CRITICAL CARE march... · 1.Triple layer medical mask: This is a disposable, 3-layered mask, made of non-woven fabric, and having a bacterial lter ef ciency (BFE) of 98% for 3-micron

www.isccm.org

VOLUME 15.2 March - April 2020

A BI - MONTHLY NEWS LETTER OF INDIAN SOCIETY OF CRITICAL CARE MEDICINE

TM

COMMUNICATIONSCRITICAL CARE

WELCOME TO CRITICARE 2021 Ahmedabad

We request our esteemed readers to send their valued feedback, suggestions & views a t [email protected]

C O N T E N T S1. Editorial

2. Message from the President

3. Message from the journal Secretary

4. Editorial Board Critical Care Communications 2020 - 2021

5. ISCCM Working Committee

6. Welcome New Members

7. Branch Activities

8. Webinar Report March To April 2020

9. Handling Hospitalized Corona Patients

10. ISCCM & Medvarsity - Leading Through Education To Train 1 Lakh Doctors in

Mechanical Ventilation

11. Journey of Indian Journal of Critical Care Medicine

12. ISCCM Fellowship in Critical Care Ultrasound

13. ORCID (Open Researcher and Contributor Id)

14. Sterilization and Disinfection In Hospital During Covid 19 Pandemic

15. Guidelines for use of face mask by the medical personnel and common public

16. How to Make Homes Safe For HCW'S and their families

17. Effects Of COVID-19 On Mental Health In ICU Staff And Its Management

18. Preparing Hospital For COVID-19 Pandemic - Team Building and

Resource Management

19. Communication in ICU During COVID Era

20. Pathogenesis Of COVID 19- How Much Do We Actually Know?

21. Convalescent Plasma Therapy For COVID-19

22. CPR In COVID-19 Era: Pearls From Literature review and algorithms

23. JOURNAL SCAN - 1,2,3,4,5,6

24. Innovations In Critical Care Series Our Platform In Our Bulletin

25. Quiz & Answers Section Jan-feb 2020

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]

th th th thWORKSHOP: 24 - 25 Feb 2021 | CONFERENCE: 26 - 28 Feb 2021VENUE: Mahatma Mandir Convention and Exhibition Centre

THEMESAFETY AND EFFICIENCY AMIDST RESOURCE LIMITATION

th

ANNUAL CONFERENCE OF INDIAN SOCIETY OF CRITICAL CARE MEDICINE

CRITICARE 2021 - AHMEDABAD

Editorial...TM

www. .orgisccm

Dear Friends

I hope you all are doing well. Despite the exemplary effort

by everyone, COVID-19 pandemic is showing no sign of

retreat. Although the number of new cases have come

down considerably in many hard-hit countries, threat of

second wave is looming once the lockdown is lifted. In India, number of new cases are piling up with exorbitant

pace. Numbers are destined to go up as our testing

capacity is building up rapidly. There is substantial

discrepancy in the number of cases in different parts of

countries. Few states are already bearing the brunt of the

pandemic and others may land up in similar situation.

Since pandemic is not going away anytime soon, we must ready to inculcate the new normal in our

day to day practice. Many aspects of patient’s care from clinical management to communication,

requires an urgent overhaul. In alignment to the previous edition, we continue to focus on

different aspects of COVID-19 management. From revisiting the pathogenesis, exploring newer

therapeutic options to physical and mental wellbeing of ICU staffs, we have tried to include a wide

array of topics. Majority of the information is based on the most recent evidences. A new series

“Innovations in critical care” has been conceived to promote innovation and lateral thinking.

I sincerely thank all of you for extraordinary effort and rising up to the occasion.

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

Right after our national congress all of us have become busy in

preparation & management of COVID19. As expected intensivist

took lead in their respective institutions in establishment & running

of COVID care services despite grave personal risk at the time of

great uncertainty. Our colleagues have fallen sick on line of duty

but still continue to provide services. I bow in reverence to all

brave men & women whether Doctors or nurses, technicians or

GDA/sanitation employees.

Organising COVID care has been a herculean task. Managing

human emotions, real or perceived threats to them or their

families, stigmatisation of Corona care providers & hypocrite

attitude of the public & to get work done from mortally feared

professionals have been a nightmare. One group of professionals who remained calm, thought & planned the

care of COVID patients, when they were/are most vulnerable both emotionally & physically, was nobody else

but the INTENSIVIST. It’s you who have led the charge of managing them. People across spectrum have

realised the importance of intensive care as an important sub-specialty of medicine & Intensivist as word has

now entered in the bible of English language dictionary.

Simultaneously a misery has been heaped on non COVID sick patients. May I take this opportunity to request

all of you to recalibrate your resources in a fashion where non-covid patients do not suffer. We have to be the

face to lead a change in societies perspective of COVID. We have to bring back compassion, humility &

empathy back. COVID is the biggest disrupter after world war II & Spanish u or earlier epidemics of Plague.

We have to relearn practice of art of medicine with science. Pendulum is shifting every day. Responses have

become knee jerk & hyperbole. What we need is cool analytical clinical mind to manage these cases.

Fundamentals of practice of critical care has become all the more important.

I am sure as a fraternity we have risen & will continue to provide critical care to the sickest of patients

irrespective of COVID status. Society & nation is asking for medical leadership; I see that in my colleagues in

critical care. Let’s raise the bar of care & set new standards of care in intensive care in particular &

compassionate care in general.

I wish & pray for the good health of all of you. Stay safe.

Warmest 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

Dear Friends Greetings from the ISCCM. Hope you have all been safe. The pandemic has really tested our resolve and strength. The ISCCM has stepped forward in taking the onus of training the grass root level professionals in managing the infection as well as in mechanical Ventilation. We have joined hands with the IMA and have been actively conducting online training sessions twice a week. We have reached out to close to 3000 professionals with this strategy. The association with the Medvarsity has also yielded good results and we have been able to reach out to a wide spectrum of front-line workers. The society has also embarked upon a strategy of tying up with AIIMS and PGI to form task forces for studying extra pulmonary manifestations of SARS COV 2 infection.

The pandemic has slowed down our preparations for the next Criticare in Ahmedabad. However, a steady channel of communication with the venue and the hotel is open and we hope to have the meeting as scheduled. The ofce bearers of

www. .orgisccmthe society have also engaged the industry in obtaining feedback and suggestions.

The rst EC meeting of this term was held online and several new initiatives have been discussed. The communication committee has received utmost attention and results will be visible soon. Several new guidelines have been proposed and the committee has started its work in right earnest.

On behalf of the ISCCM, I extend my appreciation for all of you who are leading the battle against an unknown and strange adversary. I am condent that we will weather this storm and brighter days lie ahead

With warm regardsDr. Srinivas SamavedamMD, DNB, FRCP, FNB, EDIC, FICCM, DMLE, MBA

General Secretary, ISCCMOrganising Secretary, CRITICARE 2021Head, Critical Care, Medical Director Virinchi Hospitals, HyderabadEmail: [email protected]: +91 98663 43632





EDITOR IN CHIEF

ASSOCIATE EDITORS

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

EDITORIAL BOARD

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), FICCM(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

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

QUIZ SECTION

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

IMAGES SECTION

Dr. Hrishikesh JhaDA, PGDDC

Senior Consultant and Head - Critical Care

Gurunanak Hospital and

Research Centre, Ranchi


Mob: 9471710607

Surg Ltd Cdr

(Dr) Abdul NaseerMBBS, DNB (Anaesth)

Anaesthesiologist, Indian Navy

INHS Jeevanti, Goa


Mob: 9560837993



EDITORIAL BOARD CRITICAL CARE COMMUNICATIONS 2020 - 2021



ISCCM WORKING COMMITTEE

CONSTITUTION AMENDMENT COMMITTEE

Dr Deepak Govil

Chairman

Dr Dhruva Chaudhry

Co-Chairman

Dr Manish Munjal

Member

Dr D K Singh

Member

Dr. Rajesh Pande

Member

Dr. Babu Abraham Member

Dr.Sauren Panja

Member

Dr Subhal Dixit -

Ex officio Member

Dr Srinivas Samavedam Ex officio Member

Dr Arindam Kar

Ex officio Member




GUIDELINE COMMITTEE

Dr Palepu B N Gopal

Chairman

Dr Jeetendra Sharma

Coordinator

Dr Pradeep Rangappa

Member

Dr Ashish Bhalla

Member

Dr Shrikanth Srinivasan

Member

Dr Raymond Dominic Savio

Member

Dr Deven Juneja

Member

Dr Dhruva Chaudhry

Ex Officio Member

Dr Subhal DixitEx officio member

Dr Deepak Govil

Ex Officio Member

Dr Srinivas Samavedam

Ex Officio Member

Dr Arindam Kar

Ex Officio Member




ELECTION COMMITTEE

Dr Subhal Dixit

Chief Election Commissioner

Dr Deepak Govil

Member

Dr Mohan Mathew

Member

Dr Susruta Bandyopadhyay

Member

Dr G C Khilnani

Member

CREDENTIALS COMMITTEE

Dr Kapil Zirpe

Chairman

Dr Banambar Ray

Member

Dr Palepu B N Gopal

Member

Dr Ashit Hegde

Member

Dr N Ramakrishnan

Member




FINANCE COMMITTEE

Dr Deepak Govil

Chairman

Dr Dhruva Chaudhry

Co-Chairman

Dr Subhal Dixit

Member


Member

Dr Shilpushp Bhosale

Member

Dr Rahul Pandit Member

Dr Khusrav Bajan

Member

Dr Ritesh Shah

Member

Dr Arindam Kar

Ex officio Member


RESEARCH COMMITTEE

Dr JV Peter Chairman

Dr. Mohan Gurjar

Coordinator

Dr. Binila Chacko

Member

Dr Bharath Kumar TVMember

Dr. Sachin GuptaMember

Dr. Sameer jogMember

Dr. Prithiwis

BhattacharyaMember

Dr. Mradul DagaMember

Dr Dhruva ChaudhryEx officio Member

Dr Subhal DixitEx officio Member

Dr Deepak GovilEx officio Member

Dr Srinivas SamavedamEx officio Member

Dr Arindam Kar

Ex officio member




COMMUNICATION COMMITTEE

Dr Deepak Govil

Chairman

Dr Tapas K Sahoo

Member

Dr Kapil Borawake

Member


Ex officio Member

Dr Gunjan Chanchalani

Coordinator

Dr Ritesh Shah

Member

Dr Dhruva Chaudhry

Ex officio Member

Dr Arindam KarEx officio member

Dr Ganshyam Jagathkar

Member

Dr Lalit SinghMember

Dr Subhal Dixit Ex officio Member




ISCCM DAY COMMITTEE

Dr Arindam Kar

Chairman

Dr Suneel Garg

Member

Dr Sharmili Sinha

Member

Dr Venkatraman Kola

Member

Dr Sanjay Dhanuka

Member

Dr Apurba Kumar BorahMember

Dr Dhruva Chaudhry

Ex officio Member

Dr Subhal Dixit

Ex officio Member

Dr Deepak Govil Ex officio Member


Ex officio Member



WELCOME NEW MEMBERS

NAME CITY CATEGORY MEMBERSHIPNO

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ATUL SRIVASTAVA KANPUR LIFE MEMBERS 20/S-1933

AAKASH BARAD MUMBAI LIFE MEMBERS 20/B-846

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KORVA SALOMI NIZAMABAD ASSOCIATE LIFE MEMBER (NURSE) 20/S-1960

TALOKAR SUNIL HYDERABAD ASSOCIATE LIFE MEMBER (NURSE) 20/S-1961

B MAHENDER,PURI PURI LIFE MEMBERS 20/M-1048

DEVAJYOTI SHARMA GUWAHATI LIFE MEMBERS 20/S-1962

KUNTAL JIVANI RAJKOT LIFE MEMBERS 20/J-575

PRIYADARSHINI GHOLAPE KOLHAPUR LIFE MEMBERS 20/G-892

SASI THADIGADAPA KRISHNA ASSOCIATE LIFE MEMBER (NURSE) 20/T-423

MERUGU JYOTHI HYDERABAD ASSOCIATE LIFE MEMBER (NURSE) 20/J-576

MAHESWARI MAHENDRAN DHARAMPUR ASSOCIATE LIFE MEMBER 20/M-1049

TUSHAR CHOPAWAR NAGPUR LIFE MEMBERS 20/C-555

JITHINA VB MUMBAI ASSOCIATE LIFE MEMBER (NURSE) 20/V-411

PEETLA BHAGYAMMA HYDERABAD ASSOCIATE LIFE MEMBER (NURSE) 20/B-858

JATOTHU NAVEEN WARANGAL ASSOCIATE LIFE MEMBER (NURSE) 20/N-349

PARIMAL DE GUWAHATI ASSOCIATE LIFE MEMBER 20/D-687

MOHAMMAD ASIM VOHRA ANAND ASSOCIATE LIFE MEMBER 20/V-409

AVIJEET SWAIN BHUBANESWAR LIFE MEMBERS 20/S-1963

SULAGNA BHATTACHARJEE NEW DELHI LIFE MEMBERS 20/B-859

ANURADHA PANDEY LUCKNOW LIFE MEMBERS 20/P-1148

ABHISHA VV MUMBAI ASSOCIATE LIFE MEMBER (NURSE) 20/V-410

JAY PRAKASH RANCHI LIFE MEMBERS 20/P-1149

KAUSHIK BARUA NEW DELHI LIFE MEMBERS 20/B-860

RINCY RAJU MUMBAI ASSOCIATE LIFE MEMBER (NURSE) 20/R-715

SOOSAN KURIAN HYDERABAD ASSOCIATE LIFE MEMBER (NURSE) 20/K-1253

GAYATHRI PERUMBOLE VISAKHAPATNAM ASSOCIATE LIFE MEMBER 20/P-1150

ADITYA TAWDE NEW DELHI ASSOCIATE LIFE MEMBER 20/T-425



WELCOME NEW MEMBERS


SOHINI RAY KOLKATA LIFE MEMBERS 20/R-716

PRIYA JINDAL NEW DELHI LIFE MEMBERS 20/J-580

ASIR TAMBOLI PUNE LIFE MEMBERS 20/T-424

MRIDUL KOSHY ERNAKULAM LIFE MEMBERS 20/K-1254

PADMAVATHI B M BANGALORE LIFE MEMBERS 20/B-861

CHANDRASHEKHAR NARE MUMBAI ASSOCIATE LIFE MEMBER (NURSE) 20/N-350

NEETHU JOY MUMBAI ASSOCIATE LIFE MEMBER (NURSE) 20/J-577

ANJANA NIRMALA DEVI MUMBAI ASSOCIATE LIFE MEMBER (NURSE) 20/N-351

SWEEGIL ANDREWS MUMBAI ASSOCIATE LIFE MEMBER (NURSE) 20/A-707

RAKESH PUNIA TONK ASSOCIATE LIFE MEMBER (NURSE) 20/P-1151

ABHISHEK WADHAWAN KARNAL LIFE MEMBERS 20/W-83

BALRAM CHOUDHAR TONK ASSOCIATE LIFE MEMBER (NURSE) 20/C-556

SARAVANAN SUBRAMANIAN ERODE LIFE MEMBERS 20/S-2003

DASHISHA SYIEMIONG GUWAHATI ASSOCIATE LIFE MEMBER (NURSE) 20/S-1964

ARUMUGAM MARIYAPPAN SALEM ASSOCIATE LIFE MEMBER (NURSE) 20/M-1056

VIJAYA RAJESWARI KARUR ASSOCIATE LIFE MEMBER (NURSE) 20/S-1965

SUMIT KUMAR LUCKNOW LIFE MEMBERS 20/K-1255

KARTHIK A VELLORE ASSOCIATE LIFE MEMBER (NURSE) 20/A-708

PARESH MOHANTA CUTTACK LIFE MEMBERS 20/M-1050

DISHITA KOTHARI RAJKOT ASSOCIATE LIFE MEMBER 20/K-1256

SAMJHANA SHARMA GUWAHATI ASSOCIATE LIFE MEMBER (NURSE) 20/S-1966

BABA DEEN BARABANKI ASSOCIATE LIFE MEMBER (NURSE) 20/D-689

PAYAL JAIN GUWAHATI LIFE MEMBERS 20/J-578

SWEETY KATRE NEW DELHI LIFE MEMBERS 20/K-1257

RAJENDER MEDIKONDA HYDERABAD ASSOCIATE LIFE MEMBER 20/M-1051

LIKHITH ROY D BANGALORE ASSOCIATE LIFE MEMBER 20/R-717

SUBHAJIT SEN KOLKATA LIFE MEMBERS 20/S-1967

VIDHEE PANCHAL BHARUCH ASSOCIATE LIFE MEMBER 20/P-1152

YAKUB BODA WARANGAL LIFE MEMBERS 20/B-862

RAM SINGH NEW DELHI LIFE MEMBERS 20/S-1968

GRACE MAKABO SENAPATI ASSOCIATE LIFE MEMBER (NURSE) 20/M-1052

V L HMUCHHUAKI CHURACHANDPUR ASSOCIATE LIFE MEMBER (NURSE) 20/H-170

NAARAKATLA PRASANNA HYDERABAD ASSOCIATE LIFE MEMBER (NURSE) 20/P-1153

NUPUR DRAVID,JAIPUR JAIPUR LIFE MEMBERS 20/D-700

SALAM DEVI,IMPHAL IMPHAL ASSOCIATE LIFE MEMBER (NURSE) 20/D-702

VIDYANAND PANDEY LUCKNOW ASSOCIATE LIFE MEMBER (NURSE) 20/P-1169

SONAL MEHTA GURGAON LIFE MEMBERS 20/M-1053

THANGAMUTHU THANGAMUTHU THENI ASSOCIATE LIFE MEMBER (NURSE) 20/T-426

GRACE JOY HYDERABAD ASSOCIATE LIFE MEMBER (NURSE) 20/J-579

NEENU IVAN MUMBAI LIFE MEMBERS 20/I-61

SUNIL PANDEY NAGPUR ASSOCIATE LIFE MEMBER 20/P-1154

TITU GEORGE OOMMEN KOLLAM LIFE MEMBERS 20/O-27

JULIYA PEARL VELLORE LIFE MEMBERS 20/P-1168

RAKESH MOHANTY VELLORE LIFE MEMBERS 20/M-1082

RUPANWITA SEN KOLKATA LIFE MEMBERS 20/S-2002

SUDARSHAN GUNTHE LATUR LIFE MEMBERS 20/G-910

DHARITRI HATIBARUAH GUWAHATI ASSOCIATE LIFE MEMBER 20/H-173

HITAISHI GUPTA LUCKNOW ASSOCIATE LIFE MEMBER (NURSE) 20/G-909

CASSANDRA LYTAN JAINTIA HILLS ASSOCIATE LIFE MEMBER (NURSE) 20/L-145

SUJEET RAI LUCKNOW LIFE MEMBERS 20/R-729

JUTI MECH DIBRUGARH ASSOCIATE LIFE MEMBER 20/M-1081

ASHUTOSH AGRAWAL RAIGARH LIFE MEMBERS 20/A-715

SUNALI GUPTA JAIPUR LIFE MEMBERS 20/G-908

MANOJ SHARMA MEERUT LIFE MEMBERS 20/S-1969

THOMAS MOHAN KOTTAYAM LIFE MEMBERS 20/M-1080

MEENAKSHI DEKA GUWAHATI ASSOCIATE LIFE MEMBER 20/D-699

ANIL BHARGAV AHMEDABAD ASSOCIATE LIFE MEMBER (NURSE) 20/B-863

SHAHUL HAMEED TIRUNELVELI ASSOCIATE LIFE MEMBER (NURSE) 20/H-171

FAISAL GHAYYUR JAIPUR ASSOCIATE LIFE MEMBER 20/G-893

SAVITHA E TIRUPUR ASSOCIATE LIFE MEMBER (NURSE) 20/E-31

SWEETY PATEL AHMEDABAD ASSOCIATE LIFE MEMBER (NURSE) 20/P-1155

VINITHA M SALEM ASSOCIATE LIFE MEMBER (NURSE) 20/M-1054

ROHIT BINDAL SAWAI MADHOPUR ASSOCIATE LIFE MEMBER (NURSE) 20/B-864

JYOTI SURVASE PUNE LIFE MEMBERS 20/S-1970

KRISHNABALDEV CHUNDAWAT DUNGARPUR ASSOCIATE LIFE MEMBER (NURSE) 20/C-557

SWAPNIL NAGE AMRAVATI LIFE MEMBERS 20/N-352



WELCOME NEW MEMBERS


SUSHEEL MANTHENA HYDERABAD LIFE MEMBERS 20/M-1055

KEVAL DEDANIYA JUNAGADH ASSOCIATE LIFE MEMBER 20/D-690

SATISHKUMAR SUNDHESHA DEESA ASSOCIATE LIFE MEMBER 20/S-1971

MANGALA PRAJAPATI ANAND LIFE MEMBERS 20/P-1156

YUGAL KUMAR MAHASUMUND LIFE MEMBERS 20/K-1258

RENISHAN MAHIDA AHMEDABAD ASSOCIATE LIFE MEMBER (NURSE) 20/M-1057

ABDUL RAHIM FAZAL CALICUT LIFE MEMBERS 20/F-3

SANGRAM MOHAPATRA BHUBANESWAR LIFE MEMBERS 20/M-1058

NITIN DEOTE,PUNE PUNE LIFE MEMBERS 20/D-691

VIJETA BAJPAI,GORAKHPUR GORAKHPUR LIFE MEMBERS 20/B-865

ALPESHKUMAR PRAJAPATI BANASKHANTHA ASSOCIATE LIFE MEMBER 20/P-1167

VARUNA SINGAL HISAR LIFE MEMBERS 20/S-1972

VIVEK GOYAL HISAR LIFE MEMBERS 20/G-894

BENISHA LAWIANG GUWAHATI ASSOCIATE LIFE MEMBER (NURSE) 20/L-140

SITA KUMAR KHALOGARA ASSOCIATE LIFE MEMBER (NURSE) 20/K-1259

MD ISLAM BHUBANESWAR ASSOCIATE LIFE MEMBER 20/I-62

SURESH BADHANIA HISAR LIFE MEMBERS 20/B-866

RAMACHANDRAN RAMANATHAN MADURAI LIFE MEMBERS 20/R-718

ASHA K K,GURUGRAM GURUGRAM ASSOCIATE LIFE MEMBER (NURSE) 20/K-1260

SUMITA SHIMLA ASSOCIATE LIFE MEMBER (NURSE) 20/.-1

SRAVANI JADDU SRIKAKULAM ASSOCIATE LIFE MEMBER (NURSE) 20/J-581

KANAKA KORUKONDA VISAKHAPATNAM ASSOCIATE LIFE MEMBER (NURSE) 20/K-1261

JHANSI PULAGALA VISAKHAPATNAM ASSOCIATE LIFE MEMBER (NURSE) 20/P-1157

BALACHANDRA S R MYSORE LIFE MEMBERS 20/S-1973

OPHIR YENDLURI HYDERABAD ASSOCIATE LIFE MEMBER (NURSE) 20/Y-87

MEENA GUMPULA RAJAHMUNDRY ASSOCIATE LIFE MEMBER (NURSE) 20/G-896

ANAGHA KRISHNA G S KOTTACKAL ASSOCIATE LIFE MEMBER (NURSE) 20/G-897

UMAIR MURTUZA GULBARGA ASSOCIATE LIFE MEMBER 20/M-1059

VIBEESH S, NAGAPATTINAM ASSOCIATE LIFE MEMBER (NURSE) 20/S-1974

KULDEEP SINGH CHAMOLI ASSOCIATE LIFE MEMBER (NURSE) 20/S-1975

CARMEL R TIRUNELVELI ASSOCIATE LIFE MEMBER (NURSE) 20/R-719

CM BRYSON TRIVANDRUM ASSOCIATE LIFE MEMBER (NURSE) 20/B-867

NASILA S TRIVANDRUM ASSOCIATE LIFE MEMBER (NURSE) 20/S-1976

SHAHINAHMED KHATRI BARODA ASSOCIATE LIFE MEMBER 20/K-1262

JESINTHA A KANYAKUMARI ASSOCIATE LIFE MEMBER (NURSE) 20/A-709

HUZAIFA KHATRI BARODA ASSOCIATE LIFE MEMBER 20/K-1263

KALAIMATHY PACKIRISAMY THANJAVUR ASSOCIATE LIFE MEMBER (NURSE) 20/P-1158

KEISHAM DEVI,IMPHAL IMPHAL ASSOCIATE LIFE MEMBER (NURSE) 20/D-692

BHARAT SANGANI OTHER ASSOCIATE LIFE MEMBER 20/S-1977

JOTHI A VELLORE ASSOCIATE LIFE MEMBER (NURSE) 20/A-710

VIJAYARAM SELVARAJI SALEM ASSOCIATE LIFE MEMBER (NURSE) 20/S-1978

JOANE RODRIGUES VELLORE LIFE MEMBERS 20/R-720

RAVI BUDDHA VIJAYAWADA LIFE MEMBERS 20/B-868

ANUPRIYA MUNDARI BHUBANESWAR ASSOCIATE LIFE MEMBER 20/M-1060

RAKESH C ALLEPPEY ASSOCIATE LIFE MEMBER (NURSE) 20/C-558

SONI HARIDWAR ASSOCIATE LIFE MEMBER (NURSE) 20/.-2

BEBINA MALLICK BHUBANESWAR ASSOCIATE LIFE MEMBER (NURSE) 20/M-1061

PEEYUSH SHIVHARE NEW DELHI LIFE MEMBERS 20/S-1980

CHRIS JACOB HISAR ASSOCIATE LIFE MEMBER (NURSE) 20/J-582

RANGU CHANDRA WARANGAL LIFE MEMBERS 20/C-559

ALIFIROZ S THIRUVANANTHAPURAM ASSOCIATE LIFE MEMBER (NURSE) 20/S-1979

HARSHAD GALANDE NASHIK ASSOCIATE LIFE MEMBER 20/G-898

GRESHMA PG KOLLAM ASSOCIATE LIFE MEMBER (NURSE) 20/P-1159

DEEPIKA MARY VILUPPURAM ASSOCIATE LIFE MEMBER (NURSE) 20/M-1062

AJITH V S KOTTAYAM ASSOCIATE LIFE MEMBER (NURSE) 20/V-412

JAYASRI PARIDA KENDRAPARA ASSOCIATE LIFE MEMBER (NURSE) 20/P-1160

MURALI KANNAN VELLORE ASSOCIATE LIFE MEMBER (NURSE) 20/K-1264

PRIJI JP KOLLAM ASSOCIATE LIFE MEMBER (NURSE) 20/J-583

VISHRANTI KHOT SINDHUDURG ASSOCIATE LIFE MEMBER (NURSE) 20/K-1265

MANISHA BEHERA GANJAM ASSOCIATE LIFE MEMBER (NURSE) 20/B-869

POONAM JANGIR JHUNJHUNU ASSOCIATE LIFE MEMBER (NURSE) 20/J-584

PRIYA PAWAR AHMEDNAGAR ASSOCIATE LIFE MEMBER (NURSE) 20/P-1161



WELCOME NEW MEMBERS


RAJESH MANDA NAGAUR ASSOCIATE LIFE MEMBER (NURSE) 20/M-1063

SUDEEP HISAR ASSOCIATE LIFE MEMBER 20/.-6

NARESH TAVIYA RAJKOT ASSOCIATE LIFE MEMBER 20/T-427

BULBUL BORANG ITANAGAR ASSOCIATE LIFE MEMBER (NURSE) 20/B-870

ROHIT ANERAO MUMBAI ASSOCIATE LIFE MEMBER 20/A-711

AVANI MOHTA MUMBAI LIFE MEMBERS 20/M-1064

DEVENDRA SHARMA DAUSA LIFE MEMBERS 20/S-1981

NISHA BHOSALE PUNE ASSOCIATE LIFE MEMBER (NURSE) 20/B-871

BHANU SINGH MAHENDRAGARH ASSOCIATE LIFE MEMBER 20/S-1982

DASHRATH SEN PALI ASSOCIATE LIFE MEMBER (NURSE) 20/S-1983

RAVISHANKAR YADAV SURAT ASSOCIATE LIFE MEMBER 20/Y-88

MANOJ KHIYANI WARDHA ASSOCIATE LIFE MEMBER 20/K-1266

RUMSHAA BAJPAI JAIPUR ASSOCIATE LIFE MEMBER 20/B-872

MAREESWARI APPANASAMY THOOTHUKUDI ASSOCIATE LIFE MEMBER (NURSE) 20/A-712

BANUPRIYA V VIRUDHUNAGAR ASSOCIATE LIFE MEMBER (NURSE) 20/V-413

WANGKHEM DEVI BISHNUPUR ASSOCIATE LIFE MEMBER (NURSE) 20/D-693

LOPAMUDRA ROUT CUTTACK ASSOCIATE LIFE MEMBER (NURSE) 20/R-721

SAYALI LALSARE JAIPUR LIFE MEMBERS 20/L-141

HIMMATRAO GATE OSMANABAD LIFE MEMBERS 20/G-899

SUMIT MISHRA NAVI MUMBAI ASSOCIATE LIFE MEMBER 20/M-1065

BINIMOL BENNY ERNAKULAM ASSOCIATE LIFE MEMBER (NURSE) 20/B-873

ANJALI KRISHNAN CHENGANNUR ASSOCIATE LIFE MEMBER (NURSE) 20/K-1267

YOGITA THAKUR MANDI ASSOCIATE LIFE MEMBER (NURSE) 20/T-428

ANSU RAJU ERNAKULAM ASSOCIATE LIFE MEMBER (NURSE) 20/R-722

PRIYANKA KANGRA ASSOCIATE LIFE MEMBER (NURSE) 20/.-3

RAHUL BHATT RAJKOT ASSOCIATE LIFE MEMBER (NURSE) 20/B-874

LAVYAMOL JOSE ERNAKULAM ASSOCIATE LIFE MEMBER (NURSE) 20/J-585

LINSON KOSHY PATHANAMTHITTA ASSOCIATE LIFE MEMBER (NURSE) 20/K-1268

SHASINKUMAR GAJIPARA SURAT ASSOCIATE LIFE MEMBER 20/G-900

MOHIT KADYAN NEW DELHI ASSOCIATE LIFE MEMBER 20/K-1269

NIRUPAMA SETHI BALESWAR ASSOCIATE LIFE MEMBER (NURSE) 20/S-1984

DHARMISHTHA CHANDPA RAJKOT ASSOCIATE LIFE MEMBER (NURSE) 20/C-560

AVDHESH SHARMA DHOLPUR ASSOCIATE LIFE MEMBER (NURSE) 20/S-1985

SUNIL GOEL NEW DELHI ASSOCIATE LIFE MEMBER 20/G-901

HAMNA PUNE ASSOCIATE LIFE MEMBER 20/.-4

PRATIMA BALIARSINGH GANJAM ASSOCIATE LIFE MEMBER (NURSE) 20/B-875

SAKERA KADIVAR RAJKOT ASSOCIATE LIFE MEMBER (NURSE) 20/K-1270

MANISHABEN LEVA RAJKOT ASSOCIATE LIFE MEMBER (NURSE) 20/L-142

SUSHREE ROUT CUTTACK ASSOCIATE LIFE MEMBER (NURSE) 20/R-723

CHILAMAKURTHY NARASIMHA KUMAR SURAT ASSOCIATE LIFE MEMBER (NURSE) 20/N-353

ANIL SAINI SIKAR ASSOCIATE LIFE MEMBER (NURSE) 20/S-1986

SHASHI BALA SIRMAUR ASSOCIATE LIFE MEMBER (NURSE) 20/B-876

NAVEEN KUMAR PONDICHERRY ASSOCIATE LIFE MEMBER (NURSE) 20/K-1271

PONNU ELDHOSE ERNAKULAM ASSOCIATE LIFE MEMBER (NURSE) 20/E-32

ANAND GHINTALA NAGAUR ASSOCIATE LIFE MEMBER (NURSE) 20/G-902

RAVINDRA KUMAR ALWAR ASSOCIATE LIFE MEMBER (NURSE) 20/K-1272

ASHOK SHARMA ALWAR ASSOCIATE LIFE MEMBER (NURSE) 20/S-1987

VASANTHAN D CUDDALORE ASSOCIATE LIFE MEMBER (NURSE) 20/D-694

MOHAMMED KACHHAWA SIKAR ASSOCIATE LIFE MEMBER 20/K-1273

PRADEEP SHARMA ALWAR ASSOCIATE LIFE MEMBER (NURSE) 20/S-1988

SATHIYA P PONDICHERRY ASSOCIATE LIFE MEMBER (NURSE) 20/P-1162

VIKAS KALE PUNE ASSOCIATE LIFE MEMBER (NURSE) 20/K-1274

LEELA GOWRIPATTAPU VISAKHAPATNAM ASSOCIATE LIFE MEMBER (NURSE) 20/G-903

SANESH GARDE PUNE ASSOCIATE LIFE MEMBER 20/G-904

ROHINI JOSHI SELECT CITY ASSOCIATE LIFE MEMBER (NURSE) 20/J-586

BONFY M THIRUVANANTHAPURAM ASSOCIATE LIFE MEMBER (NURSE) 20/M-1067

HARI SUNAM,PUNE PUNE ASSOCIATE LIFE MEMBER (NURSE) 20/S-1989

THAMEENA SAKEER IDUKKI ASSOCIATE LIFE MEMBER (NURSE) 20/S-1990

KIRAN NAIR THIRUVANANTHAPURAM ASSOCIATE LIFE MEMBER (NURSE) 20/N-354

NOUFIRATH RAHIM IDUKKI ASSOCIATE LIFE MEMBER (NURSE) 20/R-724

AISHA SUDHEER ERNAKULAM ASSOCIATE LIFE MEMBER (NURSE) 20/S-1991



WELCOME NEW MEMBERS


RESHMA M.R THIRUVANANTHAPURAM ASSOCIATE LIFE MEMBER (NURSE) 20/M-1068

ARCHANA S.B TRIVANDRUM ASSOCIATE LIFE MEMBER (NURSE) 20/S-1992

NAOREM DEVI THOUBAL ASSOCIATE LIFE MEMBER (NURSE) 20/D-695

ALIKEPALLI ASWANI GUNTUR LIFE MEMBERS 20/A-713

MD RAZA, VAISHALI ASSOCIATE LIFE MEMBER 20/R-725

SUSIL KUMAR TIRUNELVELI ASSOCIATE LIFE MEMBER (NURSE) 20/K-1275

NEETHU MONICHAN KOTTAYAM ASSOCIATE LIFE MEMBER (NURSE) 20/M-1069

SREDHA SHIBU ALAPPUZHA ASSOCIATE LIFE MEMBER (NURSE) 20/S-1993

MARIA JESSEL JAMES KOCHI ASSOCIATE LIFE MEMBER (NURSE) 20/J-587

PRIYANKAR DATTA NEW DELHI LIFE MEMBERS 20/D-696

ABRAHAM PHILIP KOTTAYAM ASSOCIATE LIFE MEMBER (NURSE) 20/P-1163

SIDDHI KAMBLE KOLHAPUR ASSOCIATE LIFE MEMBER (NURSE) 20/K-1276

BUDDHA RAM ALWAR ASSOCIATE LIFE MEMBER (NURSE) 20/R-726

LILY SHARMA PATIALA ASSOCIATE LIFE MEMBER (NURSE) 20/S-1994

SHIV BAIRWA SAWAI MADHOPUR ASSOCIATE LIFE MEMBER (NURSE) 20/B-877

DHANANJAY MHETRE PUNE ASSOCIATE LIFE MEMBER (NURSE) 20/M-1070

SAPNA THAKUR NAHAN ASSOCIATE LIFE MEMBER (NURSE) 20/T-429

JYOTSNA MORE PUNE ASSOCIATE LIFE MEMBER (NURSE) 20/M-1071

DEELIP BHATKAR JALGAON LIFE MEMBERS 20/B-878

SIMI THOMAS PUNE ASSOCIATE LIFE MEMBER (NURSE) 20/T-430

VICHITRA THANGAVEL COIMBATORE ASSOCIATE LIFE MEMBER 20/T-431

VIKASH SAINI, SIKAR ASSOCIATE LIFE MEMBER (NURSE) 20/S-1995

KURACHA NAIDU VISAKHAPATNAM ASSOCIATE LIFE MEMBER 20/N-355

PRATIBHA TIGGA SELECT CITY ASSOCIATE LIFE MEMBER (NURSE) 20/T-432

SIDHA NANDHAN COIMBATORE LIFE MEMBERS 20/N-356

SULATA MAITY KOLKATA ASSOCIATE LIFE MEMBER (NURSE) 20/M-1072

PANKAJ SHARMA DHOLPUR ASSOCIATE LIFE MEMBER (NURSE) 20/S-1996

SUDIPTA MONDAL KOLKATA ASSOCIATE LIFE MEMBER (NURSE) 20/M-1073

RATNA MONDAL KOLKATA ASSOCIATE LIFE MEMBER (NURSE) 20/M-1074

SARITA KUMARI LUCKNOW ASSOCIATE LIFE MEMBER (NURSE) 20/K-1277

ISHANI AWASTHI GHAZIABAD ASSOCIATE LIFE MEMBER (NURSE) 20/A-714

RAHUL SAXENA NOIDA ASSOCIATE LIFE MEMBER (NURSE) 20/S-1997

NAGALAKSHMI P VELLORE ASSOCIATE LIFE MEMBER (NURSE) 20/P-1164

MONICA CHAUHAN RAIPUR ASSOCIATE LIFE MEMBER 20/C-561

ANURUPA ROY KOLKATA ASSOCIATE LIFE MEMBER (NURSE) 20/R-727

MADHUSUDHANA M G KOLAR ASSOCIATE LIFE MEMBER (NURSE) 20/M-1075

JISHA KURIAN PUNE ASSOCIATE LIFE MEMBER (NURSE) 20/K-1278

ARYA P HYDERABAD ASSOCIATE LIFE MEMBER (NURSE) 20/P-1165

AKSA WILSON PUNE ASSOCIATE LIFE MEMBER (NURSE) 20/W-85

PRIYANKA BILASPUR ASSOCIATE LIFE MEMBER (NURSE) 20/.-5

SIRISHA BETALA HYDERABAD ASSOCIATE LIFE MEMBER (NURSE) 20/B-879

SWAPNA VARGHESE HYDERABAD ASSOCIATE LIFE MEMBER (NURSE) 20/V-414

ALEENA GEORGE PUNE ASSOCIATE LIFE MEMBER (NURSE) 20/G-905

JIJI JOSEPH PUNE ASSOCIATE LIFE MEMBER (NURSE) 20/J-588

SAURABH SHARDA JAIPUR LIFE MEMBERS 20/S-1998

LOKESH LATTA AJMER ASSOCIATE LIFE MEMBER 20/L-143

SHARON LAMARE RYMBAI SHILLONG LIFE MEMBERS 20/L-144

TEJAL GAWADE MUMBAI ASSOCIATE LIFE MEMBER (NURSE) 20/G-906

SAMEER TARAL BELGAUM ASSOCIATE LIFE MEMBER (NURSE) 20/T-433

TANDRA KRISHNA MAHBUBNAGAR LIFE MEMBERS 20/K-1279

MUDASIR MIR SRINAGAR ASSOCIATE LIFE MEMBER (NURSE) 20/M-1076

HARENDRA PRAJAPAT AGRA ASSOCIATE LIFE MEMBER (NURSE) 20/P-1166

RINCY JACOB SECUNDERABAD ASSOCIATE LIFE MEMBER (NURSE) 20/J-589

MUBARAK MUNNOLLI BELGAUM ASSOCIATE LIFE MEMBER (NURSE) 20/M-1077

ANJANA CHANDRAN PUNE ASSOCIATE LIFE MEMBER (NURSE) 20/C-562

M BASHA KADAPA ASSOCIATE LIFE MEMBER (NURSE) 20/B-880

GAUTAM SAINI JHUNJHUNU ASSOCIATE LIFE MEMBER (NURSE) 20/S-1999

ANIMESH RAY NEW DELHI LIFE MEMBERS 20/R-728



WELCOME NEW MEMBERS


MRINALINI SINGH MUMBAI LIFE MEMBERS 20/S-2000

SUSHANT CHHABRA GURUGRAM LIFE MEMBERS 20/C-563

KAPIL GUPTA NEW DELHI LIFE MEMBERS 20/G-907

HARPALSINH DABHI BHAVNAGAR LIFE MEMBERS 20/D-697

ABDUL NASSER GOA LIFE MEMBERS 20/N-357

VIVEK DESHPANDE AKOLA LIFE MEMBERS 20/D-698

ABDUL WAHID FAIZABAD LIFE MEMBERS 20/W-86

SETU KUMAR PATNA LIFE MEMBERS 20/K-1280

RAKTAVARNA SHREY RANCHI LIFE MEMBERS 20/S-2001

PRIYAMVADA MALPANI NAGPUR LIFE MEMBERS 20/M-1078

SHRIRAM VAIDYA BANGALORE LIFE MEMBERS 20/V-415

SUDHIR BISHERWAL ROHTAK LIFE MEMBERS 20/B-881

IMRAN KHAN KOLKATA ASSOCIATE LIFE MEMBER 20/K-1281

VIVEK RAVAL, NAVSARI LIFE MEMBERS 20/R-708

SUJEET MADHUKAR PATNA LIFE MEMBERS 20/M-1066

LUXMI JAIN NOIDA ASSOCIATE LIFE MEMBER 20/J-590

ARNAB MAJI BURDWAN LIFE MEMBERS 20/M-1079

GENTLE SHRESTHA NEPAL LIFE MEMBER (SAARC) 20/S-2005

RANJEET KUMAR PATNA LIFE MEMBERS 20/K-1284

MADIHA SHADAB, RANCHI LIFE MEMBERS 20/S-2004

PRASHANT PATNA LIFE MEMBERS 20/.-7

JITESH KUMAR ARWAL LIFE MEMBERS 20/K-1283

RANJAN KUMAR FARIDABAD ASSOCIATE LIFE MEMBER 20/K-1282



BRANCH ACTIVITIES

BAREILLY PROGRAMME COVID-19 SEMINAR

Dear Sir

We pleased to inform you Sir that we conducted covid19 panne discussion seminar on 31st march 2020 with fallowing social

distancing norm at srms medical college in association with ISCCM BAREILLY CHAPTER.

We discussed preventive measures & how to control it's spread..

In pannel myself Dr Vimal , Dr Lalit Singh, Dr Rajeev Tandon, Dr Ratan Pal Singh with others distinguished faculties...

Thanking you Sir

Yours Sincerely

Dr Vimal Bhardwaj

Chairman ISCCM Bareilly Chapter

NAGPUR BRANCH PRAGRAMME

Emergency Meeting over Corona Virus

The meeting at COVID-19 was held by society members at hotel centre point , Nagpur 9 am on 7th March 2020 .

Dr Sarang Kahirsagar has read the latest papers , guidelines for the management , and our future preparedness to manage the crisis

was discussed .

The meeting was attended by all eminent intensivist , anaesthesiologist and ID specialist of Nagpur City

Few strategies were made during this time for the management of crisis



BRANCH ACTIVITIES

RAJKOT BRANCH(NEW EXECUTIVE MEMBERS)

EXECUTIVE COMMITTEE

Dr. Vishal Sadatia Dr. Amit Rupala Dr. Ritesh Maradiya

Dr. Tushar Budhwani Dr. Darshan Jani Dr.Vimal Dave

Dr. Tushar Patel

CHAIRMAN

Dr. Amit Patel Dr. Mangal Dave

SECRETARY TREASURER

DELHI & NCR BRANCH (NEW EXECUTIVE MEMBERS)

Dr. Rajesh

Kumar Pande

CHAIRMAN

Dr. Deven

Juneja

Dr. Suneel

Kumar Garg

SECRETARY TREASURER

EXECUTIVE COMMITTEE

Dr Ashutosh Bhardwaj Dr Prashant Saxena Dr Akhil Taneja

Dr Rajat Gupta Dr Amit Goel Dr Vishal Gupta

WEBINAR REPORTMARCH TO APRIL 2020

4TH APRIL 2020

COVID 19 PANDEMIC:PREPAREDNESS:1ST HAND EXPERIENCE FROM HORSE`S MOUTH



WEBINAR REPORTMARCH TO APRIL 2020

18TH APRIL 2020

Oxygen therapy in Covid-19 Conducted by IMA. Faculty: Dr. Dhruva Chaudhry, President, ISCCM



TM

smiths medical

25TH APRIL 2020

COVID 19 Managing Airway, Controlling Infection and Managing the Hospital



HANDLING HOSPITALIZED CORONA PATIENTSA VOLUNTARY INITIATIVE OF ISCCM IN ASSOCIATION WITH IMA

When Corona had started playing havoc around the world , Some times during the rst week of April The President Dr Dhruv

Choudhary called me and told me that ISCCM was entering into a MOU with IMA to train doctors across the length and breadth of

the country regarding Handling of Corona should they are called upon to serve these patients . It was a noble idea and my

spontaneous immediate reaction to this was “great “. I requested him to include me in the scheme of things if the idea matures. On

8th April the President again called me, if I was ready to take the responsibility of coordinating the program nationally. I was very

happy to agree and indeed I am thankful to him for offering it to me. He also suggested names of Dr Banambar Ray and Dr Kapil Zirpe

as my team members – the two most experienced and eligible professionals to be in the team. Both are great friends as well. Thus, a

formidable team was formed. A power point presentation was constructed on Handling corona patients in Hospital. The material

consisted of The Problem, need for understanding SOPs, strategies to protect HCWs, Organization, Management strategies and

current treatment. The interesting part of the story was that we had to make signicant changes in the PPT based on ongoing new

information at least 10 times. This was because of every day new information was arriving about Corona.

Nilay , Akhashay and Ninad from our Mumbai ofce assured all their help in providing all the IT support .We discussed about the

strategy within our team and launched the rst program on 11th April with rst program with IMA Rajasthan , it was quite

successful. and almost 100 doctors attended on zoom. Then we had 10 programs lined up, some times as many as ve programs in a

day. I must mention that despite their busy professional schedules, both Dr Banambar Ray and Kapil zirpe have been extremely

exciting and dependable colleagues. Most of the programs were coordinated by ISCCM state branch executives and a few IMA

ofce bearers. In rst 10 days we did as many as 15 schedules. Then there was the challenge of ongoing Webinar ood and overdose

of webinar discussions across the board. However, this did not come in way and our webinar programs were very well received by

the participants and each program was exciting with lot of interaction and Q/A sessions. Some programs lasted as long as almost 2

hours. By this time, we have interacted with about 4500 medical professionals through 45 programs. Many big institutions had

organized big screens in their Auditoria and had their full strength of doctors and Nurses there, which we could clearly see. I, on

behalf the task force, express sincere gratitude to ISCCM leadership, all friends who coordinated the programs and senior faculty

members who joined us as panelists In Rajasthan this event was covered prominently by leading newspapers

I feel with some more initiative from IMA leadership, this program can go a long way in educating our HCW from Kashmir to

Kanyakumari about COVID handling. We should and we can really take it to places.

Dr Narendra Rungta MD FCCM FICCM FISCCM

Chairman and Managing Trustee

Critical Care Foundation Jaipur

Past President

Indian Society of Critical Care Medicine

Founder President Association of SAARC Countries Critical Care Societies

Past Chairman - Intensive Care Chapter (IAP )

ISCCM TASK FORCE

Dr Narendra Rungta Dr Kapil Zirpe Dr Banambar Ray

Mechanical Ventilator Experts: The Need of the Hour in Healthcare

In the span of a quarter, the COVID-19 crisis has turned into a major health threat to the global population. From India’s perspective,

it took less than four months for cases to escalate, from just 3 in February to 44,029 active cases as on May 11th.

India has only 2,500 pulmonologists – 1 for over 5 lakh people. In addition to that, there is a shortage of Healthcare Professionals

(Doctors) – practitioners and nurses who are ill equipped to handle mechanical ventilators – a life-saving competence in healthcare

today. It is essential that we have more trained doctors who are equipped to handle a mechanical ventilator in this crisis situation.

In this direction, at the beginning of April, the Indian Society of Critical Care Medicine (ISCCM) collaborated with Medvarsity Online

Ltd. and has been working closely with our core team at ISCCM and is supported by our 13,000+ members to host training

programs on its platform, Dosily (www.dosily.com) . The training program aims to educate over 1 lakh healthcare professionals in

the life-saving competence of providing respiratory support to patients through mechanical ventilation.

There have been 9 sessions so far taken by experts from ISCCM and Apollo Hospitals.



S. No Speaker/s Session Name Avg. Engagement

1 Dr. Sai Praveen Haranath Pulmonologist, Apollo Hospitals, Hyderabad Safe and Effective Mechanical Ventilation: Rapid Training for Beginners

87.2%

2 Dr. Rahul Pandit Consultant - Intensive Care and Critical Care | Internal Medicine, Fortis Hospitals Mumbai

Introduction to Mechanical Ventilator 83.10%

3 Dr. Rajesh Chandra Mishra Critical Care Specialist, Gujarat How to Initiate Mechanical Ventilation 82.10%

c Dr. Vasanth Kumar. SMD DNB FNB, Pediatric critical care, Fellowship in ECMO, Consultant pediatric Critical care, Apollo Chennai

How to Troubleshoot a Patient on a Mechanical Ventilator?

86.80%

5 Dr. Srinivas Samavedam, Sr. Consultant – Critical Care MedicineMD, DNB, FRCP, FNB, EDIC, FICCM, DHQM, DMLE General Secretary ISCCM, Mumbai

Complications and Risks of a Ventilator 71.10%

6 Dr. Subhal Dixit MD IDCCM, Critical Care, ICU Incharge, Pune Non-Invasive Ventilation – Part 1 77.20%

7 Dr. Raymond Dominic Savio, Senior consultant in Critical Care Medicine at Apollo Hospitals, ChennaiDr. Sristi PatodiaAssociate Consultant at Apollo Proton Cancer Centre (APCC), Taramani, Chennai

ARDS Ventilation and Prone Ventilation 79.30%

8 DR.R.EBENEZER DNB(ANAES),IDCCM.IFCCM,EDIC SENIOR CONSULTANT and HEAD DEPARTMENT OF CRITICAL CARE MEDICINEAPOLLO HOSPITALS VANAGARAM, CHENNAI

Airway Management in COVID-19 88.4%

9 Dr. Subhal Dixit MD IDCCM, Critical Care, ICU Incharge, Pune Non-Invasive Ventilation - Part 2 99.6%

ISCCM & MEDVARSITY - LEADING THROUGH EDUCATION TO TRAIN 1 LAKH DOCTORS IN MECHANICAL VENTILATION

The Impact of the Mechanical Ventilator Training Program So Far and the Way Forward –

The Mechanical ventilator training program has been the start of a revolution in the Indian healthcare community. To date, more

than 3,000+ Doctors have received training from experts through live webinars with an engagement rate of 84% in terms of

interactions in which the learning Doctors asked all their queries to the featured expert(s). These live sessions have received an

average of 4.4/5 rating from the learners, which is to say that a good number of Doctors found this training program useful in their

practice.

To know more about this initiative, visit : https://dosily.com/ventilator-training/

ISCCM & MEDVARSITY - LEADING THROUGH EDUCATION TO TRAIN 1 LAKH DOCTORS IN MECHANICAL VENTILATION

SUBMIT YOURRESEARCH/PAPERS FOR

ISCCM BEST RESEARCH PAPER AWARD

HANSRAJ NAYYAR AWARD

YOUNG TALENT HUNT

ORAL AND E-POSTER PRESENTATION

LAST DATE FOR SUBMISSION IS 31ST OCTOBER 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



Indian Society of Critical Care Medicine came in to being in 1993. ISCCM has growth has

exploded over the last 27 years and we had 10497 members in its 26th year of existence, when

the Silver jubilee Conference, Criticare 2019, was celebrated in Mumbai. There were members

from all streams of Medicine in the formative years. However, as the years went by the members

now include mostly the hands on practitioners of Critical Care Medicine, who may have any base

specialty. In the formative years, i.e. within 3 years of its foundation, in 1996, Indian Journal of

Critical Care Medicine was born. Indian Journal of Critical Care Medicine (ISSN 0972-5229) was

initially published quarterly; by Medknow Publishers.

The stated aims of the journal are as follows:



JOURNEY OF INDIAN JOURNAL OF CRITICAL CARE MEDICINE

• To promote the practice, education and research specically related to the Critical Care Medicine and Emergency Medicine

• To promote the exchange of current and innovative procedures as well as basic and clinical research in all areas.

• Focus on extensive research to enable researchers and scientists to communicate their ndings to the rest of the community.

• To promote student’s research in Critical Care Medicine.

This journal was an attempt to give voice to the hitherto unknown Indian researchers in the eld of Adult and Paediatric Critical Care

Medicine.

The rst editor of our journal was (late) Dr. P J Mehta. However, the rst issue to come out was in 1998, under the editor ship of Dr.

Praveen Kumar Jain. Those were the days of scarce resources and our collaboration with the pharmaceutical companies was not yet

close. In these years the journal was fully supported nancially by Hansraj Nayyar Medical India. The initial issues were print only and

these were sent only to the life members and not the associate life members. Ltd.

An important milestone in the Journey of Indian Journal of Critical Care Medicine was reached when it was indexed in Pubmed in

2010. It started appearing in electronic format in 2011 and was the rst Indian Journal to do so.

(See image below from Bioline International IJCCM – http://www.bioline.org.br/ info?id=cm&doc=instr/last accessed 17th May

2020)

Another important milestone was when the rst guideline supplement was brught out in March 2013. Unfortunately, for some

reason unknown to me, this supplement was never indexed in Pubmed



JOURNEY OF INDIAN JOURNAL OF CRITICAL CARE MEDICINE

Guidelines of Indian Society of Critical Care Medicine published in Indian Journal of Critical Care Medicine,

Supplement 1, March 2013 [41]

Guidelines for acute medical management of severe traumatic brain injury in infants and children

Guidelines for the prevention of infections associated with the use of vascular catheters in Indian intensive care

units

Critical care delivery in intensive care units in India: Dening the functions, roles and esponsibilities of a

consultant intensivist

Guidelines for end-of life and palliative care in Indian intensive care to units: ISCCM consensus Ethical position

statement

Guidelines for noninvasive ventilation in acute respiratory failure

The various editors of Indian Journal of Critical Care Medicine so far as follows:

Dr. P K Jain

1998-2003

Quarterly Publication

Dr. Sandhya Talekar2003 -2010

Quarterly Publication Pubmed Indexing of IJCCM

Dr. Shirish Prayag

2010-2013

Quarterly Publication

Dr. Raj Kumar Mani

2013-2018

Monthly Publication

Dr. Atul Prabhakar Kulkarni2019- present

Monthly Publication, Started quarterly

PG Supplement Advancing Frontiers

in Critical Care Medicine

Since 2019, Indian Journal of Critical Care Medicine is being managed and published by Jaypee Medical Publishers Pvt. Ltd.; for Indian Society of

Critical Care Medicine and it now nancially self-sufcient. It is now available as an open access journal and is available online only to all.

I am sure Indian Journal of Critical Care Medicine has a great future ahead.Dr. Atul Prabhakar KulkarniMD, FISCCM, PGDHHM, FICCM.

Editor-in-Chief, Indian Journal of Critical Care Medicine, Past President, Indian Society of Critical Care Medicine

Past Chancellor, Indian College of Critical Care Medicine, Past President, Association of SAARC Critical Care Societies

Secretary General, Asia Pacic Association of Critical Care Medicine, Professor & Head, Division of Critical Care Medicine,

Department of Anaesthesiology, Critical Care & Pain

Tata Memorial Hospital, Homi Bhabha National Institute, Dr Ernest Borges Road, Parel Mumbai.



ISCCM FELLOWSHIP IN CRITICAL CARE ULTRASOUND

Overview

• One-year fellowship

• Conceptualized to cater the need for uniform and structured training in point of care Ultrasound.

• Will cover all relevant topics and competencies for head to toe evaluation of critically ill patients.

• Designed for doctors caring for critically ill patients (Intensivists, Anaesthesiologists, Pulmonologist, Emergency Physicians etc.).

Dr. Deepak Govil

Course Director

Workshops

Basic and advance( 2days each)

Proctored training

Web based | Mentor/Supervisor | Webinars

Image discussion | Logbook/Researh project | Observership

Registration Online

20 candidates Rs 25000 + GST

Certication

Log Book presentation & discussion | Image interpretation

OSCE | Skill evaluation | Simulation | Bedside

Fellowship will be granted after successful certication

Please visit: http://academy.isccm.org/Courses.aspx

What is ORCID?

It is a nonproprietary alphanumeric code to uniquely identify scientic and other academic authors and contributors. It is a

collaborative effort by publishers of scholarly research and was rst announced in 2009 as a "to resolve the author name ambiguity

problem in scholarly communication. It addresses the problem of identifying an author’s contribution to scientic literature since

the names are common and they can change (such as with marriage), have cultural differences in name order, contain inconsistent

use of rst-name abbreviations and employ different writing systems. It provides a persistent identity authors, similar to that created

for content-related entities on digital networks by digital object identiers (DOIs).

How can I register for ORCID?

It is very simple. Just go to the ORCID website (https://orcid.org). Go to the researchers tab, you will see the website as in the

screenshot below. Register yourself here.

How is it useful for me?

The aim of ORCID is to aid "the transition from science to e-Science, wherein scholarly publications can be mined to spot links and

ideas hidden in the ever-growing volume of scholarly literature". Another use is to provide each researcher with a constantly

updated ‘digital curriculum vitae’ providing a picture of his or her contributions to science.

When you upload a manuscript in a journal, particularly one which asks you to give your ORCID no., it will automatically fetch the

information that you lled when you registered for ORCID account. Just make sure that you update your information, when you get

promoted or change your institute, etc, so that the information is updated and current.

To improve the recognition of our members of ISCCM, so that their unique identify is reected when they publish in our journal,

Indian Journal of Critical Care Medicine, we request you to register for ORCID.

If you have any queries please write to us at [email protected] or [email protected].



ORCID (OPEN RESEARCHER AND CONTRIBUTOR ID)



STERILIZATION AND DISINFECTION IN HOSPITAL DURING COVID 19 PANDEMIC

Sterilization and disinfection through the use of evidence-based practices is essential for ensuring patients and equipment do not

transmit infectious pathogens to other patients and staff. This has become even more important during these times of COVID-19

pandemic. In this article we will be discussing specic actions which need to be taken with respect to COVID-19 in addition to

standard precautions.

Corona viruses are RNA viruses enveloped in lipid bilayer. SARS-CoV-2 is a type of corona virus which causes COVID-19 disease. It

is mainly transmitted through inhalation of large respiratory droplets or contact with the contaminated fomites. Hence it is crucial to

disinfect the environment which has come in contact with the virus. Airborne spread has not been reported for COVID-19;

however, it can be envisaged if certain aerosol-generating procedures (AGP) are conducted in health care facilities. Faecal shedding

has been demonstrated from some patients, and viable virus has been identied in a limited number of case reports.

Environmental cleaning and disinfection are intended to remove pathogens or signicantly reduce their numbers on contaminated

surfaces and items, thus breaking the chain of transmission.

Sterilization is a physical process that destroys or eliminates all forms of microbial life and is carried out in health-care facilities by

physical or chemical methods. Disinfection describes a process that eliminates many or all pathogenic microorganisms, except

bacterial spores on inanimate objects, usually by liquid chemicals or wet pasteurization.

A study published in NEJM by Van Doremalen and associates showed that environmental stability of SARS-CoV-2 is three hours in

the air post-aerosolisation, up to four hours on copper, up to 24 hours on cardboard and up to two to three days on plastic and

stainless steel. (1)

A study conducted in Singapore showed that the viral shredding with extensive environmental contamination is seen in patients with

SARS-CoV-2 with mild upper respiratory tract involvement. They also found that post cleaning samples were negative which

stresses on the importance of disinfection of the hospital and isolation room. (2)

The heath care cleaning workers have to be in appropriate personal protective equipment (PPE) as per the CDC guidelines. (3)

They should be t tested and trained to wear N95 respirators and face shields (or powered air purifying respirators) when cleaning

patient rooms that have been occupied by persons with known or suspected COVID-19 or have been used for aerosol-generating

procedures on patients with COVID-19. Workers have to use droplet and contact precautions, plus eye protection (surgical mask,

face shield or goggles, gown, and gloves) when cleaning areas used by health care workers who are caring for COVID-19 patients.

Common hospital disinfectants

Following are the commonly used hospital disinfectants.

• Sodium hypochlorite (household bleach): As per the WHO recommendation, the minimum concentration of chlorine should be

5000 ppm or 0.5% (equivalent to a 1:9 dilution of 5% concentrated liquid bleach). It irritates mucous membranes, the skin and the

airways; decomposes under heat and light; and reacts easily with other chemicals. Therefore, bleach should be used with caution;

and ventilation should be adequate. For disinfection by wiping of nonporous surfaces: a contact time of ≥ 10 minutes is

recommended and for disinfection by immersion of items: a contact time of 30 minutes is recommended.

• Ethyl alcohol (70%) is a powerful broad-spectrum germicide and is considered generally superior to isopropyl alcohol. Alcohol is

often used to disinfect small surfaces (e.g. rubber stoppers of multiple-dose medication vials, and thermometers) and occasionally

external surfaces of equipment (e.g. stethoscopes and ventilators).

• Phenolic compounds

• Quaternary ammonium compounds

• Peroxygen compounds

Whenever any of the above disinfectants are used manufacturer’s recommendations for use or dilution, contact time and handling of

disinfectants should be followed.

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

Associate Consultant

Manipal Hospital, Whiteeld, Bangalore

Phone number: 9075790057

Email id: [email protected]




The following is the gist of the recommendation for cleaning of healthcare settings after the management of a suspected or

conrmed case of COVID-19 based on European centre for disease prevention and control (ECDC) guidelines (4) and WHO

guidelines. (5,6)

Environmental cleaning and disinfection

• Hospital-grade cleaning and disinfecting agents are recommended for all frequently touched surfaces (e.g., light switches, door

handles, bed rails, bed tables, phones) and bathrooms. They should be cleaned at least twice daily and when soiled.

• Visibly dirty surfaces should rst be cleaned with a detergent (commercially prepared or soap and water) and then a hospital-grade

disinfectant should be applied, according to manufacturers’ recommendations for volume and contact time. After the contact time

has passed, the disinfectant may be rinsed with clean water.

Cleaning the patient-care environment

• The entire isolation rooms used for caring for COVID-19 patient including the bathroom with all its items need to be disinfected.

The rooms used by the health care workers caring for such patients should also be disinfected.

• Rooms where aerosol generating procedures have been performed (bag-valve ventilation, intubation, administration of nebulised

medicines, bronchoscopy, etc.) need to be ventilated with fresh air for 1–3 hours, if they are not functioning under negative

pressure, before cleaning and admitting new patients.

• In buildings where windows do not open and the ventilation system functions in a closed circuit, high-efciency particulate air

(HEPA) ltration should be used for the recycled air.

• Clean horizontal surfaces in isolation rooms or areas – focusing particularly on surfaces where the patient has been lying or has

frequently touched, and immediately around the patient’s bed regularly and on discharge.

• To avoid the possible generation of aerosols, use damp cleaning (moistened cloth) rather than dry dusting or sweeping.

• If vacuuming is necessary, use a vacuum cleaner that is equipped with a HEPA lter.

• Cleaning of toilets, bathroom sinks and sanitary facilities need to be carefully performed, avoiding splashes.

• The use of single-use disposable cleaning equipment (e.g. disposable towels) is recommended. If disposable cleaning equipment is

not available, the cleaning material (cloth, sponge etc.) should be placed in a disinfectant solution effective against viruses.

• The use of different equipment for cleaning the different areas of healthcare settings is recommended. In the event of shortage of

cleaning equipment, the cleaning process should start from the cleanest areas moving to the dirtiest areas (e.g. an area where AGP

have been performed).

Patient-care equipment

• If possible, use either disposable equipment or dedicated equipment (e.g. stethoscopes, blood pressure cuffs and thermometers)

• If the equipment is reused it should be washed with soap and water if visibly soiled and disinfected with 70% alcohol.

• Wipe external surfaces of large portable equipment (e.g. X-ray machines and ultrasound machines) that has been used in the

isolation area with an approved hospital disinfectant upon removal from the patient’s room or area.

Dishes and eating utensils

• When possible, wash reusable items in a dishwasher. If no dishwasher is available, wash the items by hand with detergents. Use

nonsterile rubber gloves if washing items by hand.

Linen and laundry

• Remove large amounts of solid material (e.g. faeces) from heavily soiled linen (while wearing appropriate PPE), and dispose of the

solid waste in a toilet before placing the linen in the laundry bag.

• Machine washing with warm water at 60−90°C with laundry detergent is recommended. The laundry can then be dried according

to routine procedures.

• If machine washing is not possible, linens can be soaked in hot water and soap in a large drum using a stick to stir and being careful

to avoid splashing. The drum should then be emptied, and the linens soaked in 0.05% (500 ppm) chlorine for approximately 30

minutes. Finally, the laundry should be rinsed with clean water and the linens allowed to dry fully in sunlight.




Waste management

• All waste from the patient-care area should be considered as clinical waste, and treat and dispose of it according to the health-care

facility’s policy, and in accordance with national regulations pertaining to such waste.

Packing and transporting patient-care equipment, linen and laundry, and waste from isolation areas

• Place used equipment and soiled linen and waste directly into containers or bags in the isolation room or area.

• One layer of packing is adequate, provided that the used equipment and soiled linen and waste can be placed in the bag without

contaminating the outside of the bag.

• Ensure that all personnel handling the used equipment and soiled linen and waste use standard precautions, and perform hand

hygiene after removing PPE.

• Heavy-duty tasks (e.g. cleaning of the environment) require more resistant PPE (e.g. rubber gloves and apron, and resistant closed

shoes).

Disinfection of ambulance used for the transport of SARS CoV-2 patients

• All the surfaces that may have come in contact with patient or contaminated material should be disinfected

• Disinfect (damp wipe) all horizontal, vertical and contact surfaces with a cotton cloth saturated with disinfectant solution. These

surfaces include, but are not limited to stretcher, bed rails, infusion pumps, IV poles, monitor cables, telephone, and sharp

containers.

• Damp mop oor with disinfectant

• Cleaning of all surfaces and equipment should be done morning, evening and after every use with soap/detergent and water.

Decontamination of PPE and N 95 respirators

• Decontamination of PPE and N 95 respirators has been employed in regions where there is a severe shortage of these. CDC (3)

and WHO (7) have formulated guidelines for the same. They can be decontaminated using ultraviolet light (UVC), hydrogen

peroxide vapour or moist heat.

• Given the uncertainties about the impact of decontamination on respirator performance, the CDC recommends that these

decontaminated N 95 respirators should not be worn by healthcare providers when performing or present for an aerosol-

generating procedure.

Environmental cleaning and disinfection on a regular basis is essential for reduction of the transmission of COVID-19. No single

disinfectant is found to be better than the others. It is important to follow the manufacturer’s recommendations for use or dilution,

contact time and handling of disinfectants. With meticulous practices we can beat the COVID-19 pandemic.

References

1. van Doremalen N, Bushmaker T, Morris DH, Holbrook MG, Gamble A, Williamson BN, et al. Aerosol and Surface Stability of

SARS-CoV-2 as Compared with SARS-CoV-1. New England Journal of Medicine. 2020.

2. Ong SWX, Tan YK, Chia PY, et al. Air, Surface Environmental, and Personal Protective Equipment Contamination by Severe Acute

Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) From a Symptomatic Patient. JAMA 2020.

3. Centers for Disease Control and Prevention. Decontamination and Reuse of Filtering Facepiece Respirators using Contingency

and Crisis Capacity Strategie https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/decontamination-reuse-

respirators.html

4. European Centre for Disease Prevention and Control. Disinfection of environments in healthcare and non-healthcare settings

potentially contaminated with SARS-CoV-2. ECDC: Stockholm; 2020.

5. World Health Organization 2020, Water, sanitation, hygiene and waste management for COVID-19, accessed 19 March 2020




6. World Health Organization 2020Infection Prevention and Control guidance for Long-Term Care Facilities in the context of

COVID-19 . Interim guidance 21 March 2020Centers for Disease Control and Prevention. Interim Infection Prevention and Control

Recommendations for Patients with Conrmed 2019 Novel Coronavirus (2019-nCoV) or Patients Under Investigation for 2019-

nCoV in Healthcare Settings. https://www.cdc.gov/coronavirus/2019-nCoV/hcp/infection-control.html

7. World Health Organization. Rational use of personal protective equipment for coronavirus disease (COVID-19) and

considerations during severe shortages. https://www.who.int/publications-detail/rational-use-of-personal-protective-equipment-

for-coronavirus-disease-(covid-19)-and-considerations-during-severe-shortages



GUIDELINES FOR USE OF FACE MASK BY

THE MEDICAL PERSONNEL AND COMMON PUBLIC

Use of Face mask by the Medical personnel

Rationale: Since its outbreak in December 2019, the novel coronavirus disease, renamed as COVID-19, has spread world-wide to

almost 212 countries and is still showing no signs of abatement. In view of its widespread seriousness, WHO had to declare it as a

Pandemic on 11th of March 2020. The causative agent, known as SARS-CoV2, spreads via transmission by direct & indirect contact

and a lot has been emphasized to prevent the same by Hand hygiene and good practices. Airborne transmission through aerosol and

droplet occurs when people cough, sneeze, exhale & talk. The droplets formed are > 5-10 microns and transmission can occur

within 1 meter of someone sneezing or coughing. When the size of these droplets are < 5 microns they are called droplet nuclei.

Airborne transmission (through aerosol) occurs through the virus laden droplet nuclei, that lingers in air for a long time and can

travel a distance of more than one meter. Healthcare personnel and auxiliary staff working in the wards and critical care areas of the

hospital are at a greater risk of exposure to the virus as they work in close proximity of the infected people. Among the

recommended measures to prevent transmission, use of a face mask is being advocated, apart from social distancing and hand

hygiene. Several types of face masks are available. From simple cloth masks to specially engineered masks for various professionals,

the list is long. The SARS-Cov2 virus is 0.06 - 0.14 micron in diameter, and, most facemasks can lter up to 0.3 micron only, but are

seen as effective barriers in reducing exposure to high viral load.

The Ministry of Health & Family Welfare- Govt. of India, ICMR and NCDC recommend the use of two types of mask for medical

personnel:

1. Triple layer medical masks

2. Respirators (N95 or equivalent).

Specications:

1.Triple layer medical mask: This is a disposable, 3-layered mask, made of non-woven fabric, and having a bacterial lter efciency

(BFE) of 98% for 3-micron particle size and a particle lter efciency for 0.1 micron at > 30% (China: YY 0469 standard) or > 98%

(USA : ASTM F2100 standard), varying by the region. The outer hydrophobic layer is uid repellent, while the middle layer lters out

bacteria & water and the inner hydrophilic layer absorbs sweat & saliva.

How to use it: There are two varieties available - a surgical mask with ties to bind behind the back of the head, and a procedure

mask with ear loops. For wearing for prolonged periods, masks with ties are more comfortable. This mask has a coloured side, a

nose piece (metal/wire) or a nose clip, and pleats present on both the surfaces. It should be worn with the coloured side facing

outwards, nose piece upwards and the pleats facing down. It should t well over the face and cover the nose and chin, with no

leakage around. First, the upper set of ties should be tied over the ears and behind the head, and secondly, the lower set should be

tied below the ears, over the nape of neck. Tying the lower tie over the head or vice versa should be avoided, as this may create a gap

at the sides of the mask and allow air to enter. The nose piece or clip should then be pinched over the bridge of the nose to adjust it. If

properly worn, this mask can be effective for 6-8 hours. If wet, it should be changed immediately. This is a single use mask and should

not be reused. It should be removed gently by unfastening the ties and discarded carefully holding it by the ties or ear loops, without

touching the outer surface and with proper hand washing.

2.Respirators: It is a device that provides safety against inhalation of hazardous materials by creating the requisite air seal, around

the nose and mouth. It has high uid resistance of at least 80 mmHg pressure based on ASTM F1862, ISO 22609, or equivalent.

Breathing is preferably better with one having an expiratory valve. The outer and inner surfaces are clearly distinguishable and has a

duckbill or cup-shaped structured design that prevents its collapse against the mouth. The ltering efciency is at least 95 % for all

particles 0.3 microns or larger, and efciency exceeds the triple layer mask. Quality compliant standards for medical N95 respirators

are NIOSH N95, EN 149 FFP2, or equivalent.

Dr Asif AhmedMBBS, DNB (Anaesthesiology - Gold Medal), IDCCM

Senior Consultant & HOD, Department of Critical Care Medicine


Dr. Anu PrasadMBBS, MD(Anaesthesiology), FNB (Critical Care Medicine)

Specialist, Department of Critical Care Medicine






How to use it: The N95 respirators are available with or without an exhalation valve. It has two elastic bands and a nose piece

(metal or wire). A t test is required before using this to get the correct size for the wearer, otherwise it may be difcult to have a

good seal. It may also become uncomfortable & stuffy for people to wear it for long period of time along with feeling of

claustrophobia. The respirator should be worn by holding it, outer surface down, in the cup of the palm. The respirator should cover

the face, nose and chin. The lower elastic band should be pulled over the head and placed below the ears on the nape of neck. The

upper elastic band should be pulled and adjusted over the top of the head. Crossing of elastic bands should be avoided. The nose clip

should be pinched over the nose. The respirator should be covered with both hands and one should inhale and exhale deeply. There

should ideally be no leak from the sides or near the nose. If there is a leak then respirator should be adjusted and the leak test redone,

before entering the patient care area. During removal, one should refrain from touching the outside of the respirator with bare

hands and instead both upper and lower elastic bands should be pulled clear off the head, over the face, and mask should be

discarded in a safe bin. Reuse of mask should be discouraged especially when it is visibly soiled or has been used during an aerosol

generating procedure. Various methods have been advocated for its re-use during scarcity, but it depends on the institutions and

places to follow the same.

Rational Use based on risk prole: Since the declaration of the pandemic the consumption of these masks has gone up

exponentially, and with lack of quick and adequate production, an acute crisis has developed regarding its availability. Hence the

recommendation by the Medical advisory bodies worldwide to rationalize its use based on the risk prole of the medical workers in

their areas. The guideline issued by the Ministry of Health & Family Welfare, Govt of India gives a detailed information about the use

of the different PPEs including the masks and certain key points are as follows:

Triple layer mask: For people working in areas with mild risk of transmission, the use of triple layered mask is recommended. Such

areas can be the help desk, pharmacy, doctors’ chambers, linen & sanitation staff & Non-COVID wards. Personnel collecting blood

samples, emergency staff in Non-COVID centers, ambulance drivers, personnel shifting dead bodies should use a triple layered

mask.

N95 respirators: Respirators have specically been recommended in moderate to high risk areas where people are dealing with

highly suspected/conrmed cases of COVID-19 along with the other PPEs. It should be used in Dental & ENT OPD, PAC clinic and

ICU where aerosol generating procedures like suctioning, intubation and bronchoscopy are carried out in a hospital which has both

COVID & Non-COVID treatment areas. It should be used in Operation theaters where patients from Containment areas are being

operated. Laboratory persons taking respiratory samples of COVID suspects and staff escorting a patient with severe acute

respiratory syndrome(SARI) in ambulance, especially if that patient is on ventilatory support, should wear a N95 respirator grade

mask. Healthcare personnel performing aerosol generating procedure on a seriously ill patient in the emergency or a doctor

providing intrapartum care to a pregnant woman from a containment zone should also use an N95 respirator. The used respirators

and masks should be disposed of in bins that have been designated for COVID-19 wastes.

In addition to stringent use of masks, standard precaution should be followed. Hand hygiene should be performed frequently, and

utmost care should be taken not to repeatedly touch your face, nose or mouth with unclean hands. Cough etiquette should also

become a habit. While coughing or sneezing always cover nose and mouth with handkerchief, paper tissue. If handkerchief or tissue

paper is not available cough into the exed elbow. Dispose of tissue immediately and wash hands with soap and water.

Use of Face mask by the Common Public

Rationale: Wearing of facemask by the common public was not recommended earlier by the WHO based on the lack of evidence

that this method prevents infection with COVID19. Also were other concerns like shortage of mask for medical supplies, having a

false sense of security and use of correct techniques for its use and disposal. But others claimed that though evidence regarding its

effectiveness is lacking, even measures like covering the mouth and cough etiquette to reduce respiratory droplet transmission are

not based on clinical trials and none of the previous trials were done during a pandemic. Face masks can reduce transmission by

reducing the droplets that people emit during talking and coughing and can benet the population which has possible asymptomatic

transmission. Some countries showed benets of using the face mask and gradually CDC and other countries like Canada, South

Korea and Czech Republic advised the usage of these masks.





The need was also acknowledged by the Ministry of Health and Family Welfare of India and advisory in this context was released on

3rd April 2020. Apart from social distancing and personal hygiene, which are the key measures to prevent the spread of COVID 19

infection, it has been recently claimed that homemade face masks or face covers can also be benecial. It is being seen as a good

method of maintaining personal hygiene and overall hygienic health condition and also limiting the spread of infection.

What mask should the common public wear – The general public should wear a cloth mask or face cover when they are moving

out of their house, preferably homemade cloth masks. Care should be taken that they should not be suffering from medical

conditions and having breathing difculty and associated problems.It is not for use by the health personnel who are working with or

in contact with the COVID 19 patients nor should it be used by the patients.

Where is it available – It can be prepared at home by sewing cotton cloth-piece or can be stitched out of a handkerchief. The

advisory by MoH&FW on Homemade Protective cover for Face & mouth clearly depicts the steps to be followed to prepare these.

How to use it – A home-made face mask or face cover should be washed thoroughly with soap and water before its rst use and

this should be preceded by proper hand washing. It should be dry before use and t well around the mouth and nose without any gap

in between. The pleats should be downwards and be on the inner side. It should be removed once it is damp or wet. The homemade

face mask should not be ever reversed for use nor should it be re-used without proper measures. It should not be shared with any

family member or any other person. All members should have separate masks and it is preferable to have two or more masks for

each member so that while one is in use, the other is washed and dried.

Never should one touch the outer surface of the mask nor people should be putting it up and down with unwashed hands. During

removal, the lower string should be untied rst and followed by the upper one. After removal, the mask should be put in soap

solution or boiling water with added salt. Hands should be cleaned with alcohol-based rub or soap solution.

How to keep it and reuse it – The used homemade face mask should be thoroughly washed in soap and warm water followed by

drying in sun for at least 5 hours. Other alternative is to put it in a pressure cooker lled with water and added salt, and boil it for at

least 10 minutes.

It can also be boiled in hot water, without a pressure cooker, for at least 15 minutes. Other option is to wash and clean it with soap

and water and apply heat on it Option 3 – Wash and clean with soap and apply heat on it using an Iron for 5 minutes. CDC

recommends washing the homemade face masks in a washing machine followed by drying. After washing and drying, the

homemade mask should be stored in a clean and dry plastic bag, which has been washed and dried properly. The plastic bag should

be sealed and kept for reuse with all proper care again.

References:

1. Novel Coronavirus Disease 2019 (COVID-19): Guidelines on rational use of Personal Protective Equipment, Issued by Ministry

of Health & Family Welfare.

2. Advisory on use of Homemade Protective Cover for Face & Mouth, Issued by the Ofce of the Principal Scientic Advisor to the

Government of India_ April 3, 2020, MoH&FW.

3. Additional guidelines on rational use of Personal Protective Equipment (setting approach for Health functionaries working in non-

COVID areas). Issued by Ministry of Health & Family Welfare.

4. https://www.bbc.com/news/health-51205344

5. Wearing masks in the community during COVID 19 pandemic: altruism & solidarity.Kar Keung Cheng et al, Lancet, April 2020.

6. http://covid19.ncdc.gov.ng/resource/UseOfPPEnew.pdf

7.https://www.mohfw.gov.in/pdf/UpdatedAdditionalguidelinesonrationaluseofPersonalProtectiveEquipmentsettingapproachforH

ealthfunctionariesworkinginnonCOVID19areas.pdf

8.https://www.who.int/publications-detail/rational-use-of-personal-protective-equipment-for-coronavirus-disease-(covid-19)-

and-considerations-during-severe-shortages

9. https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html



HOW TO MAKE HOMES SAFE

FOR HCW'S AND THEIR FAMILIES

Health Care Workers (HCW) have dual responsibility, not only to take care of patients in hospital, but also look after their

respective families once they are off duty. It really pays heavy on their minds so as to not harm/infect their family who are the

backbone of their support system.

There is limited guidance available for HCW’s as to effectively take care of their moral and personal responsibilities.

However, the risk of exposure should be gauged by individuals as per CDC recommendations.

It is known and well-established fact that the major route of transmission of COVID -19 is through aerosol generation. So,

the most important factor for HCW is prevention of generation of such aerosols and avoidance of it from suspected

patients.

There are various methods through which HCW can at least try to decrease the guilt of taking infection home. The

foremost is extreme hygiene. The HCW tend to carry least things from home to hospital, like pens, bottles, stethoscope,

bags, laptop etc. so as to decrease the contaminated objects brought back home. It’s also prudent to change to hospital

dress/scrubs, put on disposable cap, mask and shoe covers on reaching the hospital and take a shower before changing back

and returning home. Repeated hand washing with soap and water/alcohol-based solutions both at workplace and home

should be a routine practice. Also, clean the phone, stethoscope etc with alcohol-based solutions prior to returning home.

Some HCW also tend to isolate themselves from their families at their home itself or have moved to hotels for the period of

quarantine. If it’s a shared space, ensure good airow in the room, windows should be kept open and fans switched on for

good air circulation. If the bathroom is shared then the HCW should clean and disinfect it after every use. (CDC

recommendations)

Routine cleaning of frequently touched surfaces at home is also recommended. Surfaces like door knobs, handles, switches,

table tops, sinks, toilets etc should be initially cleaned with soap and water then with disinfectant (where applicable).Diluted

home based bleaches can be used if appropriate for the surface. Alcohol based solutions with 70% concentration can also

be used. (CDC Recommendations)

Electronic surfaces can be covered with wipeable material for easy cleaning e.g. Touchscreen monitors, keyboards,

remote controls etc. Laundry should be cleaned separately using the warmest appropriate water for the clothes. Do not

shake dirty laundry. (CDC recommendations)

The HCW should not let their guard down or decrease the level of precautions to be taken as the time passes, as it looks like

virus is here to stay for some time, before an actual antidote or vaccine is commercially gets available in the market.

Dr Vikas Sikri DNB, IDCCM

Consultant Pulmonary & Critical Care

SPS Hospitals, Ludhiana

Dr Seema Singhal MD

Senior Consultant Microbiology & Infection Control Ofcer

SPS Hospitals, Ludhiana



HOW TO MAKE HOMES SAFE

FOR HCW'S AND THEIR FAMILIES

Do’s

REGULAR HAND WASHING

CHANGE TO HOSPITAL SCRUBS

HOME ISOLATION IN SEPRATE ROOM

MAINTAIN SOCIAL DISTANCING

MUST FOLLOW AND KNOW

COUGH/SNEEZING ETIQUETTE

Don't’s

TOUCH YOUR FACE CLOSE CONTACT PANIC

SPREAD MISINFORMATION

INFORMATION BOMBARDMENT

CREATING PROBLEMS FOR HCW’S



EFFECTS OF COVID-19 ON MENTAL HEALTH IN

ICU STAFF AND ITS MANAGEMENT

The COVID-19 pandemic is an unexpected challenge for whole society including health care services provider. Covid 19

infection has spread very rapidly and its spread across the globe has led to escalation in the mortality as well. The gures of

number of person affected and numbers of person dying due to COVID-19 are rising day by day, which has become the

primary concern for all the nations affected by it.

Health staff working in specic area like intensive care unit (ICU) or emergency department have to stay vigilant & cautious

at the same time. The job prole, working hours, shift duties, type of responsibility and many other factors add to the stress

level of health service provider of such specic areas. Treatment of illness like COVID- 19 with high infection rates and being

a major health concern due to unavailability of specic vaccine or medicine and number of mortalities caused by it; has

certainly added more burden to the already existing high stress level & burnout of health care provider working in intensive

care unit or emergency department. Thus supporting the mental health of health services provider and afliated healthcare

workers becomes as important as treatment of person affected with COVID-19. [1]

Health care providers and afliated healthcare workers (staff) may go under constant physical and psychological stress

while dealing with any patient presenting with symptoms like COVID-19. In addition, the staff which is frontline worker, for

example, who are screening these patients in special Flu OPDs or COVID OPDs and those who are treating them in

Intensive care set up are at highest risk of going through more physical and psychological stress. [2]

In this article the psychological effect on Intensive care unit (ICU) staff and its various aspects are discussed.

Reasons for stress in ICU staff while treating COVID-19

• Fear of getting infection

• Fear of transmitting infection to their family member

• Repeated change of the treatment & management guidelines & adapting to these changes

• Issues related to availability and knowledge of using personal protective equipment (PPE)

• Caring for and witnessing patients who are very sick and quickly deteriorating

• Worries acquired from colleagues who have got similar kind of symptoms or who are sharing bad news frequently in the

team

• exhaustion due to constant use of protective gear and not able to maintain personal hygiene

• feeling powerless to handle patients' conditions

• Fear of being quarantined and staying away from beloved ones

• Fear in special population like those with co-existing illness or pregnancy or aged staff.

• Stigma being faced from society

• Denial of family member to attend duties

• Fear of getting in nancial trouble if not going to work

Mehul M Luhar # Krunal Patel *, Anuj Clerk**#M.B.B.S., D.P.M., Consultant Psychiatrist, Manan Mind Care Clinic

*Consultant Intensivist, **Head, Intensive Care Services,

Sunshine Global Hospital, Surat, Gujarat






EFFECTS ON ICU STAFF:

Psychological EffectsHealth care provider working in such facilities may develop fear, phobia, acute or chronic stress reaction, panic attacks, generalised anxiety, insomnia, depressive features, inappropriate guilt. [3] [4]

Effects on Motivation and Attitude

Constant stress and worries may affect their working capacity, motivation and attitude towards their own work. Staff may develop maladaptive behaviour while coping with such a high stressful situation. They may start avoiding work & remain absent by giving different excuses and sometimes not even giving any reason, might start escaping from certain duties assigned to them or nally resort to resigning from work without giving any prior notice. In turn this may over burden the staff who are punctual in duty and motivated because of extra duties and extra work load which will further expose the later staff to more added stress.

Effect on work

The added stress and burnout will lead to decreased focus and attention with the staff making more mistakes than usual at work. To avoid the exposure to infection & scolding due to their increased mistakes and decreased working efciency they might start manipulating and falsely report data. They might become forgetful at work due to increased stress and inattentiveness.

Physical EffectsPhysically they can develop headache, excessive perspiration, palpitation, fatigue, increased frequency of urine and stool, vivid dreams & nightmares due to the constant stress.

DO’S AND DONT’S FOR HOSPITAL ADMINISTRATION

Do’s Don't’s

Focusing on workload management

Ensuring staff do not exceed safe hours Clear guideline on role expectations A v o i d p o s t i n g i n unconventional areas unless continuous guidance of expert onsite[ Ward nurse posted in ICU]

Addressing resource inequities Avoid Punitive actions, if taken, avoid public disclosure

Helping in food, water, transport and housing issues, including special provisions of meals, laundry services to boost morals

Avoid undue favours in postings, role assignments, leaves, payment, protective equipment allocations etc

Regular update of current situation in facility as well as in city and state

Do not take cost cutting measures without taking relevant staff in condence

Regular update on new guidelines of practices and relevant knowledge

Avoid comparisons among staff of different strength and weaknesses

Regular encouragement of staff by messaging apps, social media platforms.

Avoid using social media platform to discuss work related personal issues.

Ensuring that they receive their due salary on time Avoid using threats or coercion for getting any task done

Being easily available for addressing their issues Avoid one way dialogue during meetings.

Empathetic attitude towards staff Avoid shunting staff between departments when they fall sick.

Providing adequate PPE and identifying/ and helping high-risk staff to reduce psychological symptoms

Avoid mental and social isolation if they have to be quarantined [ physically isolated].

Support staff’s mental health and wellbeing needs- rapid access to counselling, psychiatry and contingency for time off work.

Avoid stigmatising the staff working in COVID wards, suspected, infected or recovered from COVID infection or seeking support of mental health professionals.

Drop-in sessions with Psychologists/psychiatrists or Remote sessions on phone or video call.

Avoid labelling “escapism” for those staff having genuine reasons for avoiding duties





DO’S AND DONT’S FOR HEALTH CARE PROFESSIONALS

Do’s Don't’s

Keep in regular contact with family and friendsAvoid using any substance like alcohol, weed, tobacco for de-stressing

Open up- let oneself talk about his/her feelings and share his/her experiences with others. (Talking about work is also not an issue)

Avoid reading bad news too many times

Try and use helpful coping strategies such as taking sufcient rest Avoid tracking the numbers of new cases or deaths

Try to concentrate on the present. Don’t dwell on the past or future worries.

Avoid contact of person who always spreads negativity or bad news

Own up to yourself that you are feeling stressed – half the battle is admitting it.

Do not over burden with work

Change attitude towards situation. Cultivate positive ones intentionally.

Do not take too much responsibility

Eat proper healthy foodDon’t feel inappropriate guilt for limitations of medical science in saving COVID victims

Do regular exerciseAvoid trusting unsolicited news on social media or non-scientic platforms

Take proper sleep Avoid self medication in anticipation of COVID 19.

Take regular ongoing medicines if anyAvoid violation of institutional or government guidelines about managing COVID related aspects of Health care because personal or perceived beliefs

Relaxation or leisure time each day is importantAvoid forwarding COVID related informations without validation

Spend time for yourself and take part in things which gives you pleasure, for example- listening music, reading books, watching comedy videos.

Avoid being over or under condent regarding risk of acquiring COVD infection

Be thankful for the good things in your life, for example family and friends.

Avoid keep concerns to yourself.

Learn to say “no” when it is out of limit Don’t feel embarrassed while discussing your concerns.

ROLE OF MENTAL HEALTH SERVICE PROVIDER IN SUPPORTING ICU STAFF IN

SUCH STRESSFUL SITUATION

• Running special OPDs or session for such staff in privacy. (dedicated hours for the same)

• 24-hour telephonic help for any unforeseen psychological issues

• Conducting brief sessions on stress management including Deep Breathing Exercises and Progressive Muscle Relaxation

• Periodic release of structured, stress busters or positive motivating quotes among staff.





• Encouraging staff’s Self Care- Physical and Mental.

• Educating staff about common and natural response of mind in such stressful situation

• Recommending health promoting behaviours eg. Sharing, time management, setting priorities.

• Facilitate Problem-Solving by teaching Problem Solving Approach

• Educating staff about “Positive Coping Skills”

• Pharmacological help in moderate or severe cases

References/ Links-

[1] https://rcni.com/nursing-standard/newsroom/news/covid-19-call-psychological-support-icu-nurses-they-face-surge-cases-

159286

[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7118532/

[3] https://www.medicalnewstoday.com/articles/covid-19-medical-staff-experience-insomnia-and-higher-stress#The-stress-of-

frontline-COVID-19-work

[4] https://thepolicytimes.com/covid-19-more-than-one-third-doctors-suffered-from-insomnia-in-china-during-the-pandemic-

studies-saying/

[5] https://www.who.int/docs/default-source/coronaviruse/mental-health-considerations.pdf

[6]https://www.psychiatrictimes.com/sites/default/les/legacy/mm/digital/media/03Mar_PTMorganstein_Coronavirus_PDF_V2.

pdf



PREPARING HOSPITAL FOR COVID-19 PANDEMIC -

TEAM BUILDING AND RESOURCE MANAGEMENT

The Coronavirus disease (COVID-19) caused by severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) is

another major pandemic after H1N1 inuenzae pandemic of 2009-2010 in this century. The COVID 19 is however different from

H1N1 inuenzae because of greater infectivity, incubation period and duration of disease and can overwhelm the healthcare

infrastructure rapidly in case of rapid inux of patients. The hospitals must prepare themselves in multiple areas focused on

infection control, running of supply-chain, clinical operational challenges, beds especially intensive care surge capacity, stafng

(training and staff safety), ethics, etc.

The objective of the pandemic preparedness includes:

• Prevent the spread of respiratory illness including COVID-19 within the facility or allowing the hospital to become infection

“hotspot”.

• Promptly identify, test and isolate patients of suspected and conrmed COVID-19 infection and manage them as per government

approved directives and inform public health authorities.

• Identify own patient handling capacity of both conrmed or suspected COVID-19 as part of routine operations.

• Identify and planning for the mechanism of increasing the capacity (Surge capacity) in the context of an escalating outbreak while

maintaining adequate care of other patients

• Monitor Healthcare personnel safety and manpower planning in case of surge.

• Establish an effective Communication channel within the facility for appropriate internal and external communication related to

COVID-19.

The pandemic preparedness has two essential components: team building and resource management. The COVID-19

Preparedness plan should be prepared, reviewed and duly signed by appropriate signatories and must be part of standard hospital

document and shared with all hospital personnel.

Team building:

The preparedness of pandemic must start with a task force comprising of key stakeholders (Table 1). The task force must comprise

representation from senior hospital leadership, infection control, facility management, biomedical, supply-chain management,

quality nursing and clinicians. It must work in close liaison with hospital regulatory authority and/or government {Ministry of Health

and family welfare (MOHFW)} appointed COVID task force/committee. The task force should have an appointed head, safety

ofcer and coordinator who should work closely with hospital leadership for development of surge plan in case of rapid inux of

patients. The road map for developing a COVID facility should be based on guidance and legal framework from regional/national

guidance to of MOHFW. The hospital must adopt international best standards on Infection Control from World Health Organization

(WHO) and/or Centre for disease control and prevention (CDC). The Hospital taskforce during pandemic need to be dynamic and

must regularly review the hospital preparedness plan in reference to ongoing situation. The safety ofcer however should be

empowered to take ad-hoc decisions in emergency situations to ensure patient and staff safety.

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)





COMMUNICATION:

The task force policies and decisions should be shared regularly to all staff and there training and compliance on practices based on

protocol should be regularly monitored. The communication among staff, taskforce and healthcare professionals (HCP) through

easily accessible but accurate channels like intrahospital portals, e-mails, closed social media groups, notice boards etc cannot be

overemphasized. The current digital media especially social media has made the reach of communication faster and easier. The

information accuracy and transparency during this pandemic however been regularly questioned and has equal chances to be farce

because of uncontrolled and mostly unveried form of digital information. The outbreak situation updates therefore should always

be accessed from reliable sources like local, national or international ofcial circulars, websites (e.g., mohfw.gov.in, who.int, etc.)

and/or their ofcial social media channels.

Lu RJ, Zhao X, Li J, et al. Genomic characterization and epidemiology of 2019 novel coronavirus: implications for virus origins and

receptor binding. Lancet Adv 2020; 29.

Table 1: Stakeholders of Pandemic preparedness Task force

Must be included in the Task Force Additional members which can be considered

Hospital administration Physical therapy

Quality /Risk management Respiratory therapy

Infection control/hospital epidemiology Diagnostic imaging (radiology)

Disaster coordinator Discharge planning

Public relations coordinator/public information ofcer/Social worker

Staff development/education

Medical staff (e.g., internal medicine, paediatrics, hospitalist, infectious disease, Anaesthesiologist)

Central (sterile) services

Nursing administration Dietary (food) services

Human resources Pharmacy services

Facility personnel representative Information technology

Occupational health Purchasing agent /materials management

Intensive care Laboratory services

Emergency departmentExpert consultants (e.g., ethicist, mental/behavioral health professionals)

Engineering and maintenanceOther member(s) as appropriate (e.g., volunteer services, community representative, clergy, local coroner, medical examiner, morticians)

Security





RESOURCE MANAGEMENT:

The resource management is second most important component of preparedness plan. The resource management includes

Infrastructure, human (manpower), and supplies.

INFRASTRUCTURE

The planning should start with clear identication of COVID area in the hospital where patients will be isolated and managed. The

COVID area must be used only for conrmed cases and hospital can be divided into zones (Figure 2) based on the severity of illness

(Table 2) based on patient management and infection control. There must be clear identication of the COVID area to avoid

confusion among staff, patient and visitors. The separate safe passage for staff handling the patients into these areas should be

identied based on principle of minimizing exposure. The patient ow into the area from OP or emergency should be clearly

identied and also the inter-department transfer process especially in non COVID areas e.g. radiology, operation theatre etc.

The general administrative principles for COVID area can include:

• Ensure COVID front desk/reception for early identication area of the patient with fever and u symptoms (cough, fatigue, sore

throat, etc.) or history of contact (as per case denition by government) from entrance of the hospital.

• Dedicated waiting areas for symptomatic patients.

• Patient ow management and prevent overcrowding, especially in the emergency department and OP department

• Designated Donning and dofng area for HCP should be available at all areas and scrub stations after nishing working shift and

should be arranged for all HCP.

• Implement engineering controls to reduce or eliminate exposures from infected individuals e.g. physical barriers or partitions to

guide patients and staff appropriate air-handling systems that are properly maintained etc.

• The negative pressure isolation rooms with separate bathrooms are available for all the time for aerosols generating procedures

(e.g, intubation, extubation, bronchoscopy, non-invasive ventilation (NIV), cardiopulmonary resuscitation) and are appropriately

monitored for airow and exhaust handling.

• Ensure availability of adequately ventilated single rooms with attached bathrooms for routine patient care.

• Limit visitor access and movement within the health facility

HUMAN RESOURCE MANAGEMENT:

• The pandemic period can be overwhelming especially to HCP and can inict physical, emotional and social trauma on everyone

working in hospital especially front-line staff.

• For prevention of hospitals to become infection hotspots by themselves adequate patient to staff ratio should be maintained at all

times.

• There should be reserve group and frontline group of all HCP.

• Plan to monitor staff absenteeism and sickness every shift and pull from the reserve group.

• Ensure minimum needs of the staff to ensure optimum operational efciency and safety. (food, stay, transport, family support, etc).

• The staff supervisor/head in each clinical area should coordinate with human resource and task force for appropriate review of

staff requirement and availability.

• Plan shift rotation for self- care and to avoid burnout among healthcare and non-healthcare workers; Psychological and emotional

support for healthcare workers has to be considered whenever required.

• Job responsibilities of each staff should be identied, and job card should be available to each staff in case of surge.

• Provide adequate education and refresher training for HCPs regarding 2019-nCoV diagnosis, specimen testing, appropriate

PPE use, triage procedures including patient placement 2019-nCoV cases reporting, management guidelines and procedures

to take following unprotected exposures (i.e., not wearing recommended PPE) from a suspected 2019-nCoV patients in or out

of the health facility.

• The legal requirements to recruit temporary help (e.g. community volunteers, students, etc.) should be ready and training for all

additional team members is planned.

• There is a security team in place to ensure the safety of patients, staff and visitors

• and key supplies if needed

• A security plan should be in place to ensure safety of HCP and patients. This may include escorting HCP, patients or visitors if

necessary; staff awareness about this security plan.





SUPPLY-CHAIN MANAGEMENT

Supply chain of medications, consumables are vital armory in this ght of human to virus. The un-interrupted supply of resources is

important for safety of healthcare professionals and appropriate management of patients.

• Ensure adequate supplies of PPE e.g. surgical masks, N95 masks, gloves etc. and other infection prevention and control supplies

(e.g. disinfectants and hand hygiene supplies) are available for healthcare -personnel (HCP) as well as patients.

• The daily monitoring of essential consumables including PPE should be followed using standard toolkits.

• Stock of all the equipment and consumables related with COVID treatment to be identied separately and monitored regularly

• Anticipate supply shortages and coordinate with vendors, and emergency management to coordinate resource supply,

distribution, and scarce resource strategies. There should be critical threshold of all supplies on which contingency plan should be

activated.

Resource Management should also include following critical departments and there action plan into Hospital Preparedness plan.

HOSPITAL INFECTION CONTROL:

The Hospital Infection Control Committee is a core group in the planning, implementation and execution of the COVID-pandemic

preparedness. Infection control should be given the utmost priority in the whole planning and implementation.

• Transmission based precautions – standard, droplets and aerosols should be applied and monitored in all settings.

• Training of all medical and non -medical staff should be provided on COVID specic and as well general infection control standards.

Training with demonstration on the use of PPE should also be given separately to all HCP

• Promote and Monitor HCPs compliance to standard and droplet precautions at all areas designated for COVID-19 patients.

• Promotion of hand hygiene and respiratory hygiene as essential preventive measures with availability of educational

materials such as digital platform, posters or social media messages about hand hygiene and respiratory etiquette for all patients and

visitors.

• N95 respirator t testing for all HCP and education on recommended infection control precautions including N95 seal check,

applying surgical mask to patients with cough, and hand hygiene.

• Prepare guidelines for conservative and re-use of N95 respirators/PAPRs if severe shortages are imminent as per local/regional or

international guidance like CDC or WHO.

• Develop a rejoining to work policy post illness policy for health care workers. This should be as consistent as per national or local

government guidance.

HOUSEKEEPING.

• Calculate and identify manpower required for all shifts round-the-clock.

• Training on PPE, infection control and Disinfection standards as per hospital Infection should be imparted to all Housekeeping

staff.

• Daily screening of staff for sickness.

• Plan for procurement, acquisition, storage and adequate stockpile of disinfectants. Identify back-up vendors in case of surge.

• Monitor the daily inventory and consumption of disinfectants.

HOSPITAL LABORATORY

• Laboratory Manpower estimation and ensure availability round-the-clock.

• Staff training on PPE, Infection control and safe handling of the biological uids.

• Housekeeping and lab disinfection activities as per hospital Infection control.

• Plan for procurement, acquisition, storage, stock and stockpile monitoring of reagents. Identify multiple vendors in advance.

• Plan for estimating the daily consumption of reagents.

• Plan for the surge capacity of the lab, where samples can be outsourced and liaison with outsourcing lab. LINEN AND LAUNDRY

• Plan for safe handling of all patients and HCP linen as per Infection Control standards (Collection of used linen, disinfection,

washing and disposal).

• Training of staff in PPE, Infection control and safe handling of linen.

• Estimate and management of adequate supplies of linen.

• Plan additional infrastructure to keep an uninterrupted supply of linen especially during surge.





BIOMEDICAL WASTE MANAGEMENT

• Ensure safe segregation of biomedical waste as per infection control standards.

• Plan safe transport and disposal of all biomedical waste.

• Training of staff on safe handling of biomedical waste.

DIETARY SERVICES

• Staff training on infection control and supplies of patient food.

• Ensure disposable cutlery to avoid contamination and safety of dietetics staff.

• Preparing a list of raw materials of food for the workforce and patient and system to monitor procurement, acquisition, storage,

stock, stockpile monitoring of food in case of surge.

• Plan for updating daily inventory.

• Plan for estimating future requirements based on consumption and inventory check.

BIOMEDICAL ENGINEERING SERVICES.

• Estimate and ensure availability need for BM equipment ( Ventilators, Syringe pumps, NIV, Crash carts, airway requirements,

ventilator accessories) for expected patients.

• Pool or Liaison of critical biomedical human supplies (ECMO, Ventilators, Patient monitors, Ultrasound) in liaison with other

hospitals in vicinity.

• Plan how to ensure continuous power source and alternate power sources

• Ensure continuous O2 supply and/or Medical gas supply

• Ensure working status of all critical equipment daily.

Corrective and preventive maintenance of all equipment should be reviewed

• Clear MOU with external technical service if necessary, in case of breakdown

SURGE CAPACITY PLANNING:

• Surge capacity is the ability of a health system by increase its resources to meet an increased demand for health services. It should

be part of initial disaster preparedness plan. The inundated system has serious implications both on patients and HCP with poor

patients’ outcomes and increase rate of cross-infections to HCP.

• The contingency plans for supply-chain of essential items like PPE, ventilators medications and other infection- control materials if

requirement exceeds the available supply. The plan to ramp up resources in case of surge should be planned and reviewed regularly

depending on the dynamics of the pandemic progression.

• There should be close liaison to nearby hospitals and central command center/government units in case of surge for mobilization

of resources including manpower.

• The points of contact both external and their backups including necessary local/regional/national contacts (for management of

cases, suppliers, other hospitals, local authorities, etc.) are identied and gathered in case of surge.

• There are various checklist/toolkits available from CDC and WHO which can be used to prepare for surge capacity.

COHORTING APPROACH:

Patient cohorting means placing patients infected with the same laboratory- conrmed cases in a designated ward or area.

Cohorting may be done as per their test positivity and gender status in case of surge with ensuring minimum Infection control

standards.





Figure1: Design of COVID area Reference: SARI treatment center. Practical manual to set up and manage a SARI treatment centre

and a SARI screening facility in health care facilities, WHO March 2020.

Table 2: Severity of illness

Severity Clinical Assessment (Symptoms and Signs) Diagnosis

AsymptomaticConrmed Laboratory COVID-19 test with no symptoms

Mild

Uncomplicated Upper Respiratory Tract infection and may have other symptoms:Fever <38.5 °C, fatigue, Cough (with/without sputum)AnorexiaSore throatNasal CongestionHeadacheGI symptoms- Diarrhea, nausea, vomiting

ModerateDyspnea with other symptoms as mentioned above Signs of Pneumonia/ Bronchitis

Severe Any one of the following criteria:Signs of respiratory distress (RR >30/min, adults) (>40/min, child <5 year)Pao2/Fio2 ratio <300 mm hgSpo2 <93% at restLung inltrate >50% of the lung elds in 24-48 hours Severe Pneumonia

Critical

All mentioned above and complicated byPersistent pain/pressure in the chestNew Confusion/inability to arouseBluish lips/face

Acute respiratory distress syndrome (ARDS)SepsisShock

References:1. World Health Organization (WHO). Coronavirus disease (COVID-19) outbreak 2020 [internet; cited 2020 24 February].

Geneva: WHO; 2020. Available from: https://www.who.int/emergencies/diseases/novelcoronavirus-2019

2. Containment plan, Novel Coronavirus Disease 2019 (COVID-19), MOHFW Govt. of India.

3. Hospital preparedness for epidemics. Geneva: World Health Organization; 2014.

4 . COVID -19 : con t ro l and preven t ion . Wash ing ton , DC: Occupa t iona l S a fe ty and Hea l th Admin i s t r a t ion ;

2020.(https://www.osha.gov/SLTC/covid-19/controlprevention.html).

5. Hospital preparedness for epidemics. Geneva: World Health Organization; 2014.

6. Coronavirus Disease 2019 (COVID-19) Hospital Preparedness Checklist Available from: https://www.cdc.gov/coronavirus/2019-

ncov/hcp/hcp-hospital-checklist.html



COMMUNICATION IN ICU DURING COVID ERA

We all know about the big bang of universe, which must have destroyed many things and also lead to incarnation of mighty galaxies.

But the big bang of this century is covid 19 and we hope that mankind would survive it and evolve ourselves out of this corona

pandemic.

The pandemic is teaching us many things every day and most important battle gun which would save the medical community is

effective communication modalities with the families, administration and media. Around two months back, communication in Indian

ICUs meant bedside counselling, multidisciplinary teams’ meeting and video recorded meetings in many hospitals. Now all these

have vanished. The same video calls which were banned in our areas have become the rule of land. So online meetings and

telemedicine is not only helping the OPDs but ICU patients and their families too. The day is not far away when the ICU monitors

may become smart monitors, having attached with cameras and Bluetooth devices for their interactions with outer world.

As per Anthony Back et al, in their article in annals of internal medicine published in April 2020, the communication process is based

on three basic rules. First one is to deal with emotional aspects of patient and their families, second is to let the family get small

aliquots of information rather than bolus doses so that they may absorb and react peacefully rather than getting doused in it and the

nal one is that the family should come to appreciate that the medical treatment plans are as per patient values and needs. Though

the forms of meetings may change from direct face to face interactions to online ones, the guiding principles remain the same.

Authors said that they are not suggesting that communication skills alone are going to be a silver bullet for clinician moral distress,

exhaustion, and grief in the face of COVID-19. Communication is only one part—albeit an essential part—of what clinicians will

need to survive well.

Around the world many a COVID hospitals have been created, but our hospital had to deal with both set of patients so different

COVID and non COVID ICUs have been created. To maintain maximum of social distancing, relatives have been told to be out of

bounds from these areas. However, to deliver the daily updates of patients and to maintain family touch, the IT department has

provided the facility of video calling within the existing software of hospital so that whatever we communicate is always through the

ofcial channel and it also gets automatically backed up and stored for medico-legal purposes. In conventional units we used our own

mobile phones and a dedicated e-tab has been kept permanently in COVID ICU for communication with not only families but also

own colleagues and administrative personnel for smooth functioning of the unit. Regular sanitization of electronic devices after each

interaction is the rule. I hope some questionnaire-based study comes up soon to conrm or refute our hypothesis that the video

calling system is non inferior to direct person to person counselling sessions.

This COVID pandemic also taught us the value of audio-visual conversation between the team members. Use of Teams app at our

centre had enabled us to have a look at the patient, monitor and ventilator graphics and their waveforms, a part which we used to

miss earlier. Current pandemic has raised the demand of going paperless in our ICUs as bringing case le and notes out of COVID

ICU has been an issue.

To sum up, communication with families of those patients who may or may not see the next morning should always be emphatic, in

local languages and realistic, with no false hopes offered. These interactions should also be medico-legally correct, recordable and

reproducible whenever required, while we do the work of our calling: communication, compassion, and healing.

Hope that we all treat and talk out corona well

Dr Sumeet Kumar Jhingan

MD, IDCCM

Senior Consultant

Department Critical Care Medicine

Fortis Hospital, Ludhiana

Dr. Vinay Singhal

MD

Additional Director &

Head Department of Critical Care

Medicine Fortis Hospital, Ludhiana

COMMUNICATION IN ICU DURING COVID ERA

References:

Anthony Back et al. Communication Skills in the Age of COVID-19. Ann Intern Med. doi:10.7326/M20-1376

Pic 1: In ICU with patient Pic 2: Patient’s relative at Audio-Visual Counselling Room

TM



ISCCM SALUTE CORONA WARRIORS



PATHOGENESIS OF COVID 19-

HOW MUCH DO WE ACTUALLY KNOW?

“If you know the enemy and yourself,

you need not fear the results of hundred battles” Sun Tzu.

Dr. K. Swarna Deepak, MD (Internal medicine),MRCP(UK), EDIC, IDCCM, IFCCM.

Consultant, Critical Care Medicine,

Apollo Health City, Jubilee Hills, Hyderabad.

Asst Professor, Internal Medicine,

Apollo Institute of Medical Sciences and Research

Introduction:

It is important to learn about pathophysiology of this disease as it affects multiple organ systems with signicant morbidity and

mortality. The treatment options for Covid19 remains very limited. Understanding the pathophysiology of the helps us in choosing

better management options among the available.

Conventionally, SARS Cov2 was thought to cause Acute respiratory distress syndrome (ARDS) and the management guidelines were

based on this assumption.

In this article we aim to bring to your notice, the alternative view that severe form of COVID19 is a complex interplay of vascular

endothelial dysfunction, thrombosis and dysregulated inammatory process.

1. Entry and Replication of the virus





2.

Membrane fusion causes

interruption in AngII metabolism

Increase in AngII and and

a decrease in Ang (1-7)

Augmenting inflammation,

Endothelial activation, Leucocyte and

platelet recruitment

Pulmonary endothelial activation

leading to ACE-1 shedding phenomenon

Initial Rapid rise in Ang II inducing

a positive loop of Local inflammation,

Coagulation, Capillary leak

3.

Low Ang

II Phase

Vasodilation,

Worsened capillary leak,

Endothelial dysfunction and Auto regulation

ACE, angiotensin-converting enzyme; AngI, angiotensin-I; AngII, angiotensin-II; Ang (1–7), angiotensin (1–7);

Immune response following SARS-CoV-2 is responsible both for disease resolution as well as its pathogenesis when this response

goes out of control. Multisystem involvement in COVID-19 occurs as a result of the cytokine storm and damage mediated by these

inammatory cytokines.





4.





Lung in COVID19:

COVID-19 patients present with a variety of phenotypes, likely dependent on genetic heterogeneity, age, viral load, immunological

and nutritional status, and co-morbidities.

Patients with Covid19 pneumonia fullls all the Berlins criteria but differs from conventional ARDS in lot of ways.

Their lung compliance seems only modestly decreased in comparison with the severity of hypoxemia present. This is very rare in

most forms of ARDS and suggests well preserved lung volume. But the hypoxemia responds well to proning maneuver suggesting

redistribution of perfusion in response to gravitational/or pressure forces. It was postulated to be due to ventilation-perfusion

mismatch which is in turn secondary to vasodilation and loss of hypoxic vasoconstriction. This is the “L phenotype” as reported by

Gattinoni and colleagues. Treating these patients with early intubation and the ARDNSnet treatment protocol may actually damage

this type of phenotype. These patients tend to tolerate hypoxia well, without a raise in blood lactate nor a fall in ScVo2.

Later in the course of disease patients develop a lung phenotype (H phenotype) more consistent with ARDS. These patients are

characterized by poor lung compliance, lung recruitability and severe hypoxemia not responding to oxygen supplementation. Its

histologic pattern is suggestive acute brinous and organizing pneumonia (AFOP).

“Thrombophilic phenotype” is where the patients present with severe thrombo-embolic disease with little evidence of lung

parenchymal involvement.

Inammation in Covid19

The IL6 levels in patients suffering from COVID19 have a mean value of 25pg/ml (Qin et al) which is lesser than ARDS and CRS. In

comparison, patients with CRS (cytokine release syndromes) have mean IL6 levels as high as 10,000 pg/ml. Mean IL6 levels in hypo

inammatory ARDS are 282pg/ml and 1618 pg/ml in hyper inammatory ARDS.

Alternative hypothesis





As the COVID-19 seems to be a disease which is distinct from typical ARDS or CRS, research into alternative mechanisms of

pathogenesis are much needed.

Vascular disease and Immunoregulatory dysfunction playing a central role in the alternative hypothesis Multiple studies showed cleared

evidence of hypercoagulable state in patients with COVID19. High D-Dimer and brinogen show an evidence of endotheliopathy.

Autopsies of the patients who died with severe covid19 were notable for vascular congestion in the lung. In addition to the lungs,

thrombotic complications like ischemic strokes in young, myocardial infarction, cerebral sinus venous thrombosis were also noted in

patients with covid19 suggesting a signicant vascular disease.

A mixture of multiple organ system involvement, mild inammation, low lymphocyte counts, micro vasculopathy and hypercoagulable

state is classical of diseases like vasculitides.

Possible future developments:

The picture shows the schematic proposed by Dr Farid Jalali unifying the interplay between endotheliopathy, coagulation pathway

abnormalities and immunomodulatory pathways in the body.





In summary, the pathophysiology in COVID19 is complex and yet to completely understood. Future research may unravel the

present mysteries helping us in formulating better therapies.

Acknowledgement:

The author has borrowed inputs from Dr Farid Jalali and some of his schematics were taken with due permission from him. The

author can be reached at [email protected].

References:

1. Daniel E. Leisman et al Facing COVID-19 in the ICU: vascular dysfunction, thrombosis, and dysregulated inammation., Intensive

Care Med https://doi.org/10.1007/s00134-020-06059-6.

2. Gattinoni L, Coppola S, Cressoni M, Busana M, Chiumello D (2020) Covid-19 does not lead to a “typical” acute respiratory

distress syndrome. Am J Respir Crit Care Med. https ://doi.org/10.1164/rccm.20200 3-0817L E.

3. Qin C, Zhou L, Hu Z et al (2020) Dysregulation of immune response in patients with COVID-19 in Wuhan, China. Clin Infect Dis.

https ://doi.org/10.1093/cid/ciaa2 48.



CONVALESCENT PLASMA

THERAPY FOR COVID-19

Inducing acquired passive immunity, using Convalescent Blood Products (CBP) have been tried and tested method for many

emerging infectious diseases. Emil von Behring and Kitasato, demonstrated its efcacy in 1890 to treat patients of diphtheria

although rst widespread use was documented during Spanish u pandemic. Since them it has been utilized in many emerging

infectious disease including swine u and Ebola virus disease. Convalescent plasma therapy was successfully used in many patients of

previous coronavirus outbreak-Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS). Owing

to dearth of therapeutic options and disappointing results with many existing therapies, there has been a renewed interest in CBP.

In a rst case series, Shen et al described its use in 5 patients of severe COVID-19 requiring mechanical ventilation. They received

convalescent plasma (CP) therapy after failing to improve on an investigational antiviral therapy. Oxygenation and nasopharyngeal

viral clearance improved in all the patients. In another case series by Duan.et al 10 critically ill patients received CP therapy (200 ml ,1

session, >1:640). Patients shown improvement in oxygenation with reduction of viral load and inammation. Although, it’s unwise

to generalize the result of above studies, many countries have already started utilizing CBP therapy in COVID-19 as a part of clinical

trial, for emergency and expanded access programme. As of now around 54 trials, of CBP for the treatment of COVID-19 are listed

on clinicalTrials.gov.

Barring few case series, no result is available from any clinical trial, as most of the them are either recruiting or not started yet.

Another dauting challenge is to perform a good quality RCT in pandemic setting, owing to difculty in establishing a control arm.

Many centres are routinely performing the therapy, as the other investigational treatments have not performed up to the mark.

Mechanism of action

Convalescent blood products (CBP) are obtained from a person who has developed humoral antibody against the particular

pathogen. Transfusion of antibody rich blood products neutralises the pathogen and eventually eradicate it from the patient’s blood.

Various preparations are, convalescent whole blood (CWB), convalescent plasma (CP) or convalescent serum (CS), Intravenous

immunoglobulins, high-titre human Ig; and polyclonal or monoclonal antibodies.

• Antiviral effect by neutralizing antibodies.

Neutralizing antibodies (Nabs) level in plasma is closely associated with antiviral effects of Convalescent blood products. NAbs bind

to spike1-receptor binding protein (S1-RBD), S1-N-terminal domain and S2, thus inhibiting their entry, limiting viral amplication as

seen in SARS-CoV and MERS. Other possible antiviral mechanisms are complement activation, antibody-dependent cellular

cytotoxicity and/or phagocytosis.

Dr. Mozammil Sha

MD, FNB, EDIC

Consultant, Critical Care Medicine

Medanta The Medicity, Gurugram



CONVALESCENT PLASMA

THERAPY FOR COVID-19

• Immunomodulatory actions

Immunomodulatory actions are facilitated by inhibition of various auto antibodies, pro inammatory cytokines and complements.

They help in controlling cytokine storm, Th1/Th17 ratio, complement activation and regulation of a hypercoagulable state

Figure: Components of convalescent plasma: Nabs: Neutralizing antibodies.

Opportunities and Challenges

Establishing a robust Convalescent plasma donation programme is extremely important in the context of current COVid-19

pandemic. For the same existing blood bank networks can be utilized. It’s prudent to screen all the recovered patients of COVID-19

for possible plasma donation. Prospective donors must be screened by good serological assay. Its desirable to have donors with high

neutralizing antibody titre (FDA recommends >1:320). Role of trained personnel and good infrastructure can’t be overemphasized.

Dosing schedule used in previous studies have been quite variable. Most of the previous Corona virus studies have used single plasma

transfusion of >5 ml/kg (200-250 ml), with >1:160 dilution. Ongoing trails are using 1-2 CP transfusion, in various stages of disease

(From post exposure prophylaxis to Critically ill patients).

Overall CBP therapy is quite safe owing to better testing of pathogens by blood bank nowadays. Risk of pathogen transmission is

comparable to standard plasma transfusion (less than one infection per two million donations for HIV, hepatitis B and hepatitis C

viruses). Although risks of transfusion associated lung injury (TRALI) and Transfusion associated cardiac overload (TACO) is

consistent with that of standard blood and blood product transfusion, management can be challenging owing to already hampered

cardiorespiratory reserve in many patients. Antibody-dependent enhancement (ADE), is another theoretical possibility following

transfusion of human anti- SARS-CoV-2 plasma. ADE, refers to a phenomenon of worsening clinical condition caused by the

antibodies of different strain from the previous infection. This phenomenon is well described for viral infections like Dengue, but yet

to be seen with COVID-19 infection.

Conclusion: Until effective vaccine and drugs are available, CBP remains a crucial therapeutic option for managing COViD-19

infection. The current Pandemic has given us an enormous opportunity to perform good quality clinical trials and the result of

ongoing studies in different subsets of patients will give important insight on its safety and efcacy. Till then it should be utilized

judiciously for selected group of patients.



CPR IN COVID-19 ERA: PEARLS FROM

LITERATURE REVIEW AND ALGORITHMS

A call for revision in CPR algorithms in COVID Era:

Corona virus led pandemic [COVID-19] spread over 170 countries involving over 4.2 million people with more than 0.28million

death by 12h of May, 2020.India has more than 70 thousands of SARS CoV-2/ COVID 19 positive cases with more than 22,000

deaths.1

Large majority of infected patient remain asymptomatic or mildly symptomatic,12%-19% require hospital admission and only 3%-

6% are seriously ill to require Intensive care.2-4Acute respiratory distress syndrome (ARDS), myocardial injury, ventricular

arrhythmias, and shock due to Covid-19 infection predisposes them to suffer cardiac arrest,5-8 Even proposed treatments, like

hydroxychloroquine and azithromycin can prolong the QT and generate arrhythmias.9

Health care workers [HCWs] treating COVID patients, are contracting such infection and deaths reported in them too.10-

12Limited sensitivity of tests for diagnosis, limitations in extent of testing and capability of even mild infections in spreading virus, has

led to a call for extensions in standard precautions by HCWs. Till effective medications are invented or vaccine developed, COVID

pandemic is going to continue.Medical practice patterns have to modied to mitigate the risk to HCWs.

Cardio-Pulmonary Resuscitation [CPR] involves many high aerosol generating procedures (AGP), like, chest compression,

oropharyngeal suction, insertion of articial airway, assisted ventilation [manual and mechanical]. It involves many HCWs in close

contact for prolonged time during CPR. Thus CPR on COVID patient has potential to infect many HCWs and contaminate space

where it was conducted. Unless protocols are made to minimize the same, HCWs will be afraid to perform full hearted CPR and

result not only in poor outcomes but also infection in HCWs.

Just the availability of equipment like personal protective equipment, negative pressure isolation rooms with its dedicated

equipment may not ensure good quality safe CPR unless conventional CPR algorithms are modied to accommodate the changes.

Major changes like avoidance of mouth to mouth ventilation, minimizing Bag mask ventilation, early intubation, covering victim’s

mouth and nose are desired deviations and calls for retraining in COVID era. This is possible only after we have practicable and

agreeable revised COVID-19 CPR Algorithms.

We have reviewed recent literature, compiled them in points and conceptualize it in the form of an algorithm. This when discussed

among peers can lead to revisions and ultimately new Indian guidelines.

Special consideration suggested in COVID 19:

OHCA: As 8 out of 10 patients are asymptomatic or mildly symptomatic and therefore the probability of them suffering cardiac

arrest with COVID19 rather than due to COVID19 remain substantial.2-4 Timely Bystander CPR is a key for good outcome in

OHCA14-16but lay rescuers performing CPR without protective gears, are prone to exposure of COVID19. Those who are aged

and have co-morbidities like diabetes, hypertension, heart disease, chronic lung disease 4 are at high risk of becoming seriously ill if

get infected with COVID19.16In India, approximately 80-90 % of OHCA occur at home,18likelyhood of which will increase during

lockdown due to COVID19. Not only patient but family members are likely to be infected as well and need consideration during

close contact with them during transporting victims.

Krunal PatelConsultant Intensivist

Sunshine Global Hospital,Surat,Gujarat

E Mail: [email protected]

Anuj ClerkHead, Intensive care services

Sunshine Global Hospital,

Surat,Gujarat





IHCA: In this era, all victims of cardiac arrest must be handled as covid19 infected, until proved otherwise, and this fact must be

considered at the time of revising CPR policy for the hospital.However few measures are too labor, cost, resource intensive that

they may have to be restricted to conrmed cases only.

Pearls from Literature on CPR in COVID19 era:

1. Always rst is scene safety should include consideration for location of arrest, for example red or orange zones, quarantine setups,

COVID19 dedicated hospitals. This calls for mock drill guided preparation for the setup to ensure rescuer safety and provision and

use of PPE by EMS team visiting high risk zones.

2. Check for responsiveness. If victim has agonal gasps than give him mask or cloth to cover mouth and nose to reduce aerosol

generation and exposure.

3. The call center for EMS system should include questions for screening for symptoms of COVID19 in the patient and around the

locus, in their call receiving set.

Encourage lay rescuer for hands only or Compression Only life support(COLS) in Covid19 Era.

Inform the EMS team to don PPE for suspected/conrmed COVID19 cases before reaching the scene.19

4. Those who are still following the old method of look,listen and feel for assessment of breathing must be encouraged to follow the

recent guideline insisting on assessment by visualization of respiratory chest movement only.20

5. Even in Covid19 era , Mouth to mouth breathing is encouraged in Cardiac arrest among children as respiratory causes dominate

the cause list.16As family of the victim deemed to be exposed and infected, they can be encouraged to do so, however precautions

like , barrier devices [pocket mask] are can be used to reduce the risk of exposure to respiratory secretions.

6. As debrillation is not an aerosol generating procedure[ AGP], recommendation for AED use remains unchanged.19

7. Family members and other contacts of patients with suspected or conrmed COVID-19 should not ride in the same transport

ambulance. 19

8. Pre arrest: Patients requiring intubation and ventilation in case of COVID 19 have poor survival rates 5,21and probability of

survival after an arrest become poorer. However tachyarrhythmia due to myocarditis will benet from debrillation and need

special consideration.23

9. In extremely ill COVID19 patients with multiorgan failure and co morbidities; or patient with exiting living will for limitation of care

[e.g. DNR, DNI], it is desirable to discuss direction and limits of care much in advance to prevent last moment hassles. Covid19

pandemic, calls for a relook at “end of life” or “direction of care” policy of the institute to prevent ambiguity at ground

level.Whenever possible, let direction of care be decided before large number of health care workers are exposed.

10. Emergent resuscitation not only contaminates the space and personnel but propagates a wave of fear among onlookers. All

suspected or conrm cases of COVID19 are closely monitored for signs and symptoms of deterioration and advised to have policy

involving preemptive actions like,

• Early transfer to at least a closed door room if negative pressure room not available,19

• For early planned intubation in controlled surrounding equipped for the same.19

11. Chest compressions, articial airway insertion and assisted ventilation have high potential to generate aerosols and must be

restricted to be done by rescuers donned in airborne PPE at an appropriate space.24

12. Allow minimal essential personnel in the room during resuscitation to minimize exposure. 19

13. Ensure closed loop communication and documentation about COVID-19 status of the victim with receiving team before their

arrival on the scene or receipt of the patient when transferring to a second setting.19

14. First responders in Emergency Department should be wearing at least a surgical mask, eye protection and gloves all the time in

covid19 era. rst responders should wear droplet PPE for any victim high-risk for COVID-19 or in case of lack of information.24

15. To prevent contamination by droplet or spray, use of Hudson mask with oxygen ow of up to 10 L/minute, with additional

cover of clear plastic sheet, towel, cloth or surgical mask over the victim’s face.25

16. Debrillation is not considered an AGP26however cover of patient’s mouth and nose as above is desirable.

17. To prevent re, any oxygen source is turned off prior to debrillation attempts and do not forget to restart after that.24





18. If local protocols and availability permit, use mechanical compression devices over manual ones to limit the rescuer’s exposure.

19

19. Until in an appropriate location with staff donned in airborne PPE, postpone suctioning of oral cavity or throat with conventional

method e.g. Yankuer’s set.19

20. Bag-mask ventilation (BMV) should be done 2 handed, 2 person technique. One person should seal the mask with mouth-nose

by VE grip(specially advised in obese patient to ensure proper sealing) along with head tilt chin lift maneuver and second person

should provide 2 rescue breaths at the time of pause after 30 compressions.26,28

Picture 1,2: Showing 2 person , 2 hand V.E Technique of Bag to mask Ventilation in COVID CPR. Please note the transparent

plastic sheet to minimize droplet exposure in HCWs

21. Supraglottic airway (SGA) devices cause less aerosol generation , so preferred over BMV even while intubation is delayed or

failed.29

22. SGA devise insertion or endotracheal intubation should be done while pause of compressions by senior most provider to reduce

chance of rst attempt failure and cuff has been inated properly to prevent leak .19,24

23. It is desirable to use continuous ETCo2 monitoring to conrm the placement of SGA devise or endotracheal tube and assess the

quality of CPR, as with airborne PPE, auscultation of chest is difcult.30



24. Ventilate the patient with positive pressure once in at appropriate location with airborne PPE donned staff and heat available and

moisture exchanging (HME) viral lter is connected to airway devices (endotracheal tube, SGA device, BMV) close to patient along

with all connection are secured well.24,27

25. If available, it is desirable to use video laryngoscope for endotracheal intubation as it reduce exposure of aerosolized particles to

the provider.19

26. Once SGA device or endotracheal tube in place, close circuit (double limb) of ventilator along with HME viral lters near patient

and at ventilator end of expiratory limb and close inline suction device should be attached and secured to prevent disconnections.19

27. Once connected to mechanical ventilator, it is desirable to adjust ventilator settings as described to allow asynchronous

ventilation (10 breaths per minute).19

• Pressure Control Ventilation mode

• FIO2 should be 1.0.

• Pressure limit to generate adequate chest rise(Tidal volume of approximately 6 ml/kg of ideal body weight)

• Trigger should be Off ( prevent the ventilator from auto-triggering with chest compressions)

• Respiratory rate of 10/min for adults and pediatrics.

• Positive end-expiratory pressure (PEEP) adjusted as per balance of lung volumes and venous return.

• Alarms to set appropriately to prevent alarm fatigue.

• Properly secure endotracheal tube and all connection of circuit to prevent unplanned disconnections.

28. Once ROSC (return of spontaneous circulation) ventilator settings adjusted as per patients’ clinical condition.

29. Currently ECPR( ECMO cardiopulmonary resuscitation) in presumed case of COVID-19, is not recommended, due to a high

likelihood of futility.24

30. Once ROSC is achieved prior to intubation, then its need and potential benets should be assessed.24

31. If COVID19 patient has cardiac arrest along with respiratory failure without any potentially reversible cause identied, than

provider should consider futility of resuscitation and can terminate resuscitation early.17

32. At the end of event, PPE dofng should be done appropriately as per local guideline under supervision to prevent breach in

infection control protocol. 24

33. Disposable equipment should be discarded and reusable equipment should be cleaned and disinfected according to hospital

protocols.24

34. As there is lots of panic regarding COVID19, it is desirable to conduct a debrieng meeting of team members including special

consideration for PPE and prevention of COVID-19 transmission, communication, clinical care and decision-making.24

35. Family members are restricted outside resuscitation room in this COVID era with some exception like cardiac arrest in a child.

They should be allow with all precautions for only seeing the body if resuscitation is unsuccessful as per hospital protocols.22





CPR Algorithms in COVID ERA:











Scope of application of COVID CPR Algorithms:

Who is not infected with COVID-19 ? Until answer to this question is clear, one might have to scrutinize each deviation [in CPR

algorithm] on its protective [to HCWs] ability vs compromising [outcome of victim] potentials. Till this brain storming task is done,

these deviations can be considered guideline at its best and local modications are desirable. Unless it is considered “New Normal”,

scope of its implementation [universal or covid19 victims only], be determined, in institutional CPR committee and published as

advisory. Weight of these decisions must not be levied upon the stressed ACLS team leader, to decide on “case to case basis” on site.

Acknowledgement:

Special thanks to Mr. Viral Patel, Graphic designer, IT Department, Sunshine Global hospital for his time and expertise in designing

algorithms.

References:1. World Health Organization. Novel Coronavirus (2019-nCoV) situation reports. https://www.who.int/emergencies/diseases/novelcoronavirus-

2019/situation-reports.

2. Centers for Disease Control and Prevention. Severe Outcomes Among Patients with Coronavirus Disease 2019 (COVID-19) - United States, February

12-March 16, 2020. MMWR Morbidity and mortality weekly report. 2020;69:343-346.

3. Wu Z and McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a

Report of 72314 Cases From the Chinese Center for Disease Control and Prevention. JAMA. 2020 323:1239-1242.

4. Guan W-j, Ni Z-y, Hu Y, Liang W-h, Ou C-q, He J-x, Liu L, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. New Eng J Med. Feb 28,

2020.

5. Bhatraju PK, Ghassemieh BJ, Nichols M, Kim R, Jerome KR, NallaAK,et al. Covid-19 in Critically Ill Patients in the Seattle Region — Case Series. New Eng

J Med. March 30, 2020.

6. Guo T, Fan Y, Chen M, Wu X, Zhang L, He T,et al. Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-

19). JAMA Cardiol. March 27, 2020. doi: 10.1001/jamacardio.2020.1017.

7. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, Zhang L, Fan G, et al.Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. The

Lancet. 2020;395:497-506.

8. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected

Pneumonia in Wuhan, China. JAMA 2020;323:1061-1069.

9. Centers for Disease Control and Prevention. Information for Clinicians on Therapeutic Options for COVID-19 Patients. Updated April 7, 2020.

https://www.cdc.gov/coronavirus/2019- ncov/hcp/therapeutic-options.html/. Accessed April 8, 2020.

10. Gamio L. The Workers Who Face the Greatest Coronavirus Risk. New York Times. 2020.

11. The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. The epidemiological characteristics of an outbreak of 2019 Novel

Coronavirus Diseases (COVID-19) – China, 2020. http://weekly.chinacdc.cn/en/article/id/e53946e2-c6c4-41e9-9a9b-fea8db1a8f51

12. Integrated surveillance of COVID-19 in Italy : 10 April 2020. https://www.epicentro.iss.it/en/coronavirus/bollettino/Infograca_10aprile%20ENG.pdf

13. Gandhi M, Yokoe D S, Havlir D V.Asymptomatic Transmission, the Achilles’ Heel of Current Strategies to Control Covid-19. NEJM. April 24,2020

14. Kragholm K, Wissenberg M, eta l. Bystander Efforts and 1-Year Outcomes in Out-of-Hospital Cardiac Arrest. New Eng J Med. 2017;376:1737-

1747.

15. Pollack RA, Brown SP, et al . Impact of Bystander Automated External Debrillator Use on Survival and Functional Outcomes in Shockable

Observed Public Cardiac Arrests. Circulation. 2018;137:2104-2113.

16. CARES: Cardiac Arrest Registry to Enhance Survival. 2018 Annual Report.

https://mycares.net/sitepages/uploads/2019/2018_ipbook/index.html?page=16.

17. Shao F, Xu S, Ma X, et al. In-hospital cardiac arrest outcomes among patients with COVID-19 pneumonia in Wuhan, China. Resuscitation doi:

10.1016/j.resuscitation.2020.04.005

18. Krishna C K, Showkat H I, Taktani M, Khatri V . Out of hospital cardiac arrest resuscitation outcome in North India — CARO study. World J

Emerg Med, Vol 8, No 3, 2017.

19. Edelson D P, Sasson C, Chan P S,et al. Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected

or Conrmed COVID-19: From the Emergency Cardiovascular Care Committee and Get With the Guidelines®-Resuscitation Adult and Pediatric

Task Forces of the American Heart Association .

Circulation. 9 Apr 2020. [https://www.ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.120.047463]

20. Travers AH, Perkins GD, et al; on behalf of the Basic Life Support Chapter Collaborators. Part 3: adult basic life support and automated external

debrillation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment

Recommendations. Circulation. 2015;132(suppl 1):S51–S83.

21. Yang X, Yu Y, Xu J, etal . Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered,

retrospective, observational study. Lancet Respir Med 2020:S2213-2600(20)30079-5.





22. Department of Health and Human Services. Coronavirus (COVID-19): Handling the body of a deceased person with suspected or conrmed

COVID-19. 9 April 2020. [Internet] Available from https://www.dhhs.vic.gov.au/health-services-and-general-practitioners-coronavirus-disease-

covid-19. Accessed 11 April 2020.

23. Madjid M, Safavi-Naeini P, Solomon SD, Vardeny O. Potential effects of coronaviruses on the cardiovascular system: a review. JAMA Cardiol2020.

10.1001/jamacardio.2020.1286. 32219363

24. Craig S et al. Management of adult cardiac arrest in the COVID-19 era. Interim guidelines from the Australasian

College for Emergency Medicine. Med J Aust, 24 April 2020.

25. New Zealand Resuscitation Council. Modications to Essential Life Support [Internet]. 27 March 2020. Available from https://www.nzrc.org.nz/,

accessed 8 April 2020.

26. International Liaison Committee on Resuscitation. COVID-19: Practical Guidance for Implementtation [Internet]. April 2020. Available from

https://www.ilcor.org/covid-19. Accessed 15 April 2020.

27. Resuscitation Council UK. Statement on COVID-19 in relation to CPR and resuscitation in acute hospital settings [Internet] 4 March 2020, Updated 6

April 2020. Available from https://www.resus.org.uk/media/statements/resuscitation-council-uk-statements-on-covid-19-coronavirus-cpr-and-

resuscitation/covid-healthcare/ Accessed on 8 April 2020.

28. Fei M, Blair JL, Rice MJ, et al. Comparison of effectiveness of two commonly used two-hand mask ventilation techniques on unconscious apnoeic obese

adults. British Journal of Anaesthesia 2017; 118: 618–24.

29. Brewster DJ CN, Do TBT, Fraser K, et al. Consensus statement: Safe Airway Society principles of airway management and tracheal intubation specic

to the COVID-19 adult patient group. Med J Aust. 16 March 2020.

30. T. M. Cook, K. El-Boghdadly, B. McGuire, et al ; Consensus guidelines for managing the airway in patients with

COVID-19. Anaesthesia.2020 Jun;75(6):785-799.

JOURNAL SCAN - 1Hydroxychloroquine and azithromycin as a treatment of COVID-19:

Results of an open-label non-randomized clinical trial



1. Are the Title and Objectives appropriate?

• 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?

• In present day, when the number of cases in the world is increasing exponentially.

• it is imperative to continue studies for all possible drugs that can affect the replication or propagation of the COVID-19 virus.

• Hydroxychloroquine has shown to have in-vitro effects on the virus and it is expected to prevent the endocytosis of the virus into

the human cell.

a) Was it studied previously and what were the results? - No

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 study was a non-randomised open label multicentre study conducted in France.

• It compared the effect of Hydroxychloroquine (200mg TDS) both with and without azithromycin to a control group of no

hydroxychloroquine.

• aged over 12 years of age and RT-PCR positive for the virus in a naso-pharyngeal sample at admission

• The control group consisted of patients who refused treatment, had an exclusion criteria, and patients presenting to other centres

in southern France.

4. What statistical methods have been used?

• Categorical variables were evaluated by Pearson’s chi-square or Fisher’s exact tests while quantitative data were compared using

the Student’s t-test.

• The primary outcome monitored was the clearance of the virus based on PCR at day 6 post inclusion.

• Secondary outcomes were virological clearance overtime during the study period, clinical follow-up including respiratory rate,

length of stay at the hospital, mortality and occurrence of side effects.

a) Are they appropriate for the data and methods? –Yes

b) What is the Power of the study?

• The study was powered for 48 patients with an allowance for 10% loss to follow up assuming that the efcacy of

hydroxychloroquine at reducing the viral load at the 7th day was 50%.

5.What were the results?

• Out of the 48 patients 36 patients for analysed.

• 20 patients received Hydroxychloroquine,

• The intervention group was found to be older

• Higher proportion of lower respiratory tract symptoms (30% vs 12%).

• Of those treated with hydroxychloroquine and azithromycin, 100% were negative at day 6 vs 57.1% with hydroxychloroquine

alone vs 12.5% in the control group.

MD ANESTHESIOLOGY AND CRITICAL CARE (JIPMER),

DNB ANESTHESIOLOGY,

PDF (CRITICAL CARE)-JIPMER,

DM CRITICAL CARE MEDICINE (ONGOING), AIIMS NEW DELHI

Dr. Ajeetviswanath. T. P

This is a brief appraisal of the article published in “The international Journal of Antimicrobial Agents”- “Hydroxychloroquine and

azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial”



6. Conclusions:

a) What conclusions have been drawn?

Hydroxychloroquine treatment was associated with a signicant reduction in viral load and was reinforced by the use of

azithromycin.

b)Are they relevant to clinical or scientic practice? – YES

c)Are the conclusions justied by the methodology and the ndings? -No

There are several issues with the methodology and the statistical analysis with this particular study which are explained later.

7. Strengths

• The study was completed in a short time.

• Findings of the study has been incorporated in the treatment and prophylaxis algorithm of Covid-19 in several countries.

8. Limitations

• Non-randomised trial with an inherent risk of selection bias.

• It was also underpowered for a major outcome trial and did not even achieve the target sample size.

• The fragility index of the study was 1, meaning that all that was needed for the ndings to lose statistical signicance was for 1

patient’s data to go the other way.

• The authors didn’t use appropriate statistical methods to account for repeated measurements in the same patient.

• The study was mentioned as a 14-day study but data has been given only till the 10th day,

• All of those lost to follow up belonged to the treatment group only.

• Those excluded from the intervention were directly used as controls.

• All patients in the control group did not receive their treatment at the same centre.

• Moreover, the denition of a “negative” patient was based on just one negative PCR result with no conrmation at a set time later.

• Issue of conict of interest

9. The Utility:

• Unclear at the present moment.

• Follow up studies showed mixed results.

• This study is indeed relevant to our population.

• However, the effectiveness of the drugs in question are yet to be proved conclusively.

• A single study of a small cohort cannot be taken as the nal take on the effectiveness of HCQ and Azithromycin in the treatment of

Covid-19.

• Further randomised control studies and clinical trials are required.

JOURNAL SCAN - 1Hydroxychloroquine and azithromycin as a treatment of COVID-19:

Results of an open-label non-randomized clinical trial








• Anti-malarial drugs like Chloroquine (CQ) and Hydroxychloroquine (HCQ) are commonly used drugs for treatment as well as

prophylaxis of COVID-19 at present

• It answers the question whether a higher dose of chloroquine more effective in CVID- 19?

• Till date there is no specic therapy for treatment of COVID-19.

• The effective dose of drugs used for COVID-19 is not known.

• in vitro studies show that a high concentration of CQ is required for its antiviral effect in COVID-19;

• CQ has various side effects including prolongation of QTc and cardiac arrhythmia.

a) Was it studied previously and what were the results? - NO direct comparison of low vs high doses.



• Analytical randomized study

• Study is an unplanned interim analysis of a parallel, double-masked, randomized, phase IIb clinical trial,

• 81 adult patients admitted with severe COVID-19 were recruited.

• High dose CQ regimen - 600 mg CQ base twice daily for 10 days. low-dosage CQ regimen - 450 mg CQ base twice daily on day 1

followed by once daily for next 4 days.

• All patients in both groups received standard care including antibiotics with or without antiviral agents as per the hospital protocol


Though the primary objective to analyse the lethality rate between both groups at day 28; but data was analysed till day 13.

a) Are they appropriate for the data and methods? – YES

b) Sample size calculation appropriate? -yes

c) What is the Power of the study? Under powered – an interim analysis

5. What were the results?

signicantly higher lethality in the high-dosage group (39.0% vs. 15.0%) by day 13.

Overall lethality rate was 27.2% (95% CI, 17.9%-38.2%) which is even higher than among similar patients not receiving CQ. As per

safety is concerned, the high-dosage group had more incidence of QTc prolongation (18.9% vs.11.1%) compared with the low-

dosage group at day 13 (a secondary outcome).

Dr. Srikant BeheraMD General Medicine,PDCC,CCM

DM CRITICAL CARE MEDICINE (ONGOING),

AIIMS NEW DELHI

JOURNAL SCAN - 2Effect of high vs low doses of chloroquine diphosphate as adjunctive

therapy for patients hospitalized with severe acute respiratory syndrome coronavirus 2(SARS-CoV-2) infection. A Randomized Clinical Trial

This is a brief appraisal of the article published in “JAMA”- “Effect of high vs low doses of chloroquine diphosphate as adjunctive

therapy for patients hospitalized with severe acute respiratory syndrome coronavirus 2(SARS-CoV-2) infection.

A Randomized Clinical Trial”



6. Conclusions:

The interim analysis of this study revealed that the higher CQ dosage is associated with increased mortality as well as adverse effects

in severe COVID-19; and so, should not be recommended.

b) Are they relevant to clinical or scientic practice? – YES

c) Are the conclusions justied by the methodology and the ndings? -Not really since it is only an interim analysis.

7. Strengths

• It was well conducted, parallel, double-masked, randomized control trial performed in a public hospital with good clinical practices

• Answer to a very important and relevant question in present pandemic situation i.e. safety and efcacy of CQ in 2 different dose

regimens in the treatment of patients with severe COVID-19.

8. Limitations

It is single centre study

1. It is an unplanned interim analysis of the main study.

2. Small sample size / under powered study

3. All patients are not virologically conrmed COVID-19 cases

4. The dosing i.e. high and low dose is not based on evidence

5. Base line characteristics are not similar in both the groups (e.g. patients in high dose group were comparatively older and

associated with more co-morbidity)

6. There was no placebo control group

7. QTc interval was not taken into account at baseline

8. Laboratory investigations and ECG were performed at the clinician’s discretion (adverse effects may be missed). Similarly, only

baseline radiologic ndings are presented.

9. Therapeutic drug concentration was not monitored

10. Virological clearance monitoring was done in only one third patients

11. Per-protocol analysis was not performed

9. The Final Message: What are the ndings of this article?

• High-dosage of CQ is not safe in treatment of severe COVID-19.

• There is increase in mortality as well as adverse effects in high dose group.

• Though, this is an under powered study, still we can’t ignore the more mortality in high dose group. As per the present practice is

concerned, it is not going help in any recommendation for use of CQ in COVID-19.

• Further studies should be done, preferably with lower dose regimen to establish effectiveness CQ in mild to moderate COVID-19

before using it in severe disease associated with high mortality.

JOURNAL SCAN - 2Effect of high vs low doses of chloroquine diphosphate as adjunctive

therapy for patients hospitalized with severe acute respiratory syndrome coronavirus 2(SARS-CoV-2) infection. A Randomized Clinical Trial








• ACEIs and ARBs are commonly used antihypertensives. However, there are no clinical data indicating whether patients who are

taking ACEIs/ ARBs have increased severity of illness or risk of mortality during COVID-19 infection

• But Levels of ACE2 are a double-edged sword- increase of ACE2 receptor, decrease the chance of pulmonary oedema and

facilitate the chance of viral binding.

• But there is no clear evidence about the effect of ACEI/ARB on ACE2 receptor

a) Was it studied previously and what were the results? - NO



• Analytical cohort study

• Admission APACHE, baseline SOFA score was not included in baseline characteristic’s

• Acute Myocarditis was one of the most common manifestations of COVID infection. but admission echocardiography was not

included in study

• Upregulation of ACE2 receptors can prolong viral shedding. it was not measured in follow-up


• Continuous variable- median

• Categorical variable- numbers

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

a) Are they appropriate for the data and methods? – YES

b) Sample size calculation appropriate? - YES

convenience sampling, the most common method was used

c) What is the Power of the study and what is the fragility index?

• Fragility index for severity was -0 , fragile study p value was-0.653, so study was less fragile

• Fragility index for non-survival was- 0, fragile study p value was 0.408, so study was less fragile


• Hypertension have more severe illness and higher mortality rates and ARDS than those without hypertension.

• The frequency of severity of illness, acute respiratory distress syndrome, and mortality did not differ with respect to ACEI/ARB

therapy and also between ACEI and ARB

Dr. Vetriselvan ParasuramanMD ANESTHESIOLOGY AND CRITICAL CARE

DM CRITICAL CARE MEDICINE (ONGOING), AIIMS NEW DELHI

This is a brief appraisal of the article published in “JAMA Cardiology”- “Association of Renin- Angiotensin System Inhibitors with

severity or risk of death in patients with hypertension hospitalized for coronavirus disease 2019 (COVID-19) infection in Wuhan,China”

JOURNAL SCAN - 3Association of Renin- Angiotensin System Inhibitors with severity or risk of death

in patients with hypertension hospitalized for coronavirus disease 2019 (COVID-19) infection in Wuhan,China



6. Conclusions:

a) What conclusions have been drawn?

Current ndings did not identify an association between treatment with ACEIS/ARBS and either severity or clinical outcomes of

COVID-19 hospitalizations in patients with hypertension.

b) Are they relevant to clinical or scientic practice? – YES

c)Are the conclusions justied by the methodology and the ndings? -YES

7. Strengths

• Hypertension patients have more severe illness and higher mortality rates than those without hypertension

• All major societies recommend that patients with hypertension do not discontinue using ACEIs, ARBs, this study also supports

these societal recommendations.

8. Limitations

• Very Small number of HT patients taking ACEI/ARB in this study

• Reason for admission of non-severity patients were not mentioned

• SOFA scoring system is useful in predicting the clinical outcomes of severely-ill patients not measured

• What treatments for COVID patients received not mentioned

• Heart failure, diabetics patients requiring ACEI are not included in study

• Reason for mortality was not mentioned


• Intensive surveillance and care are required for patients with co-morbidities

• Hypertension had more than 3 times the mortality rate of all other patients hospitalized with COVID-19

• No need to discontinue the ACEIS, ARBS, or other renin-angiotensin aldosterone antagonists in hypertensive patients in COVID-

19

10. The Utility:

This study points no association between ACEI/ARB and severity or outcomes of COVID-19 patients, but sample size was small.

One retrospective study rarely provides sufcient evidence to recommend changes to clinical practice

CRITICAL APPRISAL

JOURNAL SCAN - 3Association of Renin- Angiotensin System Inhibitors with severity or risk of death

in patients with hypertension hospitalized for coronavirus disease 2019 (COVID-19) infection in Wuhan,China



Title of the study:

“Clinical course and outcome of 107 patients infected with the novel coronavirus, SARS-CoV-2, discharged from two hospitals in

Wuhan, China.”

Wang et al. Critical Care (2020) 24:188. https://doi.org/10.1186/s13054-020-02895-6

Critical Analysis:


Clinical courses and prognosis in COVID-19 patients from the epicentre were analysed to share the information with the world in

the pandemic.

2. What is the clinical importance of that objective? Was it studied previously and what were the results?

The objective is to describe the complete picture of the clinical course of COVID-19 along with identication of risk factors

associated with poor outcome.

Such articles describing the clinical course during the pandemic are lacking for novel Corona virus. SARS-CoV-2 is more

phylogenetically related to SARS-CoV than to MERS-CoV. Only minor differences have been found between the genome sequences

of SARS-CoV-2 and SARS-CoV. SARS-CoV-2 afnity for angiotensin-converting enzyme 2 (ACE2) receptor is higher than that of

SARS-CoV. COVID-19 fatality rate is lower than that found in SARS and MERS. SARS-CoV-2 RNA has been detected in the stools of

infected patients, similarly to SARS-CoV and MERS-CoV. 1.2% of COVID-19 cases are asymptomatic COVID-19 is not very

different from SARS and MERS regarding demographic characteristics, laboratory and radiological ndings. Clinical complications in

COVID-19 are as frequent as in SARS, but less frequent than in MERS. Viral loads in COVID-19 patients are higher at the time of

symptom onset and progressively decrease during the clinical course of the disease (1).



This is retrospective case series of descriptive nature, including all positive patients infected with SARS -COV-2 according WHO

guidelines in which epidemiological, demographic, and clinical data were retrieved. The clinical course of survivors and non-

survivors were compared along with risk factors for death were analysed.

4. What statistical methods have been used? Are they appropriate for the data and methods? The data of 107 patients

were represented as frequencies and percentages for categorical variables and mean, median, and interquartile range (IQR) for

continuous variables. Univariate analyses were performed to evaluate the risk factors associated with death. Multiple logistic

regression analysis was used to identify independent predictors of mortality.

Dr. Shreyas GutteMD Anaesthesia;

Senior Resident (DM),

Department of Critical Care Medicine, SGPGIMS;


JOURNAL SCAN - 4Clinical course and outcome of 107 patients infected with the novel coronavirus,

SARS-CoV-2, discharged from two hospitals in Wuhan, China.




Out of 107 patients there were 88 survivors and 19 non-survivors.

Symptoms: Fever [97.2%], dry cough [62.6%], fatigue[64.5%], dyspnea [32.7%], anorexia [30.8%], and myalgia [30.8%] were the

most common symptoms. Less common symptoms were sore throat, headache, dizziness, abdominal pain, diarrhea, nausea, and

vomiting.

Risk factor: Age (73years [IQR, 64–81] and male gender were the independent risk factor for mortality. Non-survivors were more

likely to have underlying comorbidities, including hypertension (52.6%) and other cardiovascular diseases (36.8%).

Among laboratory and radiological ndings:

Lymphopenia and prolonged prothrombin time were noted. Non-survivors had higher neutrophil counts, lower platelet counts and

higher D-dimer levels.

Around 84% patients showed multi-lobar involvement on initial radiographs.

Triphasic pattern of the disease:

Week 1:

Mild: Fever, cough, dyspnea, lymphopenia, and radiological multi-lobar pulmonary inltrates.

Severe: Thrombocytopenia, acute kidney injury, acute myocardial injury, and adult respiratory distress syndrome were observed.

Week 2:

Mild: fever, cough, and systemic symptoms began to resolve and platelet count rose to normal range, but lymphopenia persisted.

Severe: Leukocytosis, neutrophilia, and deteriorating multi-organ dysfunction were noted.

Week 3:

Mild: Lymphopenia persisted but recovered clinical symptoms

Severe: Persistent lymphopenia, severe acute respiratory distress syndrome, refractory shock, anuric acute kidney injury,

coagulopathy, thrombocytopenia leading to death Complications: Non-survivors were more likely to have one of these

complications like ARDS (26.2%), shock (20.6%), AKI (13.1%), and acute cardiac injury (11.2%) than survivors. Secondary

infections included 1 case of bacteremia caused by Staphylococcus caprae and 4 cases of bacterial pneumonia caused by

Acinetobacter baumannii. Coinfection with virus included one patient tested positive for inuenza A, two for inuenza B, three for

respiratory syncytial virus, three for parainuenza, and 3 for adenovirus.

Conclusions:

What conclusions have been drawn?

A period of 7–13 days after illness onset is the critical stage in the COVID-19 course.

Age (>73years)and male gender were the independent risk factor for mortality.

Are they relevant to clinical or scientic practice?

Being the rst scientic report from epicentre, the clinicians can keep these results in mind while initiating or managing such patients

after correlating with their local results

Are the conclusions justied by the methodology and the ndings ?

Yes





6. Strengths

First report describing the clinical course along with laboratory and radiological ndings of COVID-19 from the epicentre.

7. Limitations

Viral load has not been measured and it would have been better if viral loads were correlated with clinical course.

Retrospective study design, data about the values of creatine kinase, creatine kinase-MB, and lactate

dehydrogenase from day 11 to day 17 were missing. The enzyme activity could not be analyzed in week 3 after illness onset. Further

study should be conducted to clarify the dynamic change of the three-lab index.

Only 107 patients with conrmed SARSCoV- 2 infection were enrolled in this study. Future studies should be needed to enroll larger

sample sizes to evaluate the clinical course and analyze the risk factor for death in COVID-19.

Loss of results in follow up and non-response rate is not mentioned.

Results discussed in article are not compared with any previously published data.


A period of 7–13 days after illness onset is the critical stage in the COVID-19 course. Age and male gender were independent risk

factors for death of COVID-19.

9. The Utility:

Can I generalise the ndings to my patients?

Results may not be generalized to different population.

Are my patients sufciently like those in the study to extrapolate the ndings?

Clinical prole of covid 19 patients admitted in tertiary care hospital in North India (SMS Hospital, Jaipur) is the case series of 21

patients with following results: Clinical investigations in initial Covid-19 patients in the Indian subcontinent reveal lymphopenia as

predominant nding in hemogram. Patients with older age and associated comorbid conditions (COPD and diabetes) seem to have

greater risk for lung injury thereby requiring oxygen support during the course of disease and these patients also had greater

derangement in their biochemical prole (2).





Critical evaluation of a study:

Title of the study: Buetti N, et al.1 The insertion site should be considered for the empirical therapy of short-term central venous and

arterial catheter-related infections. Crit Care Med 2020; 48:739–744.

DOI: 10.1097/CCM.0000000000004270.

What is the clinical importance of that objective? Was it studied previously and what were the results?

Data on the causative microorganisms for catheter related blood stream infection (CRBSI), based on the site of the insertion of

intravascular catheters (arterial: AC and central venous catheters: CVC) is scarce.

The objective of the study is to describe the epidemiology of causative microorganisms of catheter-related infections and

colonization according to the insertion site for central venous and arterial catheters.

Lorente L et al.2 (Crit Care Med 2007) did such s prospective cohort study in a medical ICU with results suggesting higher (odd’s

ratio: OR-7.48) intravascular catheter-related bloodstream infection (IVC-RBSI) due to Gram-negative bacteria in femoral (venous

and arterial), than in the other catheter sites, Also, the proportion of IVC-RBSIs due to yeasts was higher in femoral (OR:10.20).

Study design:

Multicentre observational (analytical) study using data from four large randomized controlled trials (Dressing 1 and 2 studies, Elvis

and Clean studies) during the period of 2006 to 2014 in 25 ICUs in France.

These studies focussed on different prevention strategies for CRBSI dened as a combination of :

one or more positive peripheral blood cultures sampled 48 hours before or after catheter removal;

isolation of the same microorganism from the colonized catheter or from

the catheter insertion site, or a blood culture differential time to positivity of 2 hours or more; and 3) no apparent source of

bacteraemia other than the catheter.

Catheter colonization was dened as a quantitative catheter tip culture yielding greater than or equal to 1,000 colony-forming

units/mL.

Statistical methods used:

The microbiological, epidemiological, and clinical characteristics of the

catheters were described as frequency (percent) and compared between insertion site groups using Wilcoxon signed rank, Chi-

square, or Fisher exact test, as appropriate.

Logistic regression models were used to analyse the risk factors. Conrmatory analysis using univariate and multivariate marginal

Cox model.

What were the results?

Total of 7,235 patients and 15,259 catheters in 25 ICUs were included (Fig. 1). There were 9,242 CVCs (65,300 catheter days) and

6,364 ACs (40,990 catheter-days).

Dr. Sai Saran PVQualication: MD, DM, IDCCM, EDIC

Current afliation: Assistant Professor, Department of Critical Care Medicine,

Super speciality Cancer Institute and Hospital, Lucknow, Uttar Pradesh


JOURNAL SCAN - 5The insertion site should be considered for the empirical

therapy of short-term central venous and arterial catheter-related infections.



Among CVC’s:

Nonfermenting gram-negative bacilli (NFGNB) were more frequently detected at the femoral site (31% vs 4% for nonfemoral site;

p < 0.01).

Diabetes mellitus and duration of catheter maintenance at the femoral site was associated with an increased risk for CR-BSI due to

NFGNB ( OR: 6.33; 95% CI, 1.59–25.28; p < 0.01).

Among colonized CVCs, those from the femoral group were associated with higher sequential organ failure assessment (SOFA)

score; p < 0.01) and more immunosuppression (14% vs 6%; p < 0.01).

The proportion of colonized catheters due to Gram-negative bacilli (Enterobacteriaceae and nonfermenting) and enterococci was

higher for the femoral site (33% vs 24% for nonfemoral site; p = 0.03).

Increased risk for colonization with nonfermenting Gram-negative bacilli for the femoral site (hazard ratio:9.28; 95% CI,

2.70–31.87; p < 0.01).

Fungi were rarely observed in CR-BSI (n = 5; 6.8%) and colonized catheters (n = 22; 2.9%).

Among Ac’s:

The proportion of colonized catheters due to gram-positive bacteria other than enterococci was higher for the radial site (60% vs

41%).

No fungal CR-BSI was observed.

The femoral site tended to be associated with an increased risk for colonization with nonfermenting Gram negative bacilli (OR, 1.69;

95% CI, 0.96–2.97; p = 0.07).

Conclusions:

What conclusions have been drawn?

The proportion of intravascular catheter infections due to nonfermenting Gram-negative bacilli was high for the femoral insertion

site.

Empirical antipseudomonal therapy should be considered if a femoral CR-BSI is suspected.

Fungal CRBSI is rare with CVCs and almost negligible with Ac’s.

Are they relevant to clinical or scientic practice?

Denitely useful further highlighting the avoidance of femoral cannulation and to guide in the selection of empirical antibiotic therapy

in suspicion of CRBSI. Apart from that the incidence of CRBSI in arterial catheters was also highlighted.

Strengths

The rst multicentre observational study giving data on causative microorganisms based on the site of insertion for CVCs and arterial

catheters.

It further highlights the avoidance of femoral cannulation adding further evidence

Gives an idea of incidence of fungal CRBSI (very low in CVCs and rare in Ac’s).

Limitations





Observational study based on four RCTs

Limited generalisability of the microbiological data as the studies were done in University-afliated ICUs as no microbiological

resistance data were included and, therefore, the role multi-drug resistant microorganisms according to the insertion site could not

be assessed.

Data of peripheral venous catheters which can account for 35% of such infections is not considered.

Data from hemo-dialysis catheters (Elvis study)3 was also considered into analysis which cannot be interpreted similar to CVCs used

in ICUs.

A conclusion stating the use of empirical anti-pseudomonal therapy without the knowledge of sensitivity pattern of NFGNB is

controversial as the growth of NFGNB like Burkholderia cepacia, Stenotrophomonas maltophilia (previously labelled as

Pseudomonas group) and others like Chrysobacterium indologenes, Sphingobacterium species, Ralstonia pickettii, Elizabethika

meningoseptica, Morganella morganii, Achromobacter species is increasingly reported with the use of automated diagnostic

technologies (Saran et al. Inf Dis London 2020).4 These NFGNB have varied intrinsic and acquired resistance proles.

The Final Message: What are the ndings of this article?

Femoral cannulation (central venous and arterial) has higher incidence of colonization and CRBSI when compared to other sites.

Empirical antimicrobial therapy could be considered based on the site of insertion of the catheters, if microbiological data regarding

the site is available, hence mentioning the site of catheter is extremely important on the culture sheets when obtaining cultures





Remdesivir in adults with severe COVID-19: a randomised, double-blind, placebo-controlled, multicentre trial.

Background: Remdesivir, a nucleoside analogue prodrug, has inhibitory effects on pathogenic animal and human coronaviruses.

Design : Investigator initiated ,individually randomised, double blinded, placebo controlled, multicentre trial at Hubei , China.

Between Feb 6, 2020, and March 12, 2020, 237 patients were enrolled and randomly assigned to a treatment group (158 to

remdesivir and 79 to placebo).

Eligible patients : Adults admitted to hospital with laboratory-conrmed SARS-CoV-2 infection, with an interval from symptom

onset to enrolment of 12 days or less, Spo2 94% or less on room air or a ratio of arterial oxygen partial pressure to fractional inspired

oxygen of 300 mm Hg or less, and radiologically conrmed pneumonia.

Study ndings : Remdesivir was not associated with a difference in time to clinical improvement (hazard ratio 1•23 [95% CI

0•87–1•75]). Although not statistically signicant, patients receiving remdesivir had a numerically faster time to clinical

improvement than those receiving placebo among patients with symptom duration of 10 days or less (hazard ratio 1•52

[0•95–2•43]).

Conclusion : In this study of adult patients admitted to hospital for severe COVID-19, remdesivir was not associated with

statistically signicant clinical benets. However, the authors suggested that numerical reduction in time to clinical improvement in

those treated earlier requires conrmation in larger studies. (Yeming Wang et al, www.thelancet.com April 29,2020

https://doi.org/10.1016/S0140-6736(20)31022-9).

Our View: The above Chinese study is randomized, double blinded, placebo controlled, multicentric trial done over period of 36

days at 10 hospitals. 237 patients were enrolled and randomly assigned in 2:1 ratio All patients were concomitantly administered

lopinavir and ritonavir, corticosteroids & interferons. They dened Clinical improvement, their primary clinical endpoint as a two-

point reduction in patient’s admission status on a six-point ordinal scale, or discharge alive from the hospital, whichever came rst.

Time for clinical improvement is not statistically signicant between both groups, but numerically it was better in remdesivir group

(18 days) compared to placebo (23 days). Weakness of study include insufcient power to detect assumed differences in clinical

outcomes, initiation of treatment quite late in COVID-19, impact of co-treatment with antivirals, steroids etc. and the absence of

data on infectious virus recovery or on possible emergence of reduced susceptibility to remdesivir.

Compassionate Use of Remdesivir for Patients with Severe Covid-19

Dr Manjunath T MD, FNB(CCM), EDIC

Consultant Critical Care Medicine,

Manipal hospital, Whiteeld, Bengaluru 560066

Email: [email protected] | Phone: 9845878406

JOURNAL SCAN - 6Remdesivir in adults with severe COVID-19: a randomised, double-blind,

placebo-controlled, multicentre trial.



Background: Remdesivir is a prodrug of a nucleotide analogue that is intracellularly metabolised to an analogue of adenosine

triphosphate that inhibits viral RNA polymerases.

Methods: Funded by Gilead sciences company, Patients were those with conrmed SARS-CoV-2 infection who had an oxygen

saturation of 94% or less while they were breathing ambient air or who were receiving oxygen support. Patients received 10 day

course of Remdesivir consisting of 200 mg administered intravenously on day 1, followed by 100mg daily for remaining 9 days of

treatment.

Results : During a median follow-up of 18 days, 36 patients (68%) had an improvement in oxygen-support, including 17 of 30 patients

(57%) receiving mechanical ventilation who were extubated. A total of 25 patients (47%) were discharged, and 7 patients (13%)

died;

Conclusions : In this cohort of patients hospitalised for severe Covid-19 who were treated with compassionate use of remdesivir,

clinical improvement was observed in 36 of 53 patients (68%).( J. Grein et al,Online April 10, 2020, at NEJM.org. DOI:

10.1056/NEJMoa2007016)

Our View:

This study was designed and conducted by Gilead sciences, No sample-size calculations were performed. Among 61 patients, 53

patients were included in analysis and 40 received the full 10-day course of remdesivir, 10 received 5 to 9 days of treatment, and 3

received fewer than 5 days of treatment leading to variation in treatment among included patients. Improvement in oxygen support

status was observed in 68% of patients, and overall mortality was 13% over a median follow-up of 18 days. This compassionate

program did not collect viral load data to conrm the antiviral effects of drug or any association between baseline viral load and viral

suppression and clinical response. Weakness of this study include that it’s not a randomized control trial, absence of control group,

small size of the cohort, the relatively short duration of follow-up, potential missing data owing to the nature of the study and the lack

of information on eight of the patients initially treated.

Effectiveness of convalescent plasma therapy in severe COVID-19 patients.

Background: Over the past two decades, Convalescent plasma (CP) therapy was successfully used in the treatment of SARS, MERS,

and 2009 H1N1 pandemic with satisfactory efcacy and safety. Aim of the study was to explore the feasibility of CP transfusion to

rescue severe COVID patients.

Materials & methods:

10 patients from three hospitals of Wuhan were recruited in this pilot study. All patients were diagnosed as having severe COVID-19

according to the WHO Interim Guidance with conrmation by real-time RT-PCR assay.

Donors for CP Transfusion. Ten donor patients who recovered from COVID-19 were recruited. The donor’s blood was collected

after 3-week post onset of illness and 4-day post discharge.

Intervention: One dose of 200 mL of inactivated CP with neutralisation activity of >1:640 was transfused into the patients within 4 h

following the WHO blood transfusion protocol.

Results: One dose (200 mL) of CP was well tolerated and could signicantly increase or maintain the neutralizing antibodies at a high

level, leading to disappearance of viremia in 7 days. Meanwhile, clinical symptoms and paraclinical criteria rapidly improved within 3

days.

Conclusion: This pilot study on CP therapy shows a potential therapeutic effect and low risk in the treatment of severe COVID-19

patients. One dose of CP with a high concentration of neutralizing antibodies can rapidly reduce the viral load and tends to improve

clinical outcomes. (Kai Duan et al, PNAS, April 28, 2020, vol. 117, (17) 9490–9496. doi:10.1073/pnas.2004168117/-/DC

Supplemental)





Our View: Chinese pilot study with only 10 severe COVID patients admitted over 28 days in 3 hospitals were enrolled. Nine

patients received arbidol monotherapy or combination therapy with remdesivir or ribavirin, or peramivir, while one patient received

ribavirin monotherapy. Antibacterial or antifungal treatment was used when patients had coinfection. Six patients received

intravenous methylprednisolone (20 mg every 24 h). Chest CT was done in all patients which showed different degrees of

absorption of pulmonary lesions after CP transfusion. The primary endpoint was the safety of CP transfusion. The secondary

endpoints were the improvement of clinical symptoms and laboratory parameters within 3 days after CP transfusion. Weakness of

study include, in addition to CP transfusion, all patients received antiviral treatment and impact of these antiviral agents could not be

ruled out, few patients received glucocorticoid therapy, which might interfere with immune response and delay virus clearance, the

dynamic changes of cytokines during treatment were not investigated. Even though preliminary results on CP is promising but we

need more studies with better methodology ideally randomised controlled to conrm the results of the study.

Treatment of 5 Critically Ill Patients With COVID-19 With Convalescent Plasma.

Objective: To determine whether convalescent plasma (CP) transfusion may be benecial in severe acute respiratory syndrome

coronavirus 2 (SARS-CoV-2) infection.

Design: Case series of 5 critically ill patients with laboratory-conrmed COVID-19 and acute respiratory distress syndrome (ARDS)

who met the following criteria: severe pneumonia with rapid progression and continuously high viral load despite antiviral treatment;

PAO2/FIO2 <300; and mechanical ventilation. Clinical outcomes were compared before and after CP transfusion.

Exposure: Transfusion with CP with a SARS-CoV-2– specic antibody (IgG) binding titre greater than 1:1000 (end point dilution

titre, by enzyme-linked immunosorbent assay [ELISA]) and a neutralization titre greater than 40 (end point dilution titre) obtained

from 5 patients who recovered from COVID-19.

Results: Following CP transfusion, body temperature normalized within 3 days in 4 out of 5 patients, the SOFA score decreased, and

PAO2/FIO2 increased within 12 days.

Conclusion: In this preliminary uncontrolled case series of 5 critically ill patients with COVID-19 and ARDS, administration of CP

containing neutralizing antibody was followed by improvement in their clinical status. (Chenguang Shen et al, March 27, 2020 JAMA.

2020;323(16):1582-1589. doi:10.1001/jama.2020.4783)

Our view: Chinese pilot study with only ve laboratory conrmed positive patients. Weakness of study include small case series with

no controls, different timing of CP administration, all patients were treated with multiple other agents (including antiviral

medications) hence impact of these therapy on outcomes is difcult to analyse.



INNOVATIONS IN CRITICAL CARE SERIES

OUR PLATFORM IN OUR BULLETIN



Innovation 1: Arrest Outcome Consortium Registry

Arrest Outcome Consortium.

Our Indigenous online Cardiac Arrest registry.

Authors of Indian resuscitation council guidelines on Cardiopulmonary Resuscitation expressed the dire need for Indian CPR data to

serve as base for our guidelines. A letter to authors 2, called for Indian cardiac arrest registry as solution. While working on the subject

we designed online CPR registry. This helped us to standardize not only the processes [training of code team, quality control],

documentation [standardized data collection form with vigilance on its completion], condentiality [data de-identied at

source],compilation [upload on online portal which accepts only completed forms] but also facilitated real time processing [back

ofce processing capabilities] with descriptive statistics and downloadable graphical outputs . www.aocregistry.com is one such

platform where any NABH accredited institute after approval of local institutional ethics committee approval, can register and upload

their data on the registry. We followed Utstein style format in data collection and graphical output. Webpage has a dashboard with

display of cumulative outcomes. [See Picture]

As single center data cannot be large enough to yield meaningful statistical analysis, homogenous multi-centric data base is required and online

registry is the only answer to this. AOC is consortium of clinicians to create our own multi-centric database of cardiac arrest which has started

yielding its fruits. After presentation as posters in national congress, rst pilot study [annual data analysis] is submitted for publication. Each

participating institute can access own data and graphs and their representative will be co-author to annual publications that comes out of the

registry database.

Send us an E-mail on [email protected] if interested in enrolling your institute. Lets join hands to create largest ever database on cardiac

arrests in India.

References:

1. RE Kapoor MC, Chakra Rao SSC, Mishra BB. Indian Society of Anaesthesiologists cardiopulmonary resuscitation guidelines: Ushering in a

new initiative. Indian J Anaesth. 2017 Nov; 61(11): 865–866.

2. Trichur Ramakrishnan V. Need for resuscitation registry in India based on Indian Society of Anaesthesiologists cardiopulmonary resuscitation

guidelines. Indian J Anaesth. 2017 Nov; 61(11): 895–896.

Dr. Anuj Clerk**, Dr. Krunal Patel*, Dr. Nikita Desai#

**Head, Intensive care services *Consultant Intensivist,# Research Associate

Sunshine Global Hospital, Surat, Gujarat, E Mail: [email protected]





Innovation 2: Minimising Staff - Patient Contact

COVID-19 pandemic has sparked a urry of low-cost innovations across the country. In such desperate times, altering routine

processes can bring about drastic results. The ICU team at CARE Hospital, Hyderabad, has implemented some simple measures to

minimise contact time between ICU staff and the COVID positive patient.

Much of the equipment attached to critically ill patient requires frequent changes in their parameters. It maybe ventilatory settings or

infusion ow rates, resulting in repeated exposure. To minimise the contact, the ventilator display has been detached from the

machine and placed outside the negative pressure room. Similarly, the syringe infusion pumps are attached to the patient using 3-

meter long tubing and the pump itself is placed outside the room. All the changes required can be done without entering the room.

This has allowed the staff to keep a critical patient in isolation. More importantly by decreasing repeated contact, exposure and

spread of the virus both have been reduced drastically. Some basic machine knowledge combined with out of the box thinking has

been highly rewarding.

Dr. Pavan Kumar Reddy.N





Innovation 3: Prevention of Fogging in face shield

A BREATH OF FRESH AIR: DEFOGGING THE FACE-SHIELD USING

NASAL CANNULA WITH PPEs DURING COVID-19 PANDEMIC.

Harjit Singh Mahay, Rohit Bohra, Rahul Raj Singh, Florence Almeida

Department of Critical Care, Fortis Hospital Shalimar Bagh, New Delhi

Fogging of face-shield is a frequently faced problem by healthcare workers while they wear PPEs to protect themselves during any

aerosol generating procedures (AGP) such as intubation or extubation of airways, tracheostomies, nebulisation or NIV support to

Covid positive patients. The wearing of a complete set of PPEs in Covid may cause some or all of the following problems-

1. Fogging of Face-shield and goggles or spectacles

2. A closed environment of heat around the face which may cause a feeling of claustrophobia and panic attacks

3. Possible rebreathing of CO2 and nasal congestion, headache and inability to think rationally and make critical decisions in an

intimidating environment also affect their ability to perform complex and critical tasks

We tried to look for solution to this problem, by using methods or techniques to improve the mask t using tapes around the face-

mask, increase the distance of face-shield from the face mask and also commercially available liquids or sprays to get rid of fogging,

availability of which were limited due to imposed lockdowns everywhere. Most of the available methods proved inadequate in

preventing the fogging. Consequently, we devised our own method of defogging the face-shield by attaching commonly available

nasal prongs over the forehead of the healthcare worker and running oxygen with owmeter from central supply or small oxygen

cylinder. The use of oxygen ush at a rate of 10-12 L/min resulted in immediate disappearance of fog from the face-shield, goggles or

spectacles, improving vision with no feeling of claustrophobia while the healthcare worker performed the critical intensive care tasks

(video 1).

A BFigure 1: (A) Right after donning the PPE along with N95 mask and the face-shield. Note the dense fogging especially in the visual

eld (B) The clear face-shield after starting ow of Oxygen at 10 L/min through nasal prongs xed in the head band.

https://www.youtube.com/watch?v=BZz5jshfGSE&feature=youtu.be

QUIZ SECTION



1. What is the signicance of this place?

2. What this tragic event led to?

3. This famous song released on 13 December 1977 was used for training medical professionals to provide the correct number of

chest compressions per minute while performing CPR.

4. Identify this device

5. Although this phenomenon is uncommon in adults in normal circumstance, its quite common in preterm infants and neonates. It

was rst described in 1868 by Ewalg……….and Joseph………

6. Why this company is news?

QUIZ SECTION



7. In 1929 a German doctor used this catheter in an unusual way. Although he was ridiculed by his colleagues for bringing shame to

medical profession, his experiment paved way for a great advancement in the medical science. He was later awarded Nobel prize

for Medicine. What was his experiment and what it did lead to?

8. What to N, R and P stands for in the NOISH classication of respirators?

9. Identify the unusual shadow on chest x-ray

10. This case report by V. A. Yurevitcli and N. K .Resenberg is 1914, is the rst publication on which procedure.

ANSWER FOR QUIZ SECTION

JAN-FEB 2020



1. (National Institute for Occupational Safety and Health (NIOSH)

2. Chemical Structure of Remdesevir.

3. Li Wenliang, Chinese Ophthalmologist and whistle-blower from Wuhan central hospital, who later died due to COVID-19.

4. Four essential structural proteins, spike (S) glycoprotein, small envelope (E) protein, matrix (M) protein, and nucleocapsid (N)

protein.

5. Cytokine release syndrome/Cytokine stimulation syndrome/Secondary HLH.

6. Kary Banks Mullis (December 28, 1944 –August 7, 2019) was an American Biochemist who invented PCR. He was later awarded

Nobel prize for chemistry in 1993.

7. Contagion

8. Cellex is the rst company to get US FDA approval for rapid antibody diagnostic test for COVID 19.

9. Indian epidemic act was passed.

10. All of them have isolated COVID-19 strain

Documents

CRITICAL CARE march... · 1.Triple layer medical mask: This is a disposable, 3-layered mask, made of non-woven fabric, and having a bacterial lter ef ciency (BFE) of 98% for 3-micron