CRITICAL CARE...members for successful completion of E- Criticare. Notwithstanding the dif cult situation faced by critical care community, the enthusiasm and participation was …

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

VOLUME 15.5 SEPTEMBER - OCTOBER 2020

WELCOME TO

th th th thWORKSHOP: 24 - 25 Feb 2021 | CONFERENCE: 26 - 28 Feb 2021

CRITICARE 2021 - VIRTUAL CONFERENCETHEME SAFETY AND EFFICIENCY AMIDST RESOURCE LIMITATION

WWW.ISCCM.ORG

CRITICAL CAREC O M M U N I C A T I O N S

CONTENTS1. Editorial

2. Message from the president

3. Message from the general secretary

4. Editorial Board Critical Care Communications 2020 -

2021Editorial Board Critical Care Communications

5. List of New Members

6.Corona Warriors Award

7. ISCCM postal cover release.

8. COVID-19 ARDS: Timing of Intubation- An Intensivist’s Dilemma

9. Spiritual care in healthcare

10. Impact of COVID-19 Pandemic on Family equations of Health-

care workers.

11. An Ode to Transcranial Doppler Sonography

12. POCUS in acute kidney injury-lest we forget

13. Journal section

14. Quiz Section

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]

Editorial...TM

www. .orgisccm

I hope this message nd you in good health. It has been a

wonderful journey for us so far despite facing many

challenges. We are witnessing a new normal where most of

our academic activities are being done through online

means. I would like to like congratulate the leadership and

members for successful completion of E- Criticare.

Notwithstanding the difcult situation faced by critical care

community, the enthusiasm and participation was amazing

in the recently concluded E criticare. The recent decision

by ISCCM to conduct CRITICARE-2021 as completely

virtual conference is laudable and germane in the present

scenario. ISCCM is in the forefront in spreading critical

care education amongst students and practitioners through

its online platforms like ISCCM Academy.

We present you another edition of Critical care communication. To widen the horizon, newer

topics like Use of transcranial doppler and renal ultrasound have been included. The great

conundrum of timing of intubation in COVID ARDS has been addressed. The role of spiritual care

and impact of COVID on the family equation of healthcare providers and many more excellent

topics have been added. I thank all of you for astounding success and continued support for critical

care communications.

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 FriendsGreetings & warm wishes for Christmas and new year.

After eventful 2020, I am reasonably hopeful that new year

will bring smiles back on the faces of men & women.

Year 2020, though disruptive, ushered lot of initiatives &

changes in the lives of all of us- primarily the use of

technology . It leapfrogged the education, training and

governance; bringing in transparency, participation of larger

cohort & outreach to far and wide across the globe,

dening new normals.

I am of the view that meeting of executive council and of

other committees be held virtually saving travel & money with more positive outcomes.

Examinations now should be online for all times to come & gradually simulation should become an

integral part of training & evaluation- preferably through ISCCM academy.

COVID pandemic has brought the spotlight on specialty of critical care highlighting the role of

intensivists. It highlighted our resilience, strength , great team work and areas we need to focus-

research, patient safety advocacy, technical evaluation of products used in critical care and

collaboration with industry & teaching institutions to help creating start ups and trained manpower

in critical care.

We took a conscious decision to have virtual congress in 2021 and to have next congress in

Ahemdabad as was planned earlier. We are trying our best to come up with an uptodate program

covering all the contemporary issues.I have no doubt future is bright & as a professional body we are ready to take all the challenges by

horn to come out victorious. We may have been scarred but our spirits are up with a motive to

serve the man kind.

Wish you all the best & stay safe

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



General Secretary's DeskTM

www. .orgisccm

Dear FriendsHope all of you are safe and doing well. The pandemic continues

to test the resolve of all sections of the society across geo-

political borders. While the situation has stretched our resources,

it has also taught us a few lessons. The basics of hygