafiMD, FNB, EDIC

Consultant, Critical Care Medicine

Medanta The Medicity, Gurugram


Mob: 9599557808

Dr. Vinay SinghalMD

Additional Director & Head Department of

Critical Care Medicine Fortis Hospital, Ludhiana


Mob: 9915285833

Dr. Asif AhmedDNB (Gold Medal) Anaesthesiology, IDCCM

Sr. Consultant & Head of Department

Dept of Critical Care Medicine

Tata Main Hospital, Jamshedpur


Mob: 9204657195

Dr. Khalid KhatibM.D. (Medicine), FICCM, FICP.

Professor, Department of Medicine,

Smt. Kashibai Navale Medical College,

Narhe, Pune, Maharashtra, India


Mob: 9822091745

Dr. Rajesh Mohan ShettyMBBS, FRCP(Edinburgh), FRCA(UK), FCICM(Aus&NZ)

FFICM(UK), FICCM(India)

BSE Accreditation (Transthoracic Echocardiography)

Chief of Clinical Services and Lead Consultant in

the Department of Critical Care Medicine

Manipal Hospital Whitefield, Bengaluru


Mob: 9886660477

Dr. Prashant NasaMD, IDCCM, FNB(Critical Care)

FICCM, EDICM, RCP-SCE(Acute Medicine) CIC

Head of Critical Care Medicine

Head of Infection Control and

Antimicrobial Stewardship

NMC Speciality Hospital, Dubai (UAE)

Dr. Deepak GovilMD, EDIC, FCCM

Director, Critical Care, Medanta The Medicity, Gurgaon

Email: [email protected] | Mob: 9818056688

EDITOR IN CHIEF

ASSOCIATE EDITORS

EDITORIAL BOARD



EDITORIAL BOARD CRITICAL CARE COMMUNICATIONS 2020 - 2021

JOURNAL SCAN

Dr. Kapil Dev SoniMD

Additional Prof.Critical & Intensive Care

JPN Apex Trauma Centre AIIMS,New Delhi


Mob: 9718661658

Dr. Sai Saran PVMD, IDCCM, DM, EDIC

Assistant Professor,

Department of Critical Care Medicine

Superspeciality Cancer Institute & Hospital,

CG City, Lucknow, UP


Mob: 8004505719

Dr. Anand GuptaDA, IDCCM, IFCCM, EDIC

Senior Consultant,Head Surgical and

Transplant Critical Care

AIG Hospital, Gachigowli, Hyderabad


Mob: 9313392757

Dr. Bikram GuptaMD, PDCC (CCM), EDIC (UK), FACEE - India

Associate Professor

Division of Critical Care Medicine

Dept of Anaesthesiology & Critical Care

IMS, BHU, Varanasi, Uttar Pradesh


Mob: 8400100128

Dr. Hrishikesh JhaDA, PGDDC

Senior Consultant and Head - Critical Care

Gurunanak Hospital and

Research Centre, Ranchi


Mob: 9471710607

Surg Ltd Cdr

(Dr) Abdul NasserMBBS, DNB (Anaesth)

Anaesthesiologist, Indian Navy

INHS Jeevanti, Goa


Mob: 9560837993

QUIZ SECTION

IMAGES SECTION



CONDOLENCE

DR. PANKAJ SHAH

The ISCCM pays its homage

to one of its members Dr Pankaj Shah

who laid down his life fighting the Pandemic.

We pray for the solace of his family.



ELECTION RESULT 2020

Dr Rajesh Chandra Mishra

(Elected unopposed)

PRESIDENT ELECT

Dr Srinivas Samavedam

(Elected unopposed)

VICE PRESIDENT

Dr Rajesh Pande

(Elected unopposed)

GENERAL SECRETARY ELECT

Dr Bharat Jagiasi

(Elected unopposed)

TREASURER

Dr Suneel Garg

(Elected unopposed)

ZONAL MEMBER

Dr Ahsan Ahmed

(Elected unopposed)

NORTH ZONE EAST ZONE

ISCCM



ELECTION RESULT

Dr Mohan Maharaj

(Elected unopposed)

Dr Gunjan Chanchalani

(Elected)

SOUTH ZONE WEST ZONE

ISCCM

ICCCM

Dr Pradip Kumar Bhattacharya

(Elected unopposed)

VICE CHANCELLOR

Dr Shyamsunder Tipparaju

(Elected unopposed)

SECRETARY ELECT – NURSING

2020



INTERVIEW

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ONLINE QUIZ

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th

ANNUAL CONFERENCE OF INDIAN SOCIETY OF CRITICAL CARE MEDICINE

CRITICARE 2021 - AHMEDABAD

TH27 ANNUAL CONFERENCE OF INDIAN SOCIETY OF CRITICAL CARE MEDICINE

th th th thWorkshop: 24 - 25 Feb 2021 | Conference: 26 - 28 Feb 2021 | Venue: Mahatma Mandir Convention and Exhibition Centre

Theme : Safety and Efficiency Admist Resource Limitation

QUIZ 1QUESTION ANSWER

QUIZ 2

Who invented this machine ?

QUESTION ANSWER

PURPURA FULMINANS

The "Iron Lung”, often referred to in the early days as the

"Drinker respirator", was invented by Philip Drinker and Louis Agassiz Shaw,

Jr., professors of industrial hygiene at the

Harvard School of Public Health.

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ISCCM BRANCH ACTIVITIES

HYDERABADWe from “THE CITY OF PEARLS” {Hyderabad} conducted our academic activities for students of Hyderabad as well as across India as a part of academic

webinar series. Lectures were delivered by eminent local {Hyderabad} Critical care teachers as well as renowned national ISCCM faculty with a key point of

delivering fundamental {foundation} knowledge of critical care medicine during the difcult times of COVID-19



NAGPURWebinars

Topic Date Speakers Name Moderator

Role of cyclines in ICU 17th June 2020 Dr Nikhil Balankhe ,Dr Deepak Jeswani , Dr Swapna Khanzode Dr Tushar Pande

Arterial blood gas analysis 28th June 2020 Dr Pradeep Mishra, Dr Anant Singh Rajput Dr Imran Noormohammed

In association with AMF ( Association of medical faculties Nagpur ) on COVID- 19 updates . 28th June 2020 Dr Jayesh Timane, Dr Deepti Chand Dr Sudhir Chae

Fluid and electrolyte 4th July 2020 Dr Nikhil Balankhe, Dr Jayesh Timane Dr Imran Noormohammed

Case discussions on Sodium Imbalance in ICU 11th July 2020 Dr Jayesh Timane

Webinars

Topic Date

Hyderabad Executive committee meeting 10th May 2020

COVID 19 - ICU Healthcare workers 22nd May 2020

Infectious diseases in critical care medicine 29th May 2020

Neuro Critical care medicine 5th June

NEW NORMAL INTENSIVE CARE UNIT - LEARNINGS FROM COVID-19

Healthcare is science which evolves from its experiences. In 1981, Human immunodeciency viruses (HIV) was discovered and there

was surge of cases. A series of reforms in healthcare took place like universal precautions and emergence of single use needles. The

pandemic of COVID-19 and its rapidly growing magnitude in last six months is one such event which is likely to change healthcare

signicantly. The infectious epidemics or pandemics are not new to mankind but their impact on public health and global economy still

makes the “paramount challenge” to our species and its existence. The response of pandemic has already caused major shifts in

healthcare systems including designing, construction and renovation of existing healthcare facilities, the optimum utilization, training of

healthcare workers and prioritizing resources and supply-chain management including personal protective equipment (PPE), triage and

rationing critical care equipment’s and nally building of teamwork for disaster management. This article focuses on what should be the

learnings from COVID-19 pandemic especially when we trying to achieve coexistence with this novel coronavirus, SARS-CoV-2.

Infrastructure changes

The healthcare will be the primary focus in response to COVID-19 for next 18 to 24 months till an effective vaccine or herd immunity is

achieved. The countries globally will implement phased restrictions and relaxations to control the transmission of SARS-CoV-2, along

with identifying and isolating cases, testing and quarantine contacts. The success of humans against this or future pandemic will be

determined by their ability to develop resources quickly and effectively, adjusting to the next normal, dealing with a specic set of new or

accentuated challenges, and learning from the previous experiences.

Hospitals need to be more exible in construction and designs which can help in expansion of isolation facilities including within ICU. The

design of cubicles within ICU should be based on separate heat ventilation and air conditioning units (HVAC) with fresh air exchange and

provision for negative or positive isolation if required. The staff safety with separate corridor for work, entry, donning and dofng of PPE

must be considered in all future designs of ICU (Figure 1). The ICU physicians should be actively involved into ICU designing and staff

should be regularly trained and audited on Infrastructure monitoring. A blueprint should be kept available in case a rapid scale up of the

infrastructure including isolation rooms is required in response to surge with enough staff training. There should be provision of safe

monitoring and management of these patients with minimal interaction of HCW and patients. The availability of remote access to

ventilator, patients’ monitor, and infusion pump is another important which must be acquired with advance technology.

There is also need of central pooling of resources like ICU bed capacity. These central hubs with pool beds and resources may rationalize

the available care, concentrating expertise and can be economically sustainable too. The Public hospitals or private healthcare providers

with greater footprint in the community can start with these central hubs and can also leverage remote monitoring technology to link

smaller feeding units.

Virtual Care

The conventional Intensive care is face-to-face interaction of patient and doctor. Intensivists are always being encouraged for bedside

presence and decision-making. COVID-19 has unmasked many such visits unnecessary and likely unsafe. The telemedicine integrating

technology with patient monitoring and management using real-time audio, visual and electronic health information has already been

available. The outreach however over the past two decades has been painfully slow toward regularizing virtual care, and other web-

based care. The COVID-19 virus has changed that in weeks. The virtual care at scale would reduce face-to-face time in ICU for only

necessary interaction and to be used for the patients who will truly benet from it. It would also extend the outreach of Intensivist and

intensive care to semi-urban and rural areas. The same can also be used for safe management in case of pandemic situation with

reduction in risk of occupational hazards. The Virtual screen can also help in family 24X7 available for the patient to help in emotional

support, rehabilitation, and take joint decisions about patient care. Staff- Training and Preparation

The Pandemic of COVID-19 has already realized the governments across the world about urgent need of trained health care

professionals and resources like ventilators and medications along with signicance of extensive research and development in medicine

and human health. We are planning to go beyond our planet in 21st century, however we were caught unprepared for our real health

threats. The preparedness for such future threats is crucially based on a robust public health system. The same has either never been

allowed to evolve or has eroded globally because of capitalism and social inequality.

Dr. Aanchal SinghDepartment of Critical Care Medicine,

NMC Specialty Hospital, Dubai.

Dr. Ruchi NasaLab Director and Co-Chair Infection Control

Medeor 24X7 Hospital, Dubai.

Dr. Prashant NasaDepartment of Critical Care Medicine,

NMC Specialty Hospital, Dubai.




The HCW in the time of crisis are not only physically, socially and psychologically challenged but also get overwhelmed easily. The

versatile training of HCW must be continued with refresher training and regular posting in other areas. The staff not only in ICU but

also other staffs in the hospital must be regularly trained to work on ventilators and in critical areas so that they can be quickly

assigned in these areas when need arises. Periodic training and competency assessment are to be provided to all HCWs about

appropriate use of PPE, infection control and safe provision of respiratory support to patient.

Regular drills and exercise of disaster planning, stafng skills review and relocation, optimization of available resources must be

done.

SURGE PLANNING

Surge planning is critical for the successful public health response to any pandemic. SARS-CoV-2 infection is different from

Inuenzae in terms of higher infectivity, longer incubation period and duration of illness. This epidemiology of the disease has

inundated healthcare globally including developed nations. The overwhelming of resources is not only direct hazard to healthcare

workers in terms of physical, social and emotional turmoil but also linked to higher mortality among patients.

Surge planning should be integral part of disaster management of future and it will require liaison of public and private resources

including healthcare workers.

The surge planning should be available for every unit in the hospital. The HCWs especially nurses in progressive care units, like

ward, out-patients department and stepdown units such as the post- anesthesia care unit, cardiac catheterization lab,

electrophysiology lab, should be identied, periodically trained, posted and assessed for competency. They should ne second line

which can be posted in critical areas at the time of surge. The supply-chain management should be strengthened, and surge planning

must include back-up of critical supplies with liaison of nearby healthcare facilities. Close attention to the supply-chain is needed

given the global shortage of medical masks and respirators and disruption of transport in case of pandemic. The alternative plan and

rationing of resources with monitoring of supplies of PPE to HCWs, emergency workers and general public is required.

INFECTION CONTROL

There has to be more fundamental changes in infection prevention and control practices in healthcare. The training should be

systematic and must include periodic competency assessment, mandatory compliance and integration of technology and articial

intelligence (AI). The Infection control itself need redesigning with alignment of its goal along work processes, relook of hospital

systems and engineering controls, and provision of timely information on suitable equipment and materials to limit the nosocomial

transmission of infection to HCWs. Regular drills on hospital preparedness for communicable diseases and sharing the data among

HCWs among latest outbreaks using close loop chain of communication will be main focus in near future. Use of adequate

ventilation systems and effective environmental decontamination will physically reduce exposure to infection by controlling

exposure of infection at the point of source

The future hospital planning must include infection control professional in core architectural designing and modications like ICU

cubicles having dedicated air handling units and provisions to rapidly convert existing rooms to negative pressure isolation rooms.

The stafng of the hospital and ICU should be based on acuity, exibility and standard of care with provisions for sick staff and

reserve pool staff. The annual budgeting and cost-efciency studies of the future hospitals must include pandemics response and

preparedness.

The interim infection control polices developed during this pandemic should be reviewed and developed into pandemic response

blueprint. The new evolved understanding about transmission of infection from transfer of patients among different units in hospital,

exchange of items like stationaries and consumables, risk of aerosol generating procedures should be validated with scientically

appropriate research and must become part of routine infection prevention practices. The technology must focus on developing

medical consumables especially used in ICU to reduce cross-transmission. The infection control professionals must work closely

with Intensive care staff in reviewing and developing policies on safe use or reuse of these consumables.




This pandemic has realized long-forgotten interest on public hygiene. The principles of social distancing, masks, hand hygiene and

other public hygiene measures are likely to be new normal to reduce spread of many other infectious diseases. The post COVID-19

hospital infrastructures must incorporate these changes into long term planning in order to curb the hospital being hotspots of

infection. The ICU staff, patients and visitors need to be reinforced about This pandemic has realized long-forgotten interest on

public hygiene. The principles of social distancing, masks, hand hygiene and other public hygiene measures are likely to be new

normal to reduce spread of many other infectious diseases. The post COVID-19 hospital infrastructures must incorporate these

changes into long term planning in order to curb the hospital being hotspots of infection. The ICU staff, patients and visitors need to

be reinforced about meticulous and mandatory hand washing techniques and use of technology for real-time monitoring of the

same. Same efforts are required for proper donning and dofng of PPEs, equipment decontamination and waste handling. This new

normal ICU must continue to have donning and dofng area with personal hygiene post shift for the HCWs. The aerosols are

infective and use of antimicrobial lters for equipment’s used in this pandemic are likely to be continued post COVID-19. The

doctors and staff in ICU also need to continue the train in infection control skills during aerosol generating procedures in

preparedness for future pandemics. Greater attention is required by ICU physicians in understanding infection control with

different medical equipment’s use and management of safe handling of reuse devices between patients. A closed ventilation system

with inline nebulisation and suction is useful in preventing aerosols spread and also prevention of ventilator associated pneumonia.

Ventilator circuits should not be broken unless necessary and there should be only minimal disruption of circuits if at all required for

transfer.

Critical care Triage

The importance of early recognition of the critically ill patient and immediate attention is well ingrained among intensivists and

emergency physicians. We pride ourselves to provide best and safe care to everyone in need. This pandemic however unfortunately

forced us to triage critical care resources based on age and other factors. The idea of triage of resources to a human by another

human based on selected few physiological variables is not only emotionally challenging but also invariably evoke huge criticism in

public. The validation of critical care triage by well conducted research and awareness of general public is the need of hour. These

require designated zones for transport of patients, sufcient supplies of ICU and emergency beds, medical equipment including PPE,

along with adequate staff and their training.

The triage of resources at time of pandemic should not only be based on age but frailty and quality of current life and support system

post discharge. The triage should be dynamic and should not only at entry but also after 48-72 hours to assess the response and

continuation of treatment. The end-of-life decisions are difcult and pathway for such decisions should be designed and tested

during and after pandemic.

Protocols for timely available and freeing of resources after use should be developed. Early extubation from invasive mechanical

ventilation to reduce the incidence of ventilator-associated complications and ventilator availability for next patient. This must be

balanced against the risks of premature extubation(especially without facilitative post-extubation NIV and HFNC) and risks of

subsequent re-intubation further worsening prognosis.

Legend for Figure 1:




Organization of the intensive coronavirus unit.

In red: isolated areas where full personal protection equipment is mandatory; in yellow: contaminated anteroom; in green: clean

areas. Smaller Red: buffer zone for suspected patients. Double black arrows with dotted line: self-sliding doors, Black dotted line:

glass wall; white arrows: healthcare providers’ path to enter the unit; red arrow: patients’ path to enter the unit.

REFERENCES:

1) https://hhbc.in/icu-design-of-the-future-icu-planning-and-designing-2

2) CHEST GUIDELINES AND RESOURCES Anne Marie Martland, MS, ACNP-BC; Meredith Hufnes, MS, BA, RN; and Kiersten

HenrySurge Priority Planning COVID-19: Critical Care Stafng and Nursing Considerations

3) Centers for Disease Control and Prevention. Public Health Emergency Preparedness and Response Capabilities: National

Standards for State, Local, Tribal, and Territorial Public Health. Atlanta, GA: U.S. Department of Health and Human Services; 2018

4) Xie J, Tong Z, Guan X, Du B, Qiu H, Slutsky AS. Critical care crisis and some recommendations during the COVID-19 epidemic in

China. Intensive Care Med. 2020 doi: 10.1007/s00134-020-05979-7.

5) Centers for Disease Control and Prevention Strategies for optimizing the supply of n95 respirators: crisis/alternate strategies.

March 17, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html

6) COVID-19: infection prevention control guidance :PHE publications gateway number: GW-1250,PDF, 525KB, 56 pages

7) Liew, M.F., Siow, W.T., Yau, Y.W. et al. Safe patient transport for COVID-19. Crit Care 24, 94 (2020).

https://doi.org/10.1186/s13054-020-2828-4

8) Pan L, Wang L, Huang X. How to face the novel coronavirus infection during the 2019-2020 epidemic: the experience of Sichuan

Provincial People’s Hospital. Intensive Care Med. 2020. 10.1007/s00134-020-05964-0.

9) Phua J, Weng L, Ling L, et al. Intensive care management of coronavirus disease 2019 (COVID-19): challenges and

recommendations

10) Bouadma L, Lescure FX, Lucet JC, Yazdanpanah Y, Timsit JF. Severe SARS-CoV-2 infections: practical considerations and

management strategy for intensivists. Intensive Care Med. 2020;46:579–582.

11) O Rosenbaum L. Facing Covid-19 in Italy—ethics, logistics, and therapeutics on the epidemic’s front line. N Engl J Med 2020;

published online March 18. DOI:10.1056/NEJMp2005492.



ETHICAL AND SOCIAL ISSUES RELATED TO COVID-19 PANDEMIC

Ethical issues in COVID-19

1The pandemic outbreak of COVID-19 we are in the midst of, has no effective vaccine and very little treatment. Given the lack of pre-

existing immunity, it is likely that a considerable percentage of the population will get affected, and may at some point require, medical 2 2attention . Given that this pandemic may last several years, sustained pressure will continue to be placed on essential services . It is possible

2that serious health needs may outstrip availability and difcult decisions will be required about how to distribute scarce lifesaving resources .

As the pandemic develops and health services are put under greater pressure, it is possible that decisions about the allocation of potentially

life-saving treatment to individual patients will fall to health care providers and individual health professionals. Resources will be inevitably

stretched, with doctors having to make decisions about whether patients can or cannot receive necessary treatment. Health professionals

would nd decision-making in these circumstances ethically challenging. Such extreme situations bring about a transformation of doctors’

everyday moral intuitions. The natural inclination to persevere while taking care of extremely ill patient would be challenged by now 2quantitative decisions based on maximizing the overall reduction of mortality and morbidity, and the need to maintain vital social functions.

Pandemics require incorporating public health ethics with clinical ethics. Pandemics present difcult logistical, medical and ethical challenges

to the medical workforce. The principal values that inform this guidance are that any guidance should be accountable, inclusive, transparent, 3reasonable and responsive . They are very useful principles to use while dealing with ethical issues during pandemic as they ensure that any

4,5action and decisions taken are fair, reciprocal, respectful, and equitable. Adopting this approach will support the workforce as they cope

with the increased demand, while maintaining good ethical processes in their care, and continuing to promote the ethical values they already 6maintain in their current practice.

Health care providers and individual health professional responsible for the health of the patients should keep above principles in mind when

they come across following issues and situations.

Ensuring fair and equitable care

Treatment should be provided, irrespective of the individual’s background (e.g. disability), when this treatment will help the patient survive

and not harm their long-term health and wellbeing.

Caring for COVID vs Non-COVID patients

The presence or absence of COVID-19 should not be a limiting factor in treatment decisions

Making difcult decisions

Decisions to escalate care to ITU should have input from ITU doctors. As is normally the case, it is recommended that, where appropriate,

decisions within ITU should involve the multidisciplinary team. For reasons of practical and moral support, it is advisable that assessment and

prioritization decisions are carried out by more than one clinician colleague, where feasible. These decisions must be made with the patient

and, if appropriate, their caregivers. All decisions must be appropriately documented, to ensure accountability and for the legal protection 6of frontline staff.

Accountability for decision making

During a pandemic, all accountability for decisions still holds. While doctors may have to work outside their usual location or specialty, they

will still be held accountable for their decisions, just as they would during their regular practice. Decisions, regardless of whether they are

COVID-19 related, should be made according to protocol and justied where required, as per good clinical practice. Documentation of the 6decision-making process is very important.

Dr. Rajesh Mohan ShettyFRCP(Edinburgh), FRCA(UK),

FCICM(Aus & NZ), FFICM(UK), FICCM(India),

BSE accreditation (Transthoracic Echocardiography)

Chief of Clinical Services and Lead Consultant

Department of Critical Care Medicine,

Manipal Hospital Whiteeld, Bengaluru


Mob: 9886660477

Dr. Mani Prasad ReddyMBBS, MD

Registrar in Department of Critical Care Medicine


Mail ID : [email protected]




Doctors should be reassured that they are extremely unlikely to be criticized for the care they provide during the pandemic when 2decisions are.

• Reasonable in the circumstances

• Based on the best evidence available at the time

• Made in accordance with government guidelines

• Made as collaboratively as possible

• Designed to promote safe and effective patient care as far as possible in the circumstances

Should decisions be called into question at a later day, they will be judged by the facts available at the time of the decision, not with the 2benet of hindsight.

Working outside specialty

During pandemic doctors will need to be exible, and may need to work in locations or clinical areas outside their usual practice. This

will be especially true for those doctors who nd their elective clinics and procedures cancelled during the COVID-19 crisis. Doctors 6should be prepared and supported to work outside their normal practice, but not obligated to work outside their competency.

Doctors with pre-existing conditions or over the age of 70

There is an increased risk of severe illness from COVID-19 in those aged over 70 or under 70 with certain underlying health

conditions. Doctors have a duty to protect the public from harm, an extension of which is the right to protect themselves so they can

continue to care effectively. In this respect, it is ethical for those doctors who would be harmed by contracting the virus to refrain from

treating patients with (or suspected) COVID-19. It may be necessary to reassign these doctors to roles that do not involve contact 6with these patients so that their expertise can help with the pandemic, while keeping these individuals safe.

Personal protective equipment (PPE) for frontline staff

Caring for patients with or suspected COVID-19 requires appropriate PPE. All frontline staff should have constant access to PPE

during the pandemic. If asked to care without appropriate PPE, doctors should immediately report this to the relevant hospital

authorities.

Adults lacking capacity

There is no automatic priority for those who lack capacity and decisions about their treatment should be made in the same way as for 2all other patients requiring treatment.

Triage

Triage is a form of rationing or allocation of scarce resources under critical or emergency circumstances where decisions about who

should receive treatment must be made immediately because more individuals have life-threatening conditions than can be treated at

once. Priority is usually given to those whose conditions are the most urgent, the least complex, and who are likely to live the longest,

thereby maximizing overall benet in terms of reduced mortality and morbidity. Priority decisions will be dependent upon the

relationship between the availability of resources and the demand. If serious depletion of resources arises, decisions about which 2patients should receive treatment will change over the course of the pandemic.

Efforts must be made to ensure that the public (patients, caregivers, and those not yet ill) understand the purpose of any treatment

guidelines being used. Patients and their families must understand how the guidance is applied, so they are able to trust that it is

consistently and fairly applied. This will help to avoid fears in the public that doctors and nurses are allowed to ‘ignore’ certain patients,

which is not and will not be the case.

Maintaining essential services: personnel

During pandemic it is essential to ensure availability of essential services. Hence it may become necessary to prioritize treatment of

personnel in the emergency services, security, transportation, electricity, water and sewage systems, telecommunications and 2sanitation.




Liability issues

In emergency situations, it may also be ethical for health professionals to consider intervening to provide treatment at the limits of or

even beyond their competence in order to prevent serious harm. Retired health professionals may return to practice and nal year

medical students and postgraduates may be fast-tracked to the frontline. The skills of these professionals may not meet pre-pandemic

expected standards of tness to practice, but they may nevertheless be able to make a vital contribution. In extreme circumstances,

even untrained staff may be required to undertake some functions. This will inevitably give rise to questions about professional and 2legal liability and indemnity.

Research

The arrival of a pandemic will also require the rapid development and deployment of vaccines and antivirals. The urgency of the event

will mean that the normal procedures for development and licensing may have to be suspended or adapted to the demands of the

emergency. In turn this could lead to health professionals using large numbers of relatively novel and untested pharmaceutical

interventions. Mass use of untried vaccine could result in numerous adverse events. Issues of liability will therefore have to be 2addressed as a matter of urgency by the Government.

Effective vaccine could provide a key means of overcoming this crisis. Human challenge studies involve the intentional infection of

research participants. This raises several ethical issues. This could be dealt with by transparent communication, public engagement, and 7ethical study designs with immediate access to high quality health care and strict infection control measures.

Conclusion

The ongoing COVID-19 is likely to put health services under great pressure. It is likely that decisions about the allocation of potentially

life-saving treatment to individual patients will fall to health care providers and individual health professionals. Resources will be

inevitably stretched. The principal values that inform this guidance should be accountable, inclusive, transparent, reasonable and

responsive. Adopting this approach will support the workforce as they cope with the increased demand, while maintaining good ethical

practice in their care, and continuing to promote the ethical values they already maintain in their current practice.

Social issues in COVID-19

Presently the social impacts of COVID-19 in daily life are extensive and have far reaching consequences. Some of the social impacts

are:

• Service sector is not being able to provide their proper service

• Cancellation or postponement of large-scale sports and tournaments

• Avoiding the national and international travelling and cancellation of services

• Disruption of celebration of cultural, religious, and festive events

• Undue stress among the population

• Social distancing with peers and family members

• Closure of the hotels, restaurants, and religious places

• Closure of places for entertainment such as movie and play theatres, sports clubs, gymnasiums, swimming pools, and so on.

• Postponement of examinations

Impact of social issues vary depending on people and circumstances. These are discussed briey below.

Public

COVID-19 outbreak may give rise to stigmatizing factors like fear of isolation, racism, discrimination, and marginalization with all its 10social and economic ramications. Another very important aspect is stigmatization and societal rejection regarding the quarantined

cordon in the form of discrimination, suspicion and avoidance by neighbourhood, insecurity regarding properties, workplace prejudice, 11and withdrawal from social events even after containment of epidemics. A stigmatized community tends to seek medical care late and

hide important medical history, particularly of travel. This behaviour, in turn, will increase the risk of community transmission. Health 12,13crime originated out of the fear of being corona positive has also been reported from India.




Health care practitioners (HCP)

Many of the HCPs directly related to care of conrmed/suspected COVID-19 patients are being isolated and quarantined. Remaining

separated from family during an infectious disease outbreak may exact an enormous emotional toll on HCPs. News of assault on

doctors after deaths of COVID-19 patients and eviction of resident physicians from their rented houses amidst the ongoing pandemic 14,15,16are being reported. A sense of vulnerability may arise among clinicians due to lack of denitive therapy and preventive vaccines,

uncertain incubation period of the virus, as well as its possible asymptomatic transmission. Being incompletely supported by

government due to deciency of PPEs, feeling of worthlessness due to lack of training in proper infection-control procedures, and

isolation can cause signicant burnout and withdrawal among HCPs resulting in increased substance dependence behaviours, leading to 17,18considerable functional impairment.

Family

Lockdown and social distancing measures to prevent spread of COVID-19 have heightened fears of increasing levels of domestic 19violence, which includes physical, emotional and sexual abuse. Refuge, one of the UK's domestic abuse charities, reported a 25%

20increase in calls made to its helpline since lockdown measures were announced.

Elderly

Although social distancing is necessary to reduce the spread of the disease, if not implemented correctly, such measures can also lead

to increased social isolation of older persons at a time when they may be at most in need of support. The discourse around COVID-19,

in which it is perceived as a disease of older people, exacerbates negative stereotypes about older persons who may be viewed as

weak, unimportant and a burden on society.21

Persons with Disabilities

The risks of infection from COVID-19 for persons with disabilities are compounded by other issues, such as disruption of services and

support, pre-existing health conditions in some cases which leave them more at risk of developing serious illness or dying, being

excluded from health information and mainstream health provision, living in a world where accessibility is often limited and where 21barriers to goods and services are a challenge.

Youth

Many vulnerable youths such as migrants or homeless youth are in precarious situations. They are already in a situation without even 21their minimum requirements being met on health, education, employment, and well-being. In terms of employment, youth are

disproportionately unemployed, and those who are employed often work in the informal economy or gig economy, on precarious

contracts or in the service sectors of the economy, that are likely to be severely affected by COVID-19. The disruption in education

and learning could have medium and long-term consequences on the quality of education.

Conclusions

COVID 19 pandemic is ravaging through the community causing multiple social issues with wide ramication. It is better dealt by

sensitization of public and individuals through communication. Reassuring the stakeholders and isolated/quarantined/marginalized

individuals and community through communication and counselling and social preparedness by setting up organizations specic for

future pandemics is certainly necessary.

References

1. https://www.bbc.co.uk/news/world-51839944. Accessed on 21 June 2020.

2. COVID-19 Ethical issues. A guidance note. BMA. Accessed on 23 June 2020.

3. Daniels N. Accountability for reasonableness. BMJ 2000;321: 1300–1. https://doi.org/10.1136/bmj.321.7272.1300.

4. Thompson AK, Faith K, Gibson JL et al. Pandemic inuenza preparedness: an ethical framework to guide decision-making. BMC Med

Ethics 2006; 7:12. https://doi.org/10.1186/1472-6939-7-12.

5. UK Government. Guidance: Pandemic u. 2017. www.gov.uk/guidance/pandemic-u#ethical-framework. Accessed on 23 June

2020.

6. Ethical dimensions of COVID-19 for frontline staff. Royal college of physicians. Accessed on 19.06.2020




7. COVID-19 human challenge studies: Ethical issues. Lancet Infect dis May 29, 2020

8. https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-brieng-on-covid-19---3-march-

2020. Accessed 23 June 2020

9. Guan W, Ni Z, Hu Y et al. Clinical characteristics of Coronavirus disease 2019 in China. N Eng J Med 2020; 382:1708-1720

10. Siu JY. The SARS-associated stigma of SARS victims in the post-SARS era of Hong Kong. Qual Health Res 2008;18:729e38.

11. Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al. The psychological impact of quarantine and how to

reduce it: rapid review of the evidence. Lancet 2020;395:912e20.

12.The New Indian Express. Bihar man beaten to death for informing Covid- 19 medical help center about arrival of two people from

Maharashtra. https:// www.newindianexpress.com/nation/2020/mar/31/bihar-man-beaten-todeath-for-informing-covid–19-medical-

help-center-about-arrival-of-twopeople-fr-2123828.html; 2020 (accessed on 16th June 2020).

14. India Today. 49-year old man becomes Telangana’s latest Covid-19 fatality. 786 S. Dubey et al. / Diabetes & Metabolic Syndrome:

Clinical Research & Reviews 14 (2020) 779e788 https://www.indiatoday.in/coronavirus-outbreak/story/49-year-old-manbecomes-

telangana-latest-covid-19-fatality-1662363-2020-04-02; 2020 (accessed on 16th June 2020).

15. Independent Coronavirus. NHS doctor kicked out by landlord because of Covid-19 fears.

https://www.independent.co.uk/news/health/coronaviruslatest-nhs-doctor-evicted-covid-19-oxford-a9425166.html; 2020 (accessed on

16th June 2020).

16. Today India. Kolkata landlords evict medical professionals, Resident Doctor’s Association steps.

https://www.indiatoday.in/india/story/bengal-kolkatalandlords-evict-medical-professionals-coronavirus-1659333-2020-03-25; 2020

(accessed on 16th June 2020).

17. Carville O, Court E, Brown KV. Hospitals tell doctors they’ll Be red if they speak out about lack of gear. Bloomberg 2020.

https://www.bloomberg.com/ news/articles/2020-03-31/hospitals-tell-doctors-they-ll-be-red-if-theytalk-to-press (accessed on 16th

June 2020).

18. Wong TW, Yau JK, Chan CL, Kwong RS, Ho SM, Lau CC, et al. The psychological impact of severe acute respiratory syndrome

outbreak on healthcare workers in emergency departments and how they cope. Eur J Emerg Med 2005; 12:13e8.

19. Coronavirus: domestic abuse calls up 25% since lockdown, charity says. https://www.bbc.co.uk/news/uk-52157620;BBC News

(accessed on 24th June 2020).

20. 25% increase in calls to national domestic abuse helpline since lockdown measures began - refuge charity - domestic violence help.

https://www.refuge.org.uk/25-increase-in-calls-to-national-domestic-abuse-helpline-since-lockdown-measures-began/ (accessed on

24th June 2020).

21. Everyone included: Social impact of COVID-19. United Nations. https://www.un.org/development/desa/dspd/everyone-included-

covid-19.html (accessed on 24th June 2020).



CHALLENGES OF MANPOWER PLANNING DURING CURRENT COVID-19 PANDEMIC

Impact of COVID-19 pandemic

COVID-19 is a novel disease. Presently, no therapeutics or vaccines have been proven to treat or prevent COVID-19. Data from affected

nations, predicts about 40% of cases will experience mild disease, another 40% will experience moderate disease including pneumonia,

15% will experience severe disease, and 5% will have critical disease.1

Hospitals need to develop their individual plans catering to their available resources, and if possible, share the models/strategies that they

institute so that others can potentially learn and adapt these plans to their own centers. The scope of the pandemic will always be uncertain,

but, care providers will need to be able to care for many more patients very quickly. Because most Intensive Care Units (ICU) function at

very high occupancy rates, absorbing such additional numbers is unimaginable. In addition, care providers must be prepared to make tough

decisions regarding triage and standards of care. 1

Why there is a need for manpower planning?

The diagnosis of COVID-19 relies on a high index of clinical suspicion because there is no early, reliable and readily available diagnostic test

for the responsible virus (SARSCoV).2 As patients present to medical institutions with unprepared staff, the risk for spread is considerable.

Outbreaks may arise quickly and without warning, depleting the resources of any health care system and the ability of its personnel to cope.

The most fundamental guidance offered by previous outbreaks, is that we need to have a plan well in advance.

During previous outbreaks, the supply of healthcare workers, critical care beds became a signicant concern because of the need to manage

a surge of unanticipated critically ill patients. This supply issue will become a crucial concern in the current pandemic. In addition, the human

resources component further exacerbates the problem; the staff numbers are reduced by fear of contracting the disease, quarantine, and

illness. During the previous outbreaks, when SARS transmission occurred in ICUs, entire units were quarantined for 12–14 days.

Maintaining provision of ICU services to non-COVID patients becomes an important consideration as the outbreak progresses.

In the early reports from Wuhan, about the recent pandemic, handling of manpower was a great challenge for emergency management of all

hospitals to respond to outbreak at the early stage. The most prominent problems were the arrangement of medical staff to diagnose and

treat patients with COVID-19 and the allocation of medical protective equipment.2 Manpower planning in advance, can rapidly meet

demand by other areas of the hospital that are inadequately equipped or come under heavy load during the pandemic (e.g. recovery rooms,

operating rooms, emergency rooms, etc.).

What are the difculties in manpower planning?

Problems faced by the Human resources team to plan the manpower are –

1. Accurately predict the exact increase in demand of staff, during the different phases of the pandemic. In more cases than not, it is difcult

to predict and strategically prepare for public health emergencies, Thus, continuously updating the management plans while monitoring the

spread of the pandemic, is a better option.

2. Cancelling all elective and revenue generating procedures in view of preparation of staff to handle the pandemic related emergencies

3. Ensuring equipment and materials in adequate supply for the frontline staff, without wastage.

4. To ensure the staff at the front lines, are well trained – training should include self-protection knowledge, skills, professional knowledge

and skills, and preventive psychology and counselling as per the national policies and guidelines.

5. Periodic rotation of front-line staff, while maintaining combination of novice and procient staff – this would require providing extra

leaves, pay for non-working hours and having adequate members on the stafng rota, leading to out of pocket expenses for the institution.

Dr. Partha Sarathi GhoshMBBS, MD ANAESTHESIOLOGY

Registrar in Department of Critical Care Medicine


Dr. Rajesh Mohan ShettyFRCP(Edinburgh), FRCA(UK),

FCICM(Aus & NZ), FFICM(UK), FICCM(India),

BSE accreditation (Transthoracic Echocardiography)

Chief of Clinical Services and Lead Consultant




Mob: 9886660477




6. Setting up institutional policies to ensure that paid time off and sick days remain unaffected for all employees for COVID-19 related

illnesses.

7. Ensure no out-of-pocket expenses for employees with COVID-19 related illnesses

8. To ensure healthcare workers have measures to take care of mental stress, identify and prevent stress related burnout in themselves

and colleagues

What are the tools available for manpower planning?

Multiple tools are available to assess and plan allocation of healthcare workforce, equipment, supplies during this pandemic. World

Health Organisation (W.H.O) has developed a suite of complimentary surge calculators -- one for supplies and two for health

workforce. These use the same epidemiologic assumptions and categorize health workforce using standardized International Labor

Organization, International Standard Classication of Occupations codes.

Figure 1 shows the 3 principal healthcare system inputs: human resource, capital, and consumables. Just like other industries,

investment decisions in health are critical because they are generally irreversible, require large amount of money to places and activities

that are difcult in cancelling, closing or scaling down3

Identifying and allocating resources for the pandemic

1. Assess current resources available to the hospital on site

a. Keeping track of number and locations of general inpatient and ICU beds

i. Need for new ICU units

ii. Need for new non-ICU units

iii. Time needed to create such facilities on short notice




b. Available human resources

1. Determining the ability of the various healthcare staff and allocating them to areas best served by them - either by medical

qualication, skills, and training

2. Requires surveying current staff. Collection of this information is key to planning how to redeploy clinicians during the crisis.

3. Determining the roles current medical and non-medical staff are able to ll

4. Using the above tools, assigning the pandemic related roles to medical and non-medical workers

1. Determine roles for senior level physicians, nurses

2. Determine roles for junior staff - residents, registrars, junior nurses

3. Determine roles for non-medical workers

o Available supplies and medical inventory - currently on site

• These include PPE, ventilators, CRRT and dialysis machines that are present on site

• Keeping count and tracking the utilization of such equipment for pandemic affected and non-affected patients and allocating

units accordingly as per the severity of the patient needs. ‘

• In case of shortage, utilizing equipment from units like operation theatres, smaller hospitals etc.

2. Estimate future needs

• Project patient census using tools from WHO and the COVIDStafng.org project

• Project stafng needs

o Dene the potential compositions of teams for each unit (general inpatient, ICU)

o Dene ideal and stretch levels of care team models

• Estimate the number of staff needed in each role based on current and projected COVID-19 patient census

• Identify areas of anticipated staff shortages by comparing available staff with projected needs

3. Supplies required

o Project need for PPE, Ventilators, CRRT, and dialysis machines based on anticipated patient census using tools

o Plan response accordingly

o How will your staff be deployed?

• Assign staff to teams, and assign teams to locations, based on census

• A response planner can be developed to create a schedule for space and staff for each phase of your tiered response

4. How can you expand your capacity?

• Up-train clinical staff

• Redeploy clinical staff to new roles based on current skill level (assessed in Pandemic Role Allocation Tools)

• Enable online platforms like Microsoft Teams, Zoom for team coordination and collaborative effort.

• Develop IT infrastructure to enable cloud/ online based services for video consultations with patients for illnesses, thereby

triaging the need for patients who need to visit the hospital premises and those who need not. This signicantly reduces the

chances of exposure of workforce.

• The above measures will then enable to form a rolling rota of staff that can be utilized at the front lines on a 7 / 14 day basis,

keeping the rest of the staff safe and ready to deploy in the event of increased demand.

Conclusion

Based on the experience gained from earlier pandemics like Severe Acute Respiratory Syndrome (SARS), Middle East Respiratory

Syndrome (MERS) a great deal could be gained from simulating similar events and planning a system wide response to emerging

pathogens. The relationship between human resources management and health care is extremely complex such as those seen in the

light of the recent pandemic. Thus, careful planning of healthcare resources, gauging the demand and supply is important to efciently

manage this pandemic. This will not only prevent crippling of the existing healthcare systems, but also improve healthcare for the years

to come. Change is going to be the constant for the coming years in healthcare

References:

1. Hawryluck L, Lapinsky SE, Stewart TE. Clinical review: SARS - Lessons in disaster management. Crit Care. 2005;9(4):384-389.

doi:10.1186/cc3041

2. Liu Y, Wang H, Chen J, et al. Emergency management of nursing human resources and supplies to respond to coronavirus disease

2019 epidemic. Int J Nurs Sci. 2020;7(2):135-138. doi:10.1016/j.ijnss.2020.03.011

3. Kabene SM, Orchard C, Howard JM, Soriano MA, Leduc R. The importance of human resources management in health care: A

global context. Hum Resour Health. 2006;4:1-17. doi:10.1186/1478-4491-4-20



R and Re of COVID-19: Can we predict 0

when the pandemic outbreak will be over?

Introduction

COVID-19 is a zoonotic coronavirus similar to SARS and MERS coronavirus. Most of the people exhibiting mild or no symptoms are unable

to get tested especially in the developing world, which means that the actual number of cases could be much higher. In India, rst positive

case of the COVID-19 was detected on 30th January 2020 in Kerala. Majority of initial cases in India had travel history and acted as primary

cases and infected others. Hence it is important to estimate the transmission dynamics in the initial days of infectious disease outbreak and

predict about the potential growth of cases. (1)

One of most discussed issues about COVID-19 is R0. R0 (R naught) is the basic reproduction number, also known as basic reproduction

ratio or rate which is an epidemiological metric used to measure transmissibility of infectious agents. Public opinion and mass media are

increasingly focusing on this epidemiological value, often alarming about the spreading potential of the novel infection.

History of R0 and public health importance

Demographer Alfred Lotka proposed the reproduction number in the 1920s as a measure of the rate of reproduction in a given population.

In 1950s epidemiologist Mac Donald suggested using it to describe the transmission potential of malaria. He proposed that if R0<1, the

disease will die out in a population and on the other hand if Ro>1, the disease will spread.

R0

R0 is not a biological constant for a specic pathogen. It is an estimate of the contagiousness that is a function of human behaviour and

biological character of pathogens. R0 is not a measure of the severity of an infectious disease or the rapidity of a pathogen’s spread through a

population.(1) It is estimated when there is zero immunity in population. R0 is a derivative of the following variables- the duration of

infectivity after the patient gets infected, the likelihood of transmission of infection per contact between a susceptible person and an

infectious individual and the contact rate. The infectivity of the pathogen and duration of contagiousness are biological constants, but the

extent of human to human interaction will vary and hence R0 will vary depending on this parameter. Hence the stress on social distancing

during the COVID-19 pandemic. R0 value of COVID-19 is higher than that of SARS and MERS.

Re

Re (effective reproduction number) which also known as Rt, is the number of people in a population who can be infected by an individual at

any specic time. While measuring the transmissibility of the virus at any given time during an epidemic we use Re. It changes as the

population becomes increasingly immunized, either by individual immunity following infection or a vaccination and also as people die.

Factors affecting Re include number of people with infection, number of susceptible with whom infected people are in contact and people’s

behaviour such as social distancing.

Vaccination and herd immunity:

R0 predicts extent of immunization required to achieve herd immunity. To prevent sustained spread of infection, the proportion of

population that has to be immunized (Pi) has to be greater than 1-1/Ro. Aim of vaccination campaigns is to reduce the susceptible population

to infection by reducing R0 to <1 for that event. Removal of susceptible population cuts the transmission by effective reduction in

susceptible contacts between infectious and susceptible persons, thus it doesn’t reduce the R0 as its denition includes assumption of

completely susceptible population. While testing effectiveness of vaccination, we should use effective reproduction number (Re) which can

used in populations having immune members.

How to measure R0?

R0 is usually estimated retrospectively from serial epidemiologic data or by using theoretical mathematical models. Epidemiologists can

calculate R0 using contact-tracing data, the most common method is to use cumulative incidence data.

Dr Nithya C.A.M.D, IDCCM, FNB Critical Care Medicine, EDIC

Associate Consultant

Department of Critical Care Medicine

Manipal Hospital, Whiteeld, Bengaluru

Phone number: 9075790057

Email id: [email protected]

Dr BS SindhuQualication: MBBS MD EDAIC

Specialist in Department of Critical Care Medicine







When mathematical models are used, R values are estimated by using ordinary differential equations. Two mathematical models are used. 0

The models are susceptible-infectious-recovered model or susceptible-exposed-infectious-recovered model.

R of COVID-190

R of COVID-19 as initially estimated by World Health Organization (WHO) was between 1.4 and 2.4, as declared in a statement dated 23 0

Jan 2020.

The review by Liu Et al, compared 12 studies published from 1st of January to 7th of February 2020 have estimated R0 ranging from 1.5 to

6.68. They found a nal mean and median value of 3.28 and 2.79 respectively, with an interquartile range of 1.16. The reasons behind low

level of accordance between the studies were attributed to difference in variables considered, methods of modelling and estimation

procedures. According to Liu’s ndings, the studies using mathematical methods produce estimates that are higher than stochastic and

statistic models in determining COVID-19 R . R is proportional to the contact rate and will vary according to the local situation. (2)0 0

According to recent review, by Minah Park et al, mean R range is from 1.9 to 6.5 based on 8 published and 8 preprint papers. Of 20 0

estimates 13 studies were in range of 2 and 3. The estimates are comparable to that of SARS CoV which was estimated when excluding

super spreading events in the early phase of outbreak in Hong Kong (2.7) and Singapore (2.2-3.6).(3)

Another study conducted by Balram Rai et al showed that reproduction number for COVID-19 in India was 2.56 and herd immunity as 61%,

in which exponential growth model was applied to calculate future cases based on cumulative conrmed cases, recovered cases and death

rate over 21 days period.(4)

Mathematical model for reproduction number and herd immunity

It=( R )t/SI0

It -number of incidence cases at time

R0-reproduction number

SI- serial interval- time between onset of primary and secondary case (Taken as 4.4 as reported in previous studies done in Hong Kong) (5)

t- prediction time

The Imperial college group has estimated R to be between 1.5 and 3.5(3). While Italian model estimated R0 between 2.76 and 3.25 and 0

researchers from Lombardy who analyzed the early phase of outbreak in their region reported reduction in R0 shortly after introduction of

mitigation measures.(6)

R evaluated on diamond princess cruise ship was 2.28 in early February. They estimated that unless R0 decreases by 25-50% by strict 0

infection management and control measures the estimated total cases would be high in following period. If the R0 is reduced by 50%, the

number of cases would be reduced by half and if the R0 value is reduced to less than 1, the infectious cases would gradually die down(7)

Importance of estimating R0

The prediction has critical importance as it will not only help the government to have an estimate of cases in the near future but also helps

them to plan the required strategy to accomplish the requirement in the given time to avoid any unfavorable condition. Although the Indian

government has taken many preventive measures such as complete lockdown, national and international travel restrictions, compulsory

quarantine etc. to suppress the spread of the disease, sudden outbreaks within the communities have occurred which has piled up the

burden.

Quarantine is an effective measure to alter R . Co-ordinated global efforts help to curtail the spread of disease by mass quarantine of 0

contacts and isolation of infectious patients. Community measures and social distancing should be proactively implemented in order to

reduce the impact of the epidemic and to delay its peak, allowing healthcare systems to prepare and cope with the increased inux of

patients. However, the effectiveness may be hampered by asymptomatic carriers.

Hellewell and colleagues forecasted the potential effectiveness of contact tracing and isolation of COVID-19 cases, using different values of

R0. Accordingly with R of 1.5, outbreaks would be contained if 50% of contacts will be traced, while with R0 of 2.5, 3.5 more than 70% and 0

90% of contacts respectively have to be traced.(8)





Based on Imperial college COVID-19 response team ndings, where model assumed R0 as 2.4, the UK government imposed lockdown as it

was estimated that approximately 81% population will be infected with over half a million deaths in absence of control measures. (9)

The serial interval shorter than the incubation period implies pre symptomatic transmission and thereby should be considered in

formulating intervention strategies as it may impede containment efforts. The serial interval estimates of SARS CoV2 is also shorter than that

of SARS CoV (8.4 days) and MERS CoV(8-13 days) which suggests that it may be more challenging to contain spread compared to other

coronaviruses.

In conclusion, the basic reproductive number varies in the course of disease and is also based on epidemiological factors like susceptible

population characteristics, disease transmissibility rate and control measures adopted. The pre symptomatic transmission and

asymptomatic patients delays the contact tracing and quarantining and effectiveness of mitigation measures. Global coercive efforts are

required to mitigate the pandemic.

References

1. Delamater PL, Street EJ, Leslie TF, et al. Complexity of the basic reproduction number Ro. Emerg Infect Dis 2019;25:1-4.

2. Liu Y, Gayle AA, Wilder smith A, Rocklov J. Reproductive number of Covid19 is higher compared to SARS coronavirus. J Travel Med 2020

Feb 13.

3. Minah Park, Alex R Cook, Jue Tao Lim, Yinxiaohe Sun and Borame L Dickens. A systematic review of COVID19 epidemiology based on

current evidence. J .Clin Med 2020, 9,967.

4. Balram rai, Anandi Shukla, Laxmi kant Dwivedi. Covid19 in India;predictions, reproduction number and public health preparedness. med

Rxiv April 2020(pre print)

5. Zhao. S, gap D, Zhuang Z, Chong M, cai Y, Ran J and Yang L. Estimating the serial interval of the novel coronavirus disease(COVID19): A

statistical analysis using the public data in Hong Kong from January 16 to February 15, 2020. medRxiv.

6. Coronavirus disease 2019 pandemic:increased transmission in the EU/EEA and the UK-seventh update, European centre for disease

prevention and control.

7. Zhang S, Diao MY, Yu W, Pei L, lin Z, chen D. Estimation of the reproductive number of novel coronavirus and the probable outbreak size

on the diamond princess cruise ship: a data driven analysis. Int J Infect Dis 2020 Apr 93:201-204.

8. Hellewell J, Abbott S, Gimma A, et al. feasibility of controlling 2019 nCoV outbreaks by isolation of cases and contacts. Lancet Glob Health

2020;8:e488-96

9. Natsuko, Imai, Cori Anne, Dorigatti Ilaria, Baguelin Marc, A. Donnelly Christl, Riley Steven and M Ferguson Neil 2020. Report

3:Transmissibility of 2019-nCoV. COVID-19 Response Team, Imperial college London.



LOCKDOWN EXIT: EVOLVING PRACTICES FOR SAFE PREGNANCY AND CHILDHOOD

“Nothing in life is to be feared. It is only to be understood” well said by Marie Curie and hold true in the time of COVID pandemic when fear

is looming on everyone. After lock down exit COVID-19 cases are increasing daily. It’s easy to segregate symptomatic cases and treat them

in designated COVID-19 areas with all standard procedures but real risk comes from asymptomatic or presymptomatic cases. These

normal looking individuals can spread infection to health care workers and we doctors have to learn the new norms of practice to prevent

ourselves from getting infected. It’s all started with lots of fear and anxiety and government announcing the lock down. At that time case load

was low and community transmission was not there. We used to suspect only those who had history of travel or history of contact. But now

in community transmission phase every person coming to the hospital/clinic is to be taken as suspect and potential spreader. Even pregnant

females and children who are predominantly home bound are getting infection due to exposure to positive contacts

Infection in children and pregnant females till date is showing milder illness or more of asymptomatic phase. They are more at the receiving

end as this group need more frequent visit to clinics/hospitals for vaccinations and routine health checks. Also, in children inuenza like

illnesses are very common which creates confusion whether each and every such child should be considered suspect. This creates undue

confusion in the mind of patient and healthcare workers. To remove this fear and suspicion, some permanent changes are required in our

hospital and clinic infrastructure to make it safe. These changes give the condence of safe working environment to doctor and reduces

anxiety of patient and family to get infected while coming for a visit. These changes can be enumerated under various categories:

1) Prophylaxis for health care workers

a. At workplace

b. At home

2) Prophylaxis for pregnant females and children

a. At clinic/hospitals

b. At home

Outpatient department at clinic/ hospitals

Latest studies by CDC suggest, COVID-19 spreads by less of surface transmission and more of direct spread from person to person in close

contact. Close contact can be minimised by following measures

Avoid crowding

Crowding is mainly seen in waiting areas or inside the OPD chamber. This can be avoided by allowing one patient along with single relative

inside the waiting area and in OPD chamber for the shortest possible duration. Strict appointment schedule should be followed and

measures taken to promote social distancing are to be displayed boldly and clearly. Waiting area and OPD chamber furniture should be

reduced to minimum. Children play areas to be closed

Screening

Strict screening measures like thermal and symptoms screening at the entry point should be followed for staff and patients. Any patient with

inuenza like illness should be sent to separate u corner. Video consultation should be promoted for these patients. As incidence of Covid

19 is increasing, numbers of asymptomatic spreaders are increasing in the community and it is proposed that all patients coming to hospital

in hotspot areas and containment zone should be considered as suspects

Social distancing

Social distancing prevents transmission by close contact and it can be the most important intervention at population level. Maintaining

physical distance between persons and their secretions is important. Effective social distancing depends on various factors like maintaining

physical distance of 2 meters is safe outdoors while it is highly ineffective in closed air-conditioned OPD chamber. Effective social distancing

requires changes in infrastructure and routine practices

Dr Venus BansalMBBS, MS, FICOG (Obstretics & Gynae)

Senior Consultant

Dept. of Obstretics & Gynaecology

SPS Hospitals, Ludhiana

Dr Vikas BansalMBBS. M.D, FNB

Senior Consultant

Dept. of Pediatric & Pediatric Intensive Care

SPS Hospitals, Ludhiana




Infrastructure and practice Changes required are at clinics that must be considered by all practitioners are directed towards reducing the

touch surfaces, creating a physical barrier, reducing the exposure time and increasing the air exchange

a) To reduce touch surfaces: Follow the patient entering inside the clinic/hospital. Keep the doors open on the way. Apply air curtains to

avoid ies and mosquitoes inside. All patient information forms are to be lled by receptionist. Money transactions can be done by online

payment mode. Paper currency should be sterilized by dry heating method or by using UVC radiation boxes. Other touch surfaces should

be frequently cleaned with hypo chlorite solution or quaternary ammonium chloride solutions. This includes seating chairs, counters,

patient stool, examination table etc. Regular staff training sessions for hand hygiene using soap and water and hand sanitizers should be

conducted. Torches, stethoscope, pulse oximeter, weighing machines should be used minimally and need to be cleaned periodically.

Pregnant patients are informed to get the weight checked at home by their own weighing machine

b) Creating physical barrier between patients and health care workers: physical barrier can be made with glass partition between reception

and patient, sample collection and patient and doctor and patient. Doctor and Staff should be wearing surgical masks, face shield and gowns.

No person without mask should be allowed to enter the facility. Making children wear a mask is difcult task

Various methods can be explained to parents to make children wear a mask:

- Let them choose their own design.

- Everybody at home should wear mask and especially one going out.

- Teachers and school encouraging use of mask in their online classes.

- Mask for their favourite buddy or toy.

- Game play with mask and about COVID-19 prevention.

- Rewards for positive reinforcement.

c) Reducing exposure time: By decreasing exposure time, aerosol generation is reduced. Aerosol is generated not only by coughing or

sneezing but also by routine speech. Speaking in normal voice produces fewer aerosols rather than speaking in loud voice. Some people

generate more aerosol than other while speaking normally also. This aerosol in closed spaces becomes the main source of infection

transmission. Reducing the exposure to less than 3 minutes decreases the chances of infection signicantly

d) Increasing air ow exchanges in closed areas: Air ow direction, velocity, humidity, exchange and temperature effects the aerosol spread

of virus. By keeping the doors and windows of your clinic open more than 7 air exchange per hour can achieved. This will lead to settling

down of aerosol in less than 15 seconds thus decreasing the exposure. Even installing exhaust fans can also increase air exchange rates. Air

puriers with HEPA lters also reduce aerosol spread. Aerosol generating processes like nebulisation should be stopped in clinic area

Preventive measures at home by health care workers:

Home spread of COVID-19 infection can occur by infected visitor, maid servants and contaminated items. During this pandemic social visits

and gatherings should be strictly discouraged. No visitor should be allowed inside the house. Maid servants can be called for outdoor work.

Ofce dress codes require changes like avoiding ties, belts, wallets etc. Minimum things should be carried to the hospital or workplaces, like

avoiding carry bags, purses, laptops, bottles, etc. Coming home back from hospital too follows a new normal of removing shoes, clothes

outside the house. Installing a portable / permanent washroom outside is a need of time as COVID-19 is going to stay for long. Mobile

phones, keys, pens and other pocket items can be cleaned with alcohol wipes or by keeping them in UV-C boxes

Preventive measures for pregnant females and child:

Parents are encouraged to do Weight gain / loss monitoring and intake of breast feed monitoring which is checked by lactation nurses on

phone under supervision of paediatrician. It decreases few visits, touch to weighing machine and at the same time the audio/ video

communication with the family by health care worker gives reassurance to anxious parents. Vaccination rooms should be separate and

vaccination appointments should be given at separate time, to prevent the exposure of healthy children and parents with suspects.

Vaccination visits should be reduced by clubbing the vaccines together. Vaccination are usually scheduled on time with a little bit of exibility.

Children are a vulnerable group during COVID-19 pandemic as practising basic social distancing and hand hygiene is a challenge for their

age. They will acquire infection from positive contact in the house or in schools. Maintaining social distancing is impossible in schools so

virtual classrooms are created and online teaching has started. Overzealous approach of some countries to prematurely open the schools

has led to sudden spurt of infections in children

In the non COVID times, kids recognise their doctor and feel reassured, showing less anxiety and making examination easy. But now with

FACE MASK and GOWNS on they feel terried and more anxious. Placing certain photographs of the paediatrician in the clinic / pasting on

the front of gown can help the nervous kid to feel more relaxed




So far as pregnant females are concerned, Federation of obstetrics and gynaecology society of India (FOGSI) has issued guidelines which

emphasise that antenatal visits should be reduced to minimum, but essential ones must be planned. Vaccination of pregnancy is scheduled

during these essential visits only. Patients should be counselled for maintaining charts for weight gain, blood pressure, fetal kick count at

home and an antenatal nurse under the guidance of obstetrician can guide them through the time of confusion. Ultrasounds during

pregnancy should be done with minimum number of probe and with all fomite disinfection protocols. Online diet consultations can be done

for proper weight gain. Social gatherings for rituals and customs like ‘Baby Shower’ celebrations should be avoided and discouraged

Before the delivery, expecting COVID-19 positive or suspect mother should be counselled regarding probable but low chances of Trans

placental transmission of COVID-19 during delivery. Assuring the female that virus has not yet been isolated from vaginal secretions or

breast milk till date help her come out of fear of infecting her baby. However, transmission from mother to baby is probable during delivery

or even afterwards. Pregnant women sickness with COVID-19 is comparable to non-pregnant counterparts. There is no evidence of

increasing morbidity or mortality of COVID-19 infection during pregnancy, during normal labour and even in mothers undergoing

caesarean section. Pregnancy with co morbidities like heart disease, high blood pressure, diabetes and HIV are at higher risk of severe

disease. Few studies are supporting that COVID-19 can exaggerate the hyper coagulable state of pregnancy. SOP for labor areas are to be

created as per the guidelines to manage the COVID negative, suspect and positive cases separately. Breast feeding is individualized from

case to case basis in COVID-19 suspected / positive cases. Delivery by normal or caesarean is totally obstetric indication based. The choices

can be discussed with parents for breast feeding and individualised from case to case basis as per the symptoms of the mother. Breast feeding

is mostly encouraged with good hygiene practices

During pandemic planning conception or Infertility treatment should be avoided, as like any other viral infections in pregnancy, COVID-19

can increase chances of congenital defects. However, long term data is not available yet. Termination of pregnancy, sexual and reproductive

health services are time sensitive and should be continued even during the pandemic crisis

Stay safe

References

1.FOGSI NNF India IAP. Perinatal Neonatal Management of COVID-19 Infection. New Delhi : s.n., 2020

2. ICMR - National Institute for Research in Reproductive Health. Guidance for Management of Pregnant Women in COVID-19

Pandemic. [Online] April 13, 2020. [Cited: April 20, 2020.]

https://icmr.nic.in/sites/default/les/upload_documents/Guidance_for_Management_of_Pregnant_Women_in_CO

VID19_Pandemic_12042020.pdf

3. World Health Organization. [Online] [Cited: April 20, 2020.] https://www.who.int/dg/speeches/detail/who-directorgeneral-s-opening-

remarks-at-the-media-brieng-on-covid-19---11-march-2020



DILEMMA OF RESEARCH IN COVID ERA

The reports of the Novel Coronavirus epidemic starting in China soon gained the status of a pandemic before any superpower could

decipher it. There was panic amongst the local population as well as the medical fraternity. The rise of both morbidity and mortality amongst

the frontline medics and paramedics was also quite high. With no vaccine for prevention, lack of straightforward management protocols for

the ght against the virus made it the worst nightmare in no time.

I was sitting in my OPD looking into data regarding it’s prophylaxis. I contacted my colleague in the USA who is managing the infected

patients on ventilators there. We discussed the reports of Hydroxychloroquine in modifying the cytokine storm, a treatment that had

started to become popular recently. But with reports on its effectiveness being on both sides of the house, the search for a prophylaxis and

treatment protocol that could be regarded as the ‘Holy Grail’ for overcoming Covid-19 still remains.

When such a pandemic strike, there always remains a dilemma around research which can guide the treatment protocols. The most

effective way to determine the appropriate treatments is to have double blind randomized trials, which as obvious is not possible in such a

situation. What we do have is the analysis of the observational studies done from the collection of data from the units already managing such

pandemics. Thus, the observational data collected from these units has to be robust with meticulous records being maintained because data

collection and analysis plays a very important role in guiding healthcare providers towards the effective protocols of prevention and

treatment.

However, like in the case of Coronavirus, what about the asymptomatic patients’ data who only go for check-ups to their general

practitioners or do not show up for check-ups at all? What about the case of some of the studies done on use of hydroxychloroquine being in

favor of it but others showing it to be ineffective? The Lancet study was an observational data collection from multiple registries; however,

since it broke the fundamental principles essential for such a study, it was later withdrawn citing aws. All of these are examples that show

that we are either missing out on essential data.

But a majority of clinicians just read the conclusion and take it at face value of publication and do not dissect the studies published, perhaps

because of the workload of managing a pandemic.

Is it possible to manage patients in pandemics and to carry out research simultaneously?

As the number of patients is quite high during a pandemic, all resources and most of the time of the healthcare providers is used up in

managing the patients. Hence a set of dedicated researchers are required to collect data meticulously so as to guide us about future changes

as applicable.

The Declaration of Helsinki addresses this in its guidelines for physicians. It states that research and medical care may be combined “only to

the extent that the research is justied by its potential preventive, diagnostic, or therapeutic value and if the physician has good reason to

believe that participation in the research study will not adversely affect the health of the patients who serve as research subjects” (WMA,

2013)

The nature and design of studies to be conducted has to be ethical. The right intervention or drug, the right dose, and the time of application

of intervention and so forth are amongst the many things that matter.

As there are no drugs or vaccines approved to treat or prevent the Coronavirus infection respectively yet or ready to enter into clinical trials

at the outset of the pandemic, there is an ethical imperative for healthcare professionals to conduct such research as quickly and safely as

possible. Healthcare Providers needed to learn how best to treat patients or prevent new Corona infections and to assess how health

systems could be congured and equipped to meet these health needs.

Should the drugs still under trials be applied to the bedside?

‘Expanded access exemption’ or ‘compassionate use’ is providing experimental therapies in some circumstances outside of an approved

clinical trial. It is an ideal way to monitor and minimize risks of unproven agents while maximizing the scientic information gained.

According to FDA, 2016, in the United States, a number of conditions must be met in order for a patient to be granted access to a drug under

expanded access:

1) There is no comparable or satisfactory therapy available,

Dr Amit Gupta MBBS MD DNB ( Respiratory Ds)

Fellow - FNB (Critical Care)

Consultant Pulmonologist & Intensivist

Director Medlink Healthcare Patiala Punjab



DILEMMA OF RESEARCH IN COVID ERA

2) The probable risk from the investigational product is not greater than the probable risk from the disease, and

3) Providing the investigational product will not interfere with the conduct of clinical trials

How are trials designed?

The gold standard for any sort of trial is Randomized Control Trial as it is the most effective way to identify and study relative benets vs risks

of investigational intervention. However, according to Byar et al., 1990 exceptions exist when all of the following conditions apply:

a. There must be no other treatment appropriate to use as a control.

b. There must be sufcient experience to ensure that the patients not receiving the therapy will have a uniformly poor prognosis.

c. The therapy must not be expected to have substantial side effects that would compromise the potential benet to the patient.

d. There must be a justiable expectation that the potential benet to the patient will be sufciently large to make interpretation of the

results of a nonrandomized trial unambiguous.

e. The scientic rationale for the treatment must be sufciently strong that a positive result would be widely accepted.

The research mediated observational data pooled and analyzed in the absence of randomized control trials can guide us.

In an ongoing pandemic, the management and research must go hand in hand without hampering the quality of either of the two. As in

Corona, with growing technological expertise, both the clinicians and the scientists have joined hands all over the world to ght this

menace. As the pandemic passes through its phases, with our shared experiences we understand the threat that COVID poses better. From

community spread to safety measures, from pathophysiology to cytokine storm, from better testing techniques to quick, precise and

accurate diagnoses, from early intubation to awake proning, from the use of Hydroxychloroquine and Ivermectin in prophylaxis to that of

Toclizumab and Remdesivir in management, we have learnt a lot from these several small studies and experiences shared.

With a healthy collaboration and cooperation amongst all the management centers worldwide and dedicated data collection and sharing we

can keep improving upon the prevention and treatment protocols to provide the best possible healthcare to the patients and handle this

pandemic effectively.



CALL FOR ABSTRACTDEADLINE FOR SUBMISSION

31OCTOBER 2020

th thWORKSHOP: 24 - 25 Feb 2021th thCONFERENCE: 26 - 28 Feb 2021

VENUE: Mahatma Mandir Convention and Exhibition Centre

THEME: SAFETY AND EFFICIENCY AMIDST RESOURCE LIMITATION

TM

VISIT WWW.ISCCM.ORG FOR MORE DETAILS

MONITORING OF COVID -19 PATIENTS AT HOME

In view of large population of India and shortage of hospital beds home isolation for mild and presymptomatic cases has been recommended

by government of India.

WHAT IS DEFINITION OF A CONTACT?

A contact is dened as a healthy person who was in contact with a conrmed case or contaminated environment and is therefore at higher

risk of developing disease.

A CONTACT IN CONTEXT OF COVID -19 IS:

• A person living in the same household as a covid-19 case.

• A person having had direct physical contact with a covid-19 case or his/her infectious secretions without recommended personal (PPE) or

with a possible breach of PPE.

• A person who was in a close environment or had face to face contact with a covid-19 at a distance of within 1 meter including air travel.

DEFINITION OF ASYMPTOMATIC COVID PATIENT

Person with laboratory conrmed report of covid-19 who have no symptoms/signs.

DEFINITION OF MILD COVID CASE PATIENT

Patients presenting with mild cough, sore throat, nasal congestion, malaise and headache.

WHO IS ELIGIBLE FOR HOME ISOLATION?

1. Mild or asymptomatic cases.

2. Such cases should have requisite facility for self-isolation and for quarantining family contacts.

3. Caregiver should be there 24x7 and he should be connecting link between patient and hospital for the entire duration of isolation.

4. Caregiver and family contacts should take prophylactic hydroxychloroquine as described by treating doctor.

5. Download Aarogya setu application on mobile and it should remain active at all times through Bluetooth and wi-.

6. Patient should monitor his health regularly and has to inform district surveillance ofcer about his health status regularly.

WHAT ARE WARNING SIGNS FOR THE PATIENTS?

1. Difculty in breathing.

2. Persistent pain and pressure in the chest.

3. Mental confusion or inability to arouse.

4. Developing bluish discoloration of lips/face.

5. Persistent fever >101 F.

6. Abdominal pain or diarrhoea.

7. Decreasing urine output.

8. As advised by treating medical ofcer

WHEN TO END HOME ISOLATION?

After 17 days of onset of symptoms or 10 days after onset of fever. There is no need for testing when home isolation is over in mild cases.

INSTRUCTIONS TO BE FOLLOWED BY CONTACT WHO ARE HOME QUARANTINED

1. The room should be separate with proper ventilation with an attached or separate bathroom.

2. Another family member is staying in same room he should maintain a distance of 1 meter.

3. Elderly people, pregnant woman, children and persons with comorbidities should stay away from contacts.

Dr. Simant Kumar JhaDA,DNB,PGDHM,FICM,ATLS

instructor,FCCS Course Director,

FCCS OBS instructor,Senior consultant,

Dept. of critical care medicine, PSRI,Delhi

Dr Yudhyavir SinghAssistant Professor,

Deptt of Anaesthesiology,

Critical Care and Pain Medicine.

AIIMS, New Delhi.



MONITORING OF COVID -19 PATIENTS AT HOME

4. Restrict the movement of contact within the house and under no circumstances he should be allowed to attend social or religious

gatherings.

FURTHER INSTRUCTIONS FOR CONTACT

1. Use soap water for hand washing or alcohol-based solution for rubbing hand.

2. Do not share household items like dishes, drinking glasses, cups, beds, towels or other items.

3. Wear surgical mask always that are to be disposed of every 6-8 hours or wear reusable mask.

4. Masks used by patients/caregivers/close contacts should be disinfected either by ordinary bleach solution (5%) or sodium hypochlorite

solution (1%) and then is to be disposed by burning or burial.

5. In case of getting symptoms (cough, fever, breathing difculty, body pain or others he should immediately report to nearest health centre.

INSTRUCTIONS FOR FAMILY MEMBERS OF PERSONS BEING HOME QUARANTINED

1. A family member should be assigned to take care of contact.

2. Use disposable gloves while handling soiled linens.

3. Wash hands after removing gloves.

4. No visitors should be allowed.

5. In case person being home quarantined becomes symptomatic; all the closed contacts will be home quarantined for 14 days and followed

for additional 14 days. no test required for mild cases.

HOW TO DISINFECT ENVIRONMENT?

1. Disinfect daily with1% sodium hypochlorite solution.

2. Clean and disinfect toilet with bleach solution/phenolic disinfectant.

3. Clean clothes and linen used by contact through common household detergent.

HOW TO MONITOR CONTACT?

1. Daily monitoring of vitals (pulse rate, blood pressure, temperature and respiratory rate 6 hourly).

2. Monitoring oxygen saturation (SpO ) through portable pulse oximeter by patient himself every 15 minutes. and if drop of SpO 2 2

below 93 in successive & is alarming.

WHAT COVID KIT SHOULD CONTAIN?

1. N-95 mask, gloves, sanitisers, pulse oximeter, digital thermometer, personal protective equipment.

2. Download Aarogya setu application on mobile.

• Make sure the person who is sick drinks a lot of uids and take adequate rest.

• Asked the person to remain calm and quiet with positive thinking.

• Help them with grocery shopping, lling prescriptions and getting other necessary items as per the need.

• Consider having the items delivered through a delivery service, if possible.

UNDERTAKING ON SELF-ISOLATION

I .............................. S/W of ........................, resident of ........................................ being diagnosed as a conrmed/suspect case of COVID-

19, do hereby voluntarily undertake to maintain strict self-isolation at all times for the prescribed period. During this period, I shall monitor

my health and those around me and interact with the assigned surveillance team/with the call centre (1075), in case I suffer from any

deteriorating symptoms or any of my close family contacts develops any symptoms consistent with COVID-19.

I have been explained in detail about the precautions that I need to follow while I am under self- isolation.

I am liable to be acted on under the prescribed law for any non-adherence to self-isolation protocol.

REFERENCES

1. World Health Organisation. https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200402-sitrep-73-covid-

19.pdf?

2. CLINICAL MANAGEMENT PROTOCOL: COVID-19 guideline.MOHFW, GOI. Version4, Updated 27/06/2020.



RISK FACTORS AND EPIDEMIOLOGY OF MULTIDRUG RESISTANT ACINETOBACTER INFECTIONS AMONG CRITICALLY ILL ADULT

PATIENTS ADMITTED IN MEDICAL INTENSIVE CARE UNIT

Acinetobacter are non fermentive aerobic gram negative cocco bacilli which can survive under wide range of environmental conditions and

can persist for extended periods of time on surfaces, making it a frequent cause of outbreaks in ICU. Acinetobacter was rst described in

1911 as micrococcus calcaceticus. Since then, it had several names, becoming known as Acinetobacter in 1950’s. Acinetobacter baumannii,

acinetobacter calcoaceticus, Acinetobacter Iwofi are the species most frequently implicated in nosocomial infections. Its natural habitats

are water and soil and it has been isolated from food, arthropods and environment (1)

In recent years, emergence and changing epidemiology of acinetobacter infections has been recognized. It has also been noted for its

intrinsic resistance to multiple antibiotics and high mortality. (1, 2) The unique characteristic of acinetobacter includes desiccation tolerance

which accounts for its ubiquitous nature in the environment which promotes transmission through fomite contamination in hospitals. In

humans acinetobacter can colonize skin, wounds, respiratory and gastrointestinal tract (2)

The mechanisms of resistance in acinetobacter fall into 3 categories. Antibacterial inactivating enzymes, reduced access to bacterial targets

and mutations that change cellular targets or functions. (4) For the rst category, acinetobacter species possess a wide array of beta

lactamases that hydrolyse and confer resistance to penicillin, cephalosporin and carbapenems. AmpC cephalosporinase is common to all

strains of A.baumannii. In addition, other beta lactamases have been reported and most problematic is the emergence of OXA enzymes

which confer carbapenem resistance. Porin and outer membrane proteins are important for transport of antimicrobial agents to the cell to

gain access to bacterial targets. Carbapenem resistance has been linked to the loss of protein thought to be porin channels from the outer

membrane. Acinetobacter species possess efux pumps that are capable of actively removing a broad range of antibacterial agents from

bacterial cell. The third category of resistance mechanism involves point mutations that alter bacterial targets and functions, decreasing the

afnity for antimicrobial agents .Resistance to colistin is thought to be mediated by changes in bacterial cell membrane that interfere with

agent’s ability to bind bacterial targets .Currently the term “multidrug resistance” in reference to acinetobacter doesn’t have a standard

denition. It most of the times denotes resistance to three or more classes of drugs that would serve as treatment for Acinetobacter

infection (quinolones, cephalosporins and carbapenems) (2)

Crude mortality rate of 30-75% have been reported for nosocomial pneumonia caused by acinetobacter. (6) Multidrug resistant (MDR)

acinetobacter infection can signicantly prolong the hospital stay, ICU stay and increase economic cost. Multiple studies have been

undertaken to analyse the risk factors associated with multidrug resistant acinetobacter.

Historically, acinetobacter has been a pathogen of hot and humid climates, where it has been a major cause of infection, particularly in

intensive care units and sometimes a cause of community acquired pneumonia (1)

Multidrug resistant Acinetobacter baumannii is a pathogen associated with infections that include bacteremia, pneumonia, meningitis,

urinary tract infection and wound infection. The risk factors for multidrug resistant A.baumannii include prolonged stay in hospital, exposure

to intensive care unit, mechanical ventilation, central venous catheterization, prior exposure to antimicrobials, colonization pressure,

enteral feeding, and severity of illness and receipt of invasive procedures(2, 3, 4, 5)

Infection with MDR acinetobacter tends to occur in debilitated patients, mostly in ICU. Residents of long-term facility are at increased risk.

Acinetobacter outbreaks have been traced to common source contamination, particularly contaminated respiratory therapy, ventilator

equipment, cross infection by hands of health care workers. Wills et al reported the outbreak of MDR acinetobacter infection with

environmental contamination found on curtains, laryngoscope blades, door handles, knobs, key boards. (1) Selective pressure from broad

spectrum antimicrobial therapy such as therapy involving carbapenems, third generation cephalosporins increases the risk of infection (2)

Community acquired infections with acinetobacter have been reported in Australia and Asia. These were characterized by pharyngeal

carriage of organisms, aggressive pneumonia and high fatality rates and were linked to alcoholism and malignancy(1)

Dr. Anjana Raina MisriConsultant critical care medicine

MBBS, MD, IDCCM, FACC (Toronto)

Manipal Hospital Whiteeld

E-mail- [email protected]





To conclude, several factors work together to maintain the presence of MDR Acinetobacter in health care setting which includes presence

of susceptible patients, presence of patients already colonized , selective pressure from antimicrobial use and incomplete compliance with

infection control procedures .Acinetobacter is a marker of increased mortality in patients with severe underlying illness but not an

independent predictor of mortality

We need to adopt multiple strategies to control an outbreak of MDR infection in our ICU. When the cases of MDR Acinetobacter are

increasing, epidemiological investigation is warranted. Once a transmitted organism is endemically established, and irrespective of whether

a common source could be eliminated, contaminant may require multifaceted interventions and in most of cases, aggressive and resource

demanding measures. Infection control interventions, cohort isolation, improved hand hygiene compliance, enhanced cleaning and

environmental disinfection have been successful at reducing nosocomial infection rates and outbreaks. Hand Hygiene is of paramount

importance because majority of transmission events occur via health care workers. Single rooms are advisable, if not possible cohorting of

patients is an alternative. Surveillance cultures may be taken in outbreak situation. A wide range of surface may be sampled, from equipment

to wall surfaces and water supplies. Antibiotic stewardship is an important intervention to prevent the MDR infection. Rigorous cleaning and

disinfection protocol decrease the risk. The programme should have institutional and administrative support(11)

REFERENCES:

1. Current concepts Acinetobacter infection, L.Silvia Monaz-Price,Robert A.weinstein et al, N Engl of Med 2008;358:1271-81

2. Acinetobacter baumannii: Epidemiology, Antimicrobial Resistance, and Treatment Options, Maragashi.L, PerlT, Clin.infect Dis.2008;46

:1254-63

3. MDR Acinetobacter baumannii: a descriptive study in a city hospital Lemuel L Dent, Dana R Marshall, Siddharth Pratap and Robert B

Hulette Dent et al. BMC Infectious Diseases 2010, 10:196

4. Risk factors for hospital-acquired antimicrobial-resistant infection caused by Acinetobacter baumannii, Darcy Ellis, Bevin Cohen, Jianfang

Liu, Elaine Larson,antimicrobial resistance and infection control(2015) 4;40

5. A multi-center study on the risk factors of infection caused by multi-drug resistant Acinetobacter baumannii. Huiping Huang, Borong

Chen, Gang Liu, Jing Ran, Xianyu Lian, Nan Wang, Zhengjie Huang,BMC Infectious Diseases (2018) 18:11

6. Risk Factors for Occurrence and 30-Day Mortality for Carbapenem-Resistant Acinetobacter baumannii Bacteremia in an Intensive Care

Unit Song Yee Kim, Ji Ye Jung, Young Ae Kang, Joo Eun Lim, Eun Young Kim, Sang Kook Lee, Seon Cheol Park, Kyung Soo Chung, Byung Hoon

Park, Young Sam Kim, Se Kyu Kim, Joon Chang, and Moo Suk Park ,J KoreanMed Sci 2012;27;939-947

7. Poirel L, Nordmann P. Carbapenem resistance in Acinetobacter baumannii: mechanisms and epidemiology. Clin Microbiol Infect 2006;

12: 826-36

8. Garcia-Garmendia JL, Ortiz-Leyba C, Garnacho-Montero J, Jimenez-Jimenez FJ, Perez-Paredes C, Barrero-Almodovar AE, Gili-Miner

M. Risk factors for Acinetobacter baumannii nosocomial bacteremia in critically ill patients: a cohort study. Clin Infect Dis 2001; 33: 939-46

9. Epidemiology of infection in medical ICU in India, Rajesh.V.Ghanshani, Rajeev Gupta et al,Intensive care Medicine ,2014,40;456-457

10. Risk factors and outcome of Acinetobacter baumannii infection in severe trauma patients,Amselmo caricato,Luca Montini et al,Intensive

care medicine (,2009) 35 ;1964-1969

11. Task force on management and prevention of acinetobacter baumannii infection in ICU,Jose Garnacho-Montero, George Dimopoalis et

al ,Intensive care Medicine (2015) 41;2057-2075

12. Mc Donald et al, International network for the study of emerging antimicrobial resistance. Emerg Infect Dis7:319-322





Several investigators have found an association of MDR Acinetobacter with comorbidities. It has been associated with diabetes mellitus,

cardiovascular disease, Chronic obstructive pulmonary disease (COPD), and neurological impairment. Neurological injury in particular

paraplegia has been shown to be associated with development of resistant acinetobacter.

It is well accepted that patients with chronic lung disease are at increased risk of airway colonization and pneumonia especially when they

require intubation. Additionally, intubated patients with COPD are often treated with prophylactic antibiotics which increase the risk of

resistance. The greater resistance among respiratory tract infections may be explained by high levels of Acinetobacter contamination on

respiratory and suctioning equipment particularly in ICU which may lead to environmental reservoirs of resistant strains. This nding

highlights the importance of environmental hygiene for preventing MDR infection. (6, 8, 1) The duration of mechanical ventilation has been

found to be a strong predictor of MDR infection

The association with diabetes is most likely due to the high prevalence of chronic diabetic lower extremity wounds in this population. The

ability of acinetobacter to colonize or infect soft tissue and bone many of surgical patients can develop resistant acinetobacter in chronic

diabetic wound, amputation sites or decubitus ulcers. (4, 5)

Incidence of acinetobacter infection in trauma patients is high. Trauma favours a state of relative immunosuppression which correlates with

severity of injury and is characterized by blunt response of both humoral and cell mediated immunity. Data has shown that in multiple

trauma patients it doesn’t increase the mortality rate but a longer duration of ICU stay(10)

Ghanshani et al studied epidemiology of infection in medical ICU in India and concluded that most of the patients at risk for MDR

Acinetobacter were patients with respiratory disease followed by liver disease. Comorbidities associated with infection were patients with

chronic obstructive pulmonary disease, diabetes and hypertension. Antibiotic exposure was noted in 98% of patients(9)

Presence of immunosuppression, organ replacement therapy like haemodialysis signicantly increases the likelihood of infection with MDR

gram negative bacteria. Chemotherapy or radiotherapy within 6 months before admission to ICU has been found to be a risk factor for

carbepenem resistant acinetobacter bacteremia. Several studies have documented higher rate of MDR infection in patients with history of

prior hospitalisation(6, 7)

Another important risk factor is the use of multiple types of antibiotics. Previous antibiotic use appears to be a most important factor for

MDR infection and creates an intricate pattern of resistance, not only by selecting resistant or hypermutant clones but also by inducing

defence mechanisms against classes of antimicrobials in various species of microbes. Studies have reported that use of carbapenem

antibiotics within 28 days of infection was signicantly related with MDR bacterial infection. Inappropriate drug combination leads to the

selective pressure, which increases the opportunity of Acinetobacter infection and promotes the selection of drug resistant bacteria. The

beta lactam antimicrobial drugs can induce acinetobacter to produce beta lactamase and inactivate antimicrobial drugs, resulting in

resistance of acinetobacter to other beta lactam antibiotics(4, 5)

Indwelling catheter is also an independent risk for MDR acinetobacter infection. Renal failure during ICU stay has been identied as

independent risk factor for 30-day mortality in patients with carbapenem resistant Acinetobacter bacteraemia (CRAB). Recent abdominal

drainage has also been associated with increased risk of CRAB bacteraemia(6)

Acinetobacter infection also has shown a seasonal variation. Since 1974, CDC has noted higher rate of nosocomial acinetobacter infections

in the summer than in other seasons.MC Donald and colleagues evaluated 3447 acinetobacter infection in ICU that were reported to CDC

between 1987 and 1996 infection rates were 50% higher from July to October than at other times. (12) Possible explanation includes

warmer, more humid ambient air, which favours growth of acinetobacter in its natural habitats and potentially preventable environmental

contaminants such as condensate from air conditioning units, which has been implicated as a cause of epidemic acinetobacter infection(1)



1. Are the Title and Objectives appropriate?

• Title is clear and appropriate

• Objectives of the study are clearly stated

2. What is the clinical importance of that objective?

• Frequency of venous thromboembolism (VTE) in critically ill (severe) COVID-19 patients is signicantly higher (25-27%) when compared

to critically ill non-COVID 19 patients where it is 5-10 %.

• Acute phase proteins and inammatory mediators are elevated in pathogenesis of COVID 19. But inadequate data to prove this as the

cause of increased rates of VTE.

Was it studied previously and what were the results?

• F.A. Klok, et al looked at 184 proven COVID 19 ICU patients receiving standard doses of thromboprophylaxis – 27% had VTE (PTE being

most common – 81%) and 3.7% arterial thrombosis.

• Songping Cui et al analysed 81 severe COVID -19 ICU patients and found the incidence of VTE in these patients was 25% (20/81), of

which 8 patients died due to VTE related events. With a D-dimer cut off of 1.5 µg/mL for predicting VTE, they were able to predict VTE with

sensitivity of 85.0% and specicity of 88.5% and NPV – 94.7%. This is much higher than the current study which had sensitivity and

specicity of 89.7% and 59.5%, respectively.

• Both of these found the incidence to be as high as 25-30% which was similar to the results of this study.

• Thrombo-elastography (TEG) has not been used in any of these studies.

3. Do the study design, the variables selected and statistical methods match? Hint: Is it descriptive or analytical? Are Groups

being compared? If so how.

• Retrospective observational cohort study

• Patients were grouped into VTE & No VTE.

• Baseline characteristics were compared between these groups.

4. What statistical methods have been used?

• Continuous variable- mean with SD or median with IQR.

• Categorical variable- numbers with percentages

• Mann-Whitney U test, Chi Square Test are used for comparison

• Area under curve of ROC and Youden index used to identify best cut off points though Youden index value is not mentioned.

A) Are they appropriate for the data and methods?

Yes.

B) Sample size calculation appropriate?

Convenience sampling was used.

5. What were the results?

• Venous thromboembolism was diagnosed in 31 patients (28%) out of 109 patients included in the study, two patients at admission and the

remaining during stay despite routine chemoprophylaxis (26.6%). Two patients developed despite being on full anticoagulation. Mean time

to hospital admission to DVT was 8±7 days.

• Elevated admission d-dimer and peak d-dimer were associated with venous thromboembolism development (p < 0.05) and predicted

VTE with AUC of 0.760. (sensitivity and specicity of 89.7% and 59.5%, respectively).

• High platelet counts, AST, LDH, Troponin at presentation were signicantly associated with development of VTE.

• Peak platelet count of < 3.6lakhs predicted VTE with AUC of ROC of 0.7, sensitivity of 80.6% and specicity of 55.1% which may not be

clinically signicant.

• Though baseline LDH correlated with VTE development, the peak value was not signicantly associated with development of VTE.

• 12 patients (11%) were subjected to TEG and 58% had hypercoagulable state.

Dr. Hemalatha R V, MD, [DM Critical care]

Senior resident,

St. Johns Medical College Hospital,

Bengaluru.

JOURNAL SCAN 1Article: Maatman TK et al. “Routine Venous Thromboembolism Prophylaxis May Be Inadequate in the Hypercoagulable

State of Severe Coronavirus Disease 2019”. Critical Care Medicine 2020. doi: 10.1097/CCM.0000000000004466



6. Conclusions:

a) What conclusions have been drawn?

COVID 19 results in a hyper-coagulate state.

Routine chemical venous thromboembolism prophylaxis may be inadequate in preventing venous thromboembolism in severe corona virus

disease 2019.

b) Are they relevant to clinical or scientic practice:

Yes, the results have potential to change the practice patterns of thromboprophylaxis. However, RCTs are required to decide on optimal

dosage of VTE chemoprophylaxis in critically ill COVID-19 patients.

c) Are the conclusions justied by the methodology and the ndings?

Yes

7. Strengths

• Studies including autopsies have shown that COVID-19 patients have increased risks of developing microvascular thrombosis and this

study also supports the same.

• TEG is a point of care test, which tells us about the viscoelastic property of blood. Its interpretation can clearly tell us the defect in clotting

pathway. Using TEG would throw more light on further management of patients.

• Multicentric study.

8. Limitations

• It is a retrospective observational study and hence has its own inherent bias and limitations.

• Clinically suspected VTE were only evaluated due retrospective nature of the study, so few of VTE which were not suspected clinically

would have been missing.

• Other risk factors like presence of CVC (5 patients 2 with IJV and 2 FV), degree of viremia (correlation with viral load) were not looked

into.

• Control group of critically ill non COVID patients were not included to get a baseline prevalence of VTE in ICU.

• Prothrombin time was never measured in these patients.

• Patients who had sudden death were not autopsied to look for vascular thrombosis.

• Only quantitative analysis of platelets was done and qualitative aspects were not evaluated.

• Denition of full anticoagulation is lacking.

• Very few individuals in this study were subjected to TEG, and hence results cannot be extrapolated to all COVID-19 patients without a

bigger study.

• Inadequacy of routine chemical thromboprophylaxis was not dealt with in detail.

• Admission SOFA and APACHE score were not included in baseline characteristics.

• Critically ill non COVID-19 patients were not included as controls.

• No difference in frequency of VTE in patients with and without organ supports (Mechanical ventilation, RRT, vasopressor) is surprising.

9. The Final Message: What are the ndings of this article?

• COVID -19 is associated with hypercoagulable state and there is an increased incidence of VTE in COVID 19. Elevated D-dimer levels are

associated with development of VTE.

• Routine doses of chemical thromboprophylaxis may not be adequate to combat VTE in COVID.

10. The Utility:

• This study nds an increased incidence of VTE, especially when D-dimer levels were elevated. It also demonstrates hypercoagulability in

COVID-19 patients using TEG. But inammatory state responsible for VTE is not clear at this point.

• Even though the area under the ROC curve of 0.76 for d- dimer is statistically signicant, it may not be signicant clinically.

• In this study, the peak D-dimer value has a specicity of only 59.5%, hence it cannot rule in a VTE. However, it has a good sensitivity.

• Only 11% of sample size have undergone TEG. Further studies are needed with more people being subjected to TEG to get to a

conclusion regarding the role of TEG in COVID-19.

• Few questions remain unanswered and requires further studies, such as:

o What is the optimal dose and duration of anticoagulation to prevent VTE in COVID-19 patients? And how to treat patients who cannot

receive anticoagulants?

o Should patients treated at home receive pharmacological thromboprophylaxis?

o How long should we continue thromboprophylaxis for these patients?

o Should we screen all COVID-19 patients for DVT at the moment of hospital admission, or during hospitalization and if so, how frequently

do we need to assess?

o When should we consider performing CTPA to rule out PE in patients with COVID-19 pneumonia?

References/ Further reading:

• F.A. Klok, et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res 2020.

• Songping Cui, et al. Prevalence of Venous Thromboembolism in Patients With Severe Novel Coronavirus Pneumonia. J Thromb Haemost

2020.

JOURNAL SCAN 1Article: Maatman TK et al. “Routine Venous Thromboembolism Prophylaxis May Be Inadequate in the Hypercoagulable

State of Severe Coronavirus Disease 2019”. Critical Care Medicine 2020. doi: 10.1097/CCM.0000000000004466



JOURNAL SCAN 2

Doctors and hospitals are regularly faced with the ethical dilemma of whether or not to perform Cardiopulmonary resuscitation (CPR) in

patients suffering from terminal illness and without the prospect of a reasonable quality of life even if they are revived.

Do not attempt resuscitation (DNAR) is an option that may be exercised by the treating physician in these situations in the best interests of

the patient. A core committee of experts from various disciplines was constituted to draft the guidelines, and several other experts were

consulted. The guidelines were nalized through a national web based and in person consultative meeting with a wider representative

audience.

CPR is a form of treatment to be provided by the treating physician and the responsibility for the nal decision regarding DNAR rests with

the treating physician(s), which should be taken in consultation with the patient/surrogate(s), empowered with the required information.

The document aims to help treating physician(s) and patient/surrogate(s) in preserving dignity in death and avoid prolonged suffering to the

patient through non-benecial CPR while continuing to provide other potentially curative and supportive care. While applying this principle,

compassionate care is integral to the overall goals of medical treatment.

DNAR is distinct from withdrawal or withholding of other life-supporting treatments and advance directives which do not come under the

purview of this document. This document can be understood in the following headings: (Figure 1)

1.Role of Team work: DNAR ensures respect for human rights. The patient’s right to autonomy and, the patient’s Right to Die with Dignity

(Article 21) is upheld by this process. Teamwork and good communication are of crucial importance. There should be adequate

opportunity, time and space to discuss with the patient and family in private and facilitate clear understanding of DNAR and its implications. It

should be done in anticipation of an impending cardiorespiratory arrest, during the current hospitalization of the patient.

2. Communication skills: While communicating, the treating physician(s) should explain that the patient would continue to be provided all

treatments intended for potentially curable conditions or to reverse potentially reversible conditions and to provide supportive care. The

treating physician(s) should understand the social/cultural perspective of the patient. Often the patient’s relatives/surrogates may face an

ethical dilemma to take the decision regarding DNAR. To provide them psychological support and help them overcome any feeling of guilt,

the treating physician(s) should explain to them the futility of CPR and the harm it might cause to the patient.

3. Clinical Triggers to initiate: The clinical triggers to initiate discussions regarding DNAR include (but may not be restricted to) the

following:

• Where death is imminent (within a few hours or days),

• Advanced, progressive, incurable conditions,

• Existing conditions where sudden death may occur as an acute complication, and

• Life-threatening acute conditions caused by sudden catastrophic events or persons in persistent vegetative state (PVS).

4.DNAR is different from Withdrawal and Withholding: Moreover, DNAR does not mean withdrawal or withholding of other life-

supporting treatments.

Withholding and Withdrawal of life support refer to the processes according to which various medical interventions either are not given to

or are removed from patients respectively, with the expectation that they will die as a result.

5.If the treating physician is unsure about DNAR decision: If the treating physician is unsure, about the futility of CPR, or there is no

consensus between the physician and the patient/surrogate, combined decision may be taken with the help of another physician, a

psychologist or social worker or a counsellor or the hospital administrator, particularly in some settings, such as rural hospitals, where other

types of personnel may not be available.

Dr. Manu Varma M K,Assistant Professor,


St John’s Medical College

Benguluru - 560026

Article: ICMR Consensus Guidelines on ‘Do Not Attempt Resuscitation’. Indian J Med Res 151, April 2020, pp 303-310. DOI: 10.4103/ijmr.IJMR_395_20.



6.Documentation and Implementation: All such discussions must be noted in the patient’s case records and the DNAR form. DNAR

forms should be available in the language understood by the patient/surrogate(s) and should be signed, timed and dated by

patient/surrogate(s) and the treating physician(s). In case the patient/surrogate(s) does/do not sign the DNAR form, the same should be

recorded. The resuscitation plans and completed DNAR forms should be easily accessible to all the medical professionals to respond

appropriately in the event of cardiorespiratory arrest of the patient concerned. It is recommended to attach a copy of the DNAR form to the

patient’s case records and to be integrated with the electronic health records, if available. All the case reports along with the DNAR forms

should be archived for future reference. Hospital administration should make efforts to sensitize their healthcare professionals on all issues

related to DNAR.

7.Surrogate decision making: A surrogate is a person or persons other than the healthcare providers who is/are accepted as the

representatives of the patient’s best interests, who will make decisions on behalf of the patient when the patient loses his/her capacity to

make healthcare decisions. A hierarchy of surrogates is not dened in the Indian Law. If patient’s wishes are not known and the patient has

no surrogate a “Legally Authorized Representative (LAR)” or caregiver or hospital administration authorities should be involved in the

decision on DNAR.

8.Conict of opinion: In case of conict of opinion, an independent second opinion from a qualied medical practitioner belonging to the

relevant specialty may be sought by the treating physician/patient/surrogate(s) in a timely manner. Any decision taken contrary to patient’s

expressed wishes should be based on robust criteria, accounted for and documented in the hospital records.

9.Need for SOP’s and policies: Hospitals can put policies in place to ensure that all physicians are made aware of the DNAR option and

support its implementation. They can ensure adequate training of doctors and staff, improve the communications between doctors and

patients, set up clinical ethics committees or multidisciplinary teams which can help guide the process and effective implementation, create

educational videos, teaching material for better awareness of patients and integrate DNAR in the health records, and for review and

feedback to maintain quality of care.

References/suggested readings:

1. Cook D, Rocker G. Dying with dignity in the intensive care unit. New England Journal of Medicine. 2014 Jun 26;370(26):2506-14.

2. Cain JM, Storm C, Olver I. Making the Decision to Not Attempt Resuscitation. Journal of oncology practice. 2008 Mar;4(2):99.

3. Knipe M, Hardman JG. I. Past, present, and future of 'Do not attempt resuscitation' orders in the perioperative period. Br J Anaesth.

2013;111(6):861-863.

Figure 1 Algorithm for Do Not Attempt Resuscitation (DNAR) decision-making

JOURNAL SCAN 2Article: ICMR Consensus Guidelines on ‘Do Not Attempt Resuscitation’. Indian J Med Res 151, April 2020,

pp 303-310. DOI: 10.4103/ijmr.IJMR_395_20.



JOURNAL SCAN 3

1. Are The Title and Objectives appropriate?

Title : appropriate

Primary objective: Time to clinical improvement within a 28 day period with convalescent plasma therapy (CPT) compared to standard

therapy.

Secondary objective:

• 28-day mortality, including analysis of time from randomization to death.

• Duration of hospitalization, including analyses of time from randomization to discharge, time from admission to discharge, and 28-day

discharge rates;

• Conversion of nasopharyngeal swab viral PCR results from positive at baseline to negative at follow-up assessed at 24, 48, and 72 hours

respectively. Once nasopharyngeal swab viral PCR testing yielded negative results 2 times consecutively, no further testing was performed.

2. How were the patients and donors selected for this study?

Patients (P):

Inclusion criteria:

• Age >18 years

• COVID-19 diagnosis based on polymerase chain reaction (PCR) testing

• Positive PCR result within 72 hours prior to randomization

• Pneumonia conrmed by chest imaging

• Clinical symptoms meeting the denitions of severe or life-threatening COVID-19;

• Severe COVID-19 was dened as respiratory distress (≥30 breaths/min; in resting state, SpO2 ≤ 93% on room air; or arterial partial

pressure of oxygen (PaO2)/fraction of inspired oxygen (FIO2) of 300 or less.

• Life-threatening COVID-19 was dened as respiratory failure requiring mechanical ventilation; shock; or other organ failure (apart from

lung) requiring intensive care unit (ICU) monitoring.

• No participation in other clinical trials, such as antiviral trials, during and within 30 day the study period.

Exclusion Criteria:

• Pregnancy or lactation;

• Immunoglobulin allergy;

• IgA deciency;

• Pre-existing co-morbidity that could increase the risk of thrombosis;

• Life expectancy less than 24 hours;

• Disseminated intravascular coagulation;

• Severe septic shock;

• PaO2/ FiO2 of < 100;

• Severe congestive heart failure;

• Detection of high titres of S protein–RBD-specic (receptor binding domain) IgG antibody (≥1:640)

Donors:

• Age 18 to 55 years,

• No C/I for blood donation,

• Initially diagnosed with COVID-19 but with 2 negative PCR test results from nasopharyngeal swabs (at least 24 hours apart) prior to

hospital discharge,

• Discharged for more than 2 weeks from the hospital,

• No persisting COVID-19 symptoms.

Convalescent plasma collection was performed based on routine plasma collection procedures via plasmapheresis.

Dr Magesh ParthibanSenior Resident (DM Critical Care)

Department of Anaesthesiology and Critical care,

JIPMER, Pondicherry

e-mail: [email protected]

Effect of Convalescent Plasma Therapy on Time to Clinical Improvement in Patients with Severe and Life-threatening

COVID-19- A Randomized Clinical Trial". JAMA 2020.Published online June 03, 2020. doi:10.1001/jama.2020.10044



JOURNAL SCAN 3

2What is the clinical importance of that objective? Was it studied previously and what were the results?

a. Clinical importance/Problem (P): Convalescent plasma therapy (CPT) has been used to treat in respect to COVID-19, as an

investigational therapy in recent times with no denitive therapy available. Limited data case series from China and South Korea, have been

reported with promising results. However, the lack of good-quality RCT means the efcacy and safety of CPT still remain unanswered. This

RCT tries to address some of these queries by

• Evaluating the efcacy and safety of CPT in addition to standard regimen.

• Also, by standardising the donor criteria and quality control measures for convalescent plasma collected.

b. Was it previously studied? Previously only uncontrolled case series of CPT in patients with COVID-19 have shown a possible benet. Shen

et al. were the rst from China to evaluate this effect in an uncontrolled case series of ve patients with COVID-19 with all of them showing

clinical improvement. Later three more case series from China and one more from South Korea with similar ndings were published.

However, all of them were only case series with limited sample size and did not have a standardised donor criteria for convalescent plasma

collection.

3. Do the study design, the variables selected and statistical methods match? Hint: Is it descriptive or analytical? Are Groups

being compared? If so how.

This is an analytical randomised (open label) trial. The study was prematurely terminated due to absence of new cases following

containment strategies. After initial screening a total of 103 patients were randomised into two groups:

Comparison ©:

a. Group 1: CPT in addition to standard therapy.

b. Group 2: only standard therapy.

The standard therapy included antiviral medications, antibacterial medications, steroids, human immunoglobulin, Chinese herbal

medicines, and other medications based on evolving national guidelines.

4. a. What statistical methods have been used?

Statistical analyses were performed with SAS software, version 9.4. A per-protocol analysis was performed to exclude any signicant

protocol violations. Cox-proportional hazard models were used to calculate hazard ratios. The primary outcome time to clinical

improvement within a 28day period was assessed using hazard ratio. All the secondary outcomes were analysed using hazard ratio and odds

ratio for time to event data and discrete variables, respectively.

A post hoc analysis was added to compare rates of improvement at days 7, 14, and 28.

b. Are they appropriate for the data and methods? Yes

c. Sample size calculation appropriate? What is the Power of the study and what is the fragility index? The original sample size was calculated

to be 100 for each group with a 80% power to detect an 8-day change for CPT group in the primary outcome assuming this would be 20

days in the control group.

However, due to premature termination of the study, the sample size is underpowered to detect the change. The fragility index of this RCT

is zero indicating that the results are less robust.


The trial included 103 participants with laboratory conrmed COVID-19 that was severe or life-threatening (shock, organ failure, or

requiring mechanical ventilation). The trial was terminated early after 103 of a planned 200 patients were enrolled. They were recruited

from 7 medical centres in Wuhan, China, from February 14 - April 1, 2020.

Patients in the intervention group (n=52) received convalescent therapy in addition to standard treatment. Patients in the control group

(n=51) received standard treatment alone.

Participant demographic prole





Study Results

Control Group Intervention Group

Total patients Patients showing improvement in 28 days Total patients Patients showing improvement in 28 days

51 22 (43%) 52 27 (51.9%)

Patients enrolled 103

Patients completing the study 101 (98.1%)

Patient Median age 70

Number of male patients 60 (58.3%)

Number of female patients 43 (41.7%)

JOURNAL SCAN 3

Primary outcome: When all patients are combined for analysis there was no signicant difference in the time to clinical improvement,

difference of 8.8% with HR 1.40, p- 0.26. However, among patients with severe disease the difference increased to 23.1% with HR of 2.15,

p = .03.

Secondary outcomes: The conversion from positive to negative by viral PCR for SARS-CoV-2 were all signicant at 24,48 and 72hrs in CPT

group, difference of 29.7%, 35.6%, 49.7%, respectively. Further, sub-group analysis showed that the difference was signicant only at

72hrs in the severe group, although in the life threatening group the difference was statistically signicant at all times. No signicant

difference were observed in 28day mortality and duration of hospital mortality.

Adverse events: two participants had transfusion related adverse events in the CPT group.

6. Conclusions:

What conclusions have been drawn?

Convalescent plasma therapy in addition to standard therapy did not result in statistically signicant clinical improvement in patients with

severe or life-threatening COVID-19.

Are they relevant to clinical or scientic practice? Yes

Are the conclusions justied by the methodology and the ndings ?

No, the study is underpowered because of smaller sample size than estimated.

7. Strengths:

• This the rst RCT evaluating the efcacy and safety of convalescent plasma therapy for COVID-19.

• Standardisation of donors with clearly dened donor criteria.

•Quality control of collected plasma with clearly dened cut-off for antibody titres.

8. Limitations

• The sample size is small as the study was terminated early. Hence, the study is likely to be underpowered to detect a clinically signicant

benet from convalescent plasma therapy.

• The median time between the onset of symptoms and randomization was 30 days, therefore it is not certain if earlier treatment would

have resulted in better outcomes.

• This was an open-label study and the primary outcome was relied to some extent on the physicians clinical judgement.

• The use of standard therapy was not protocolized, which could have potentially inuenced outcomes.

• The relatively short 28-day time frame of the study follow-up may have precluded the observation of clinical improvement in patients with

severe diseases, especially life threatening COVID-19, as they may take longer time to respond and recover.

• Fresh frozen plasma could have been used for the control group, which would have made blinding possible.

• The timing of transfusing plasma was also not standardised


Convalescent plasma therapy can be used as an investigational treatment for patients suffering from severe or life threatening COVID-19.

the study ndings should be interpreted cautiously.

10. The Utility:

Can I generalise the ndings to my patients?

No, as standard treatment, supportive care, and thresholds for intubation and hospital admission may vary, it is not appropriate to generalise

the ndings of this possibly underpowered study to patients in our institution. Also, the outcomes may also be potentially inuenced by many

factors, like the quality of the convalescent plasma products, the selection of the patients (severe and life-threatening COVID-19), and the

timing of convalescent plasma transfusion. Hence, larger multi-centric RCT's are required to adequately assess the efcacy and safety of

convalescent plasma therapy in COVID-19 patients.

References/ Suggested readings:

1. Rajendran K, Krishnasamy N, Rangarajan J, Rathinam J, Natarajan M, Ramachandran A. Convalescent plasma transfusion for the treatment

of COVID-19: Systematic review [published online ahead of print, 2020 May 1]. J Med Virol. 2020;10.1002/jmv.25961.

doi:10.1002/jmv.25961.

2. Bloch EM, Shoham S, Casadevall A, et al. Deployment of convalescent plasma for the prevention and treatment of COVID-19. J Clin

Invest. 2020;130(6):2757-2765. doi:10.1172/JCI138745.





Measure of Primary Outcome in Patients with life-threatening signs


7/29 (24.1%) 6/29 (20.7%)

Measure of Primary Outcome in Patients with severe disease


15/22 (68.2%) 21/23 (91.3%)

JOURNAL SCAN 4“Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019

patients with coagulopathy” Tang N, Bai H, Chen X, Gong J, Li D, Sun Z. J Thromb Haemost. 2020;18(5):1094-1099.

CRITICAL APPRAISAL:


• Study title aims to convey that anticoagulation decreases mortality in severe COVID 19 patients with coagulopathy. It is unclear from the

title if treatment implies therapeutic or prophylactic dose of anticoagulation

• Objective looked to validate the recommendation made by expert consensus “at the time to use heparin” for treatment of COVID 19

induced coagulopathy/ DIC.

• Study also aimed at identifying COVID 19 patients who would benet from anticoagulation

2. What is the clinical importance of the objective?

• At the time of the study, very little was known about the epidemiology, risk factors for severe disease and possible therapeutic options.

• Based on three observational epidemiological studies about the disease caused by novel corona virus it was evident that COVID 19 was

associated with deranged coagulation.

• The International Society of Thrombosis and Haemostasis (ISTH) identied a new category of patients in early phase of Disseminated

intravascular coagulation (DIC) and labelled them “sepsis induced coagulopathy” (SIC) based on a scoring system (SIC score).The

components of SIC score being Prothrombin time (PT), Platelet count and total SOFA score, with score ≥4 being positive. In a study it

was observed that patients, with diagnostic criteria of SIC, beneted from anticoagulation. Present study aims to validate its usefulness in

COVID 19 patients as well.

Was it studied previously and what were the results?

• Ning Tan et al. 1 described the coagulation prole in 183 consecutive patients admitted with novel coronavirus pneumonia (NCP). It was

found that overall mortality was 11.5%. The non-survivors revealed signicantly higher D-dimer and brin degradation product (FDP)

levels, longer prothrombin time and activated partial thromboplastin time compared to survivors on admission (p < 0.05). 71.4% of non-

survivors and 0.6% survivors met the criteria of disseminated intravascular coagulation during their hospital stay. They concluded that

abnormal coagulation results, especially markedly elevated D-dimer and FDP are common in deaths with NCP

• Nanshan Chen et al. 2 in their descriptive epidemiological study on 99 patients, 36% of patients had an elevated d dimer levels, although

association with mortality had not been studied.

• Chaolin Huang et al.3 studied the clinical features of patients admitted with COVID 19 and found that D dimer and PT values were

signicantly different between patients who needed ICU care and those who did not.

• Though the previous studies had shown increased incidence of coagulopathy, there are limited evidence on the utility of SIC sore and

anticoagulation in Covid-19 patients.

3. Do the study design, the variables selected and statistical methods match?

• This was a retrospective observational cohort study

• A retrospective review of patient characteristics was done through hospital EMR

• Exclusion criteria: bleeding diathesis, hospital stay < 7 days, lack of information about coagulation parameters and medications, and age <

18 years

• Severe COVID 19 patients (dened as patients having a respiratory rate ≥30 breaths/min; arterial oxygen saturation ≤93% at rest; PaO2/

FiO2 ≤ 300 mm Hg) were grouped into those who received anticoagulation for 7 days or longer and those who did not

• Clinical prole of survivors and non survivors was also studied


• Quantitative variables compared using the Student's t-test and the Mann-Whitney U test (depending on distribution). Categorical

variables were compared using the Chi square test.

• Results expressed as the mean ± standard deviation, median (interquartile range), or number (percentage) as appropriate.

• Categorical and consecutive variables were evaluated by logistic regression analysis for their ability to predict 28-day mortality.

• A p value of < .05 was considered statistically signicant.

Dr. Alok N MD (DM Critical Care Medicine) Senior Resident,


St Johns Medical College Hospital,

Benguluru

Email ID: [email protected]





A) Are they appropriate for the data and methods?

• Yes

B) Sample size calculation appropriate?

• Sample size calculation is not disclosed in the main article, being a retrospective study design.

• Consecutive sampling from electronic medical records was done


• 449 patients with severe COVID-19 enrolled into the study, 99 of them received heparin (mainly with low molecular weight heparin:

LMWH) for 7 days or longer.

• D-dimer, prothrombin time, and age were positively correlated, and platelet count was negatively correlated with 28-day mortality in the

multivariate analysis.

• No difference in 28-day mortality was found between heparin users and nonusers (30.3% vs 29.7%, P = .910).

• 97 patients met the criteria the SIC criteria.

• 28-day mortality of heparin users was lower than nonusers in patients with SIC score ≥4 (40.0% vs 64.2%, P = .029), or D-dimer >6-

fold of upper limit of normal approximate 20% reduction was seen (32.8% vs 52.4%, P = .017).

Conclusions:


• Anticoagulant therapy mainly with low molecular weight heparin appears to be associated with better prognosis in severe COVID-19

patients meeting SIC criteria or with markedly elevated D-dimer.

b) Are they relevant to clinical or scientic practice?

• Study implies that anticoagulation treatment in patients who have severe COVID 19 induced coagulopathy improves mortality.

• American College of Chest Physicians (ACCP) recommends thromboprophylaxis for prevention of VTE in critical care patients (grade IA:

strong recommendation with high quality of evidence). Moreover, omission of thromboprophylaxis within the rst 24 hours of ICU

admission without obvious reasons is associated with a higher risk of mortality in the ICU.

• We fail to understand as “how not giving pharmacological thromboprophylaxis to severe COVID 19 patients is justiable in the absence of

an obvious contraindication”?

• A lot of weightage has been given to quantitative elevation of D-dimer in COVID 19 patients. However it is clear that D dimer is elevated in

a number of conditions in hospitalized patients and its utility in diagnosing thromboembolic events is very poor.

• Elevated D dimer values do signify a sinister underlying disease.

c) Are the conclusions justied by the methodology and the ndings?

Being a retrospective study one would be cynical to justify the ndings. However, RCTs in this pandemic will be difcult.

Study aimed at identifying subgroup of severe COVID 19 patients who would benet from anticoagulation. Retrospective analysis shows

that these patients indeed can be identied based on SIC scores.

7. Strengths:

• One of the earliest studies to look at therapeutic options, considering that severe COVID patients who died had evidence of

microvascular thrombotic complications on autopsy.

• Clear inclusion and exclusion criteria have been put down

• Authors also sought to validate the use of SIC score in COVID 19 patients

• Heparin is used for prevention of DIC and also as therapy for slowly evolving DIC

8. Limitations

• Retrospective study design with inherent biases to the study design

• Study mentioned PT values of these patients. PT values differ from laboratory to laboratory. Using INR would have made the results more

generalizable.

• Inuences of other therapies have not been studied.

• No measures of severity of illness (APACHE/ SOFA) have been produced in baseline characteristics.

• ICU mortality is a crude outcome variable which is inuenced by a number of factors. A study of proximal end point like reduction in

incidence of VTE or reduction in inammatory biomarkers may have given us additional insight

• Study design to answer if anticoagulation improves mortality in COVID 19 patients is RCT






• Patients of severe COVID 19 with higher SIC score may benet from anticoagulation.

• SIC may be used to identify COVID 19 patients at risk of developing a full blown DIC

10. The Utility:

• Study shows that patients in early phase of DIC in COVID 19 may benet from anticoagulation

• Also is an epidemiological study which may contribute to big data and a metanalysis at a later date

• Hypothesis generating study

• Utility of the above study in an ICU setup where pharmacological thromboprophylaxis is practiced routinely is uncertain

References/Suggested readings:

1. Tang N, Li D, Wang X, Sun Z. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus

pneumonia. J Thromb Haemost 2020

2. Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan,

China: a descriptive study. Lancet. 2020;395(10223):507-513.3. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019

novel coronavirus in Wuhan, China. Lancet. 2020;395(10223):497-506.

4. Iba T, Di Nisio M, Levy JH, Kitamura N, Thachil J. New criteria for sepsis-induced coagulopathy (SIC) following the revised sepsis

denition: A retrospective analysis of a nationwide survey. BMJ Open; 2017. Available from:

https://bmjopen.bmj.com/content/7/9/e017046



JOURNAL SCAN 5This is a brief appraisal of the article published in Intensive care medicine “High risk of thrombosis in

patients with severe SARS-CoV-2 infection: a multicenter prospective cohort study”

on 4th May 2020. Intensive Care Med 46, 1089–1098 (2020). https://doi.org/10.1007/s00134-020-06062-x

Clinical question:

1. What is the incidence of venous thromboembolism (VTE) in severe Novel coronavirus pneumonia(NCP)


• Clear and objective

• purpose of the study conveyed plainly and rationally

• objectives of the study clearly stated

2. What is the clinical importance of that objective?

The novel coronavirus is spreading across the world with very high morbidity and mortality. Mortality has been attributed to hypoxemia and

multiorgan failure associated with it. Literature is emerging about the increased incidence of sepsis-induced coagulopathy/disseminated

intravascular coagulation with autopsy report of the lung suggesting microvascular thrombosis. Some of the retrospective studies have

found an increased incidence of thrombosis. This prospective cohort study was done to conrm the prevalence of increased thrombosis.

a) Was it studied previously and what were the results? – yes, mainly retrospective studies.

3. Do the study design, the variables selected and statistical methods match?

Are Groups being compared?-Yes

Design:

1) a multicenter prospective cohort study.

2)Intention to determine the incidence of VTE in patients with severe NCP.


Continuous variables are presented as median with the rst and third quartile and were compared using nonparametric Wilcoxon tests.

Categorical variables are presented as numbers and proportions and were compared using Pearson’s �2 tests or Fisher’s exact tests. To

compare the outcomes in this observational study, a propensity score analysis was performed. Propensity scores were generated using a

multivariable logistic regression model with the group (non-COVID-19 ARDS or COVID-19 ARDS) as the dependent variable and baseline

characteristics that were unbalanced between groups or had clinical relevance as the independent variables. Sensitivity analysis was

performed using multivariable logistic regression models on the whole population. Results are presented as odds ratio with 95% condence

intervals. A p-value�<�0.05 was considered as statistically signicant. All the analyses were performed using R software version 3.6.0. (R

Core Team (2019). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria

a) Are they appropriate for the data and methods?

No, Non-COVID-19 ARDS is a historical prospective cohort

Setting:

1) four intensive care units (ICUs) in two centres of a French tertiary hospital.

2) March 3rd and 31st 2020

150 COVID-19 patients were included (122 men, median age 63 [53; 71] years, SAPS II 49 [37; 64] points). Medical history, symptoms,

biological data and imaging were prospectively collected.

A historical prospective cohort of “non-COVID-19 ARDS” patients (NCT #02391792) included between 2014 and 2019 was used for the

comparison of COVID-19 ARDS to non- COVID-19 ARDS. All the patients had a bacterial or viral ARDS dened according to Berlin

denition

Dr. Rajavardhan R.Consultant intensivist

MBBS, MD, FNB, EDIC

Critical care medicine

Manipal hospital Whiteeld

E mail:[email protected]

DR. V. MOHAN BABUMD( Anaesthesiology) IDCCM

Registrar

Manipal hospital, Whiteeld, Bangalore

Phone no: 7406469823

Email Id: [email protected]



JOURNAL SCAN 5This is a brief appraisal of the article published in Intensive care medicine “High risk of thrombosis in

patients with severe SARS-CoV-2 infection: a multicenter prospective cohort study”

on 4th May 2020. Intensive Care Med 46, 1089–1098 (2020). https://doi.org/10.1007/s00134-020-06062-x


Sixty-four clinically relevant thrombotic complications were diagnosed in 150 patients during their ICU stay, mainly pulmonary embolisms .

One hundred CTPA were performed in 99 patients to investigate the cause of a respiratory re-aggravation or because of a signicant

increase of D-dimers. Twenty-ve (25%) showed pulmonary embolisms (24 men, mean age 62 years old): 9 troncular, 8 lobar, 5 segmental

and 3 subsegmental pulmonary embolisms. Pulmonary embolism was diagnosed in median 5.5 [2.8; 9.3] days after ICU admission.

Two patients had a left cerebellar ischemic stroke in MRI. Twenty-eight patients out of 29 (96.6%) receiving continuous renal replacement

therapy (RRT) experienced circuit clotting. After matching, more thrombotic complications were diagnosed in COVID-19 ARDS patients

than in patients with non-COVID-19 ARDS (9 patients (11.7%) versus 7 patients (4.8%), OR 2.6 [1.1–6.1], p�=�0.035), with signicantly

more pulmonary embolisms (9 patients (11.7%) versus 3 patients (2.1%), OR 6.2 [1.6–23.4], p�=�0.008).

6.Conclusions:


A systemic inammatory response syndrome, assessed by high brinogen, was present in all patients and was responsible for activation of

blood coagulation in almost all COVID-19 patients, as demonstrated by progressive D-dimers elevation. The coagulation activation pattern

was not the same as in our cohort of non-COVID-19 ARDS patients nor severe sepsis patients indicating an alternate pathophysiology.

High prevalence of clinically relevant thrombosis, essentially pulmonary embolisms (16.7%), in COVID-19 patients, admitted to ICU for

hypoxemic acute respiratory failure. These thrombotic complications occurred despite prophylactic or therapeutic anticoagulation.

b)Are they relevant to clinical or scientic practice? – YES

c)Are the conclusions justied by the methodology and the ndings? -No

Strength:

COVID 19 group is a prospective cohort

A higher number of patients studied compared to other trials

Weakness:

• It’s an observational study with a comparative group being retrospective cohort.

• The study cohort included sicker patients, which were referred to the tertiary care centre, whereas no mention of details about the

historical NON COVID 19 cohort

• A large number of COVID-19 patients were still intubated at the time of data collection, the incidence of thrombotic complications is

probably under-estimated.

• Did not have a systematic standardized assessment of thromboembolic events, and imaging was performed based on the evolution of

clinical or laboratory parameters, which may have led to variations according to the treating physicians.

Our view:

This study conrms the increased risk of thromboembolism which was suggested by the retrospective studies. COVID 19 group underwent

more imaging (CT pulmonary angiography) because of abnormal coagulopathy irrespective of clinical parameters. This indicates the

possibility of a high risk of bias.

More prospective RCTs are required to validate the ndings of the study and to nd out the role of anticoagulation-prophylactic and

therapeutic.



1: INNOVATIONS IN CRITICAL CARENovel Engineering to effectuate airborne isolation rooms in COVID 19 pandemic

In the era of the COVID-19 pandemic, controlling the spread of infection in the health care setting is of utmost importance for the safety of

the patients and health care personnel. An isolation facility aims to control the airow in the room so that the risk of transmission is

minimized. Depending on the requirement isolation rooms can be of two types – positive pressure rooms and negative pressure rooms.

Positive and negative pressures refer to a pressure difference between two adjacent air spaces (e.g., rooms and hallways). Air ows away

from areas or rooms with positive pressure to the areas with negative pressure.

Patients harboring airborne microorganisms are set in rooms with a negative pressure to prevent the microorganisms from entering

hallways and corridors. Rooms housing severely neutropenic patients are set at positive pressure to keep airborne pathogens in adjacent

spaces or corridors from coming into and contaminating the airspace occupied by such high-risk patients. Self-closing doors are mandatory

for both of these areas to help maintain the correct pressure differential.

Creating negative pressure rooms involves coordination and communication among infection-control personnel, laboratory personnel,

facility administrators, or their designated representatives, facility managers, department of engineering, and risk-management personnel.

In normal practice, most of these patient rooms would be served by an HVAC (heating, ventilation and air conditioning) system that would

be of a recirculatory type, wherein the air from the room is taken back to the Air Handling Unit (AHU) for thermal conditioning and brought

back. The same HVAC system could also be connected to a few other areas of the hospital.

Negative pressure rooms are negatively pressured with the corridors, hence air enter from the corridors to the room. The engineering

features of negative-pressure room includes negative pressure (greater exhaust than supply air volume); pressure differential of 2.5 Pa

(0.01-in. water gauge); airow volume differential >125-250cfm exhaust versus supply; sealed room, approximately 0.5-sq. ft. leakage;

clean to dirty airow; monitoring; ≥12 air changes per hour (ACH) new or renovation; and exhaust to outside, where the droplet nuclei will

be diluted in the outdoor air or HEPA-ltered that removes most (99.97%) of the droplet nuclei before it is returned to the general

circulation if recirculated.

In this era of COVID-19 pandemic, hospital resources are strained and hospitals are required to convert existing rooms to airborne

isolation rooms or negative pressure rooms. COVID 19 patients should be managed in airborne infection isolation rooms or negative

pressure rooms.

Dr. Rajavardhan R.Consultant intensivist

MBBS, MD, FNB, EDIC

Critical care medicine

Manipal hospital Whiteeld

E mail:[email protected]

Exhaust

Posiitive

PosiitivePosiitive

Posiitive

Negative




Figure1. Illustration of negative pressure room, wherein the ow of air is from corridor to the rooms.

It is laborious and expensive to retrot already constructed hospital rooms to create negative pressure units. The simple engineering

innovation which was used to create the negative pressure units on the separate oor of our hospital will be discussed here.

We chose one entire oor with air-conditioned rooms of our hospital to create the negative pressure rooms. Fan Coil Unit(FCU) of the

rooms originally had 3-speed modes with separate temperature control for each FCU. FCU in high-speed mode will provide air supply

around 350 Cubic feet per minute (cfm) creating positive pressure effect in the rooms.

We converted the existing room into a negative pressure room by installing a high CFM exhaust blower system with a 900 cfm. This

independent exhaust blower installed extracts the room air and exhausts it out into the atmosphere. This provided airow volume

differential of >125-250cfm between the exhaust and the supply which was required to maintain the negative pressure of a minimum of 2.5

Pa (preferably >5 Pa) in the room. Exhaust/ Return duct was blocked to prevent the recirculation of air. The exhaust outlet was nowhere

near to any nearby ventilation intake or any occupied area so as to reduce any risk of recirculation of air leading to cross infection.




Figure2. High cfm exhaust blower attached in the room

Figure 3. Pressure manometer indicator in an airborne isolation room

PATIENTAREA

Figure 4. Representation of the ow of air pattern in the temporary negative pressure room. Air passes from caregiver to

dirty patient area to the exhaust




Operating theatre considerations.

Operating theatres are also converted into temporary negative pressure rooms during intubation. Inlet speed of air is 3000cfm. During

aerosol-generating procedure-intubation, the operating theatre is converted into negative pressure by turning on the fumigation mode. In

this mode, air will not be recirculated and it will be vented out through the exhaust with a capacity of 4350 cfm. The anesthesiologist and a

technician are the only people present during intubation so as the minimize the risk of infection.

Emergency room considerations:

Additional isolation rooms were constructed along with the existing ones. They were converted to airborne isolation rooms similar to those

in the oor/ICU. In addition to these measures, disinfection with ultraviolet C light which is known destroy the DNA of bacteria and viruses,

was used after each patient. Continuous low doses of ultraviolet C can kill airborne viruses without harming human tissues

Conclusion:

The above-mentioned strategies provided a cost effective and safe patient care environment with minimal risk of transmission of infection

to patients and health care personnel in our institution during the COVID-19 pandemic. The time and resources required were very

minimal which further emphasizes the importance of such innovations during crucial time.



STREGISTRATION 1 SLAB CLOSESSTON 31 AUGUST 2020

REGISTER SOON

th thWORKSHOP: 24 - 25 Feb 2021th thCONFERENCE: 26 - 28 Feb 2021

VENUE: Mahatma Mandir Convention and Exhibition Centre

THEME: SAFETY AND EFFICIENCY AMIDST RESOURCE LIMITATION

TM

2: INNOVATIONS IN CRITICAL CARECODE KRISHNA” An Innovative practice of death, dying and beyond

Few years back, our institution introduced a practice of 'Code Krishna-a Practice of respecting death, dying and beyond' The practice

comprises of offering homage and paying oral tribute to every patient who expires in the hospital and expression of empathy to the

bereaved family in moments of death by all members of the treating team. Conventional care approaches are largely technology driven; they

are indeed, tech heavy. They lack the much-needed humane dimension of care in moments of death. Health professionals believe that when

a patient die.

'Their job is over'. This is not so. When there is nothing to treat, there is still much to care about, much to heal.

This is a time to reach out to patients/their families with empathy and Join and lead them to turn to deeper existential realities of life which

alone have capacity to heal. We introduced this practice since we thought that a small and simple gesture of praying with the relatives for the

deceased patient could add 'Spiritual care tenor' in our treatment program, thereby enables us to fulll our professional obligations

genuinely.

To us, this practice provides us a means of introducing collaborative wisdom of the East and the West in our hospital. We have observed over

years that the practice gives a truly humane touch to the care of patient and his relatives in moments when treatment is coming to end.

It has soothing effect for the bereaved family, and at the same time, it has de-stressing effects on the treating team feel, making them

experience true humility.

Dr Bhalendu VaishnavProfessor & Head

Dept of medicine, Shree Krishna Hospital

Pramukhswami Medical College, Karamsad, Anand

Dr Abhishek PrajapatiConsultant Critical Care & Chest

Dept Of Critical Care, Medicine

Shree Krishna Hospital, Karamsad, Anand, Gujarat



3: INNOVATIONS IN CRITICAL CAREVIRTUAL HEALTH CARE – TELEICU SERVICES

India is a country with so much diversity. Indian healthcare sector is one of the fast growing

and digitally advancing sector. Still ICU care is primitive or nonexistent in remote areas. The number of available beds is disproportionately

low, both in private and public hospitals. there is Low doctor density ratio of 0.5 doctors per 1000 population. Qualied and trained critical

care doctors/staffs are not available even if ICU infrastructures available. That creates a big challenge to manage critically ill patients in

remote places of India.

Virtual Health Care has designed a breakthrough critical care remote monitoring system called TeleICUCare for Indian healthcare system.

TeleICUCare, which enables treatment of patients by providing 24*7 critical care support by Intensivist residing kilometres away. It is

designed to solve biggest healthcare challenges that India is currently facing.

Imagine a patient at local hospital ICU in critical condition and needing immediate treatment. The hospital is not able to proceed without

intensivist’s advice. patients and hospitals both nd themselves stuck and helpless. In such very common and difcult situations across

rural/remote parts of India, Now, what if the patient could be treated immediately, remotely and without waiting for an Intensivist to arrive

on site and treat the patient? Remote Intensivists advice is possible with revolutionary TeleICUCare system. We equip the remote hospital

ICU with a mobile kiosk which has audio-video conferencing capabilities. This remote hospital ICU is now connected to TeleICUCare

Monitoring Center with a team of Intensivist (or critical care specialists), which is available/online 24 x 7.

Through TeleICUCare we help you to digitize hospital ICU.Remote patient’s vital signs, test reports, medical records are fetched from the

TeleICUCare EMR system and displayed live on monitors at TeleICUCare Monitoring Center. The patient information gets integrated into

TeleICUCare web and mobile application. Intensivist will access all data and will provide advise at hospital ICU.

Because of the use of remote Intensivist/TeleICUCare there is

• - Substantial Reduction in Mortality Rate

• - Reduce length of stay

• - Decrease in Ventilator Time

• - Increased cost-effectiveness and efciency

Delivering high quality critical care to your patients with limited staff and nancial resources demands new approaches. Gujarat-based

Virtual Health Care is one such rm providing “third set of eyes” with the help of Tele-ICU technology to give

additional clinical surveillance and support to ICU patients in disparate geographical locations for multiple hospitals.

DR. RAJ RAWALMD,IFCCM

FOUNDER, VIRTUAL HEALTHCARE

AHMEDABAD



QUIZ SECTION

1. What is going on in this picture?

2. Prototype of which famous machine

3. Which normal anatomical Variant (Inspired by below picture) seen in about 5% of population is named after something worn by

inhabitants of central Anatolian region?



QUIZ SECTION

4. The concept of ---------------- was developed by a German Nobel laureate Paul Ehrlich in 1900 While working at the Institute of

Experimental Therapy (Institut für experimentelle Therapie), Ehrlich formed an idea that it could be possible to kill specic microbe, which

cause diseases in the body, without harming the body itself.

5. Although he was a physiologist and the Nobel prize winner for Medicine in 1904, his most famous work is in a different speciality. Name

the scientist and the work.

6. Scientist Ignaz Semmelweis is known for giving this concept for the rst time while analysing the death of large number of women by

purpureal sepsis. His idea was strongly rejected by doctors at that time.

7. This name of this disease is believed to have been derived from a description in the Makonde language, meaning "that which bends up".

8. Which Condition is described as St Fiacre’s curse?

9. Identify the famous Swedish radiologist

10. Name the sign and the disease



ANSWER TO THE QUIZ MARCH-APRIL 2020

1. Huoshenshan Hospital is an emergency specialty eld hospital in Wuhan, China constructed from 23 January 2020 to 2 February 2020 in

response to the COVID-19 pandemic.

2. Birth of ATLS. James K. Styner, an orthopedic surgeon piloting a light aircraft, crashed his plane into a eld in Nebraska in 1976. His wife

and three of four Children died. Styner and his colleague Paul 'Skip' Collicott, with assistance from advanced cardiac life support personnel

and the Lincoln Medical Education Foundation, produced the initial ATLS course which was held in 1978.

3. "Stayin' Alive" is a song written and performed by the Bee Gees from the Saturday Night Fever motion picture soundtrack.

4. AnaConDa (Anaesthetic Conserving Device) is an anaesthetic delivery system developed for the administration of volatile anaesthetics

such as Isourane or Sevourane to invasively ventilated patients.

5. The Hering–Breuer ination reex, named for Josef Breuer and Ewald Hering.

6. For developing Remdesivir.

7. First attempt for central venous catheterization.

8. “N,” if they are Not resistant to oil, “R” if somewhat Resistant to oil, and “P” if strongly resistant (oil Proof).

9. LUCAS CPR device.

10. Therapeutic plasma Exchange.



ENSURING SAFETY AT EVERY STAGE FOR CRITICARE 2021, AHMEDABAD



Venue: Mahatma Mandir Convention and Exhibition Centre

Documents

A BI - MONTHLY NEWSLETTER OF INDIAN SOCIETY OF CRITICAL ... · Dr. Deepak Govil, President - Elect, ISCCM, Chairman, Scientiﬁc Committee, Criticare 2021 Director Critical Care Medanta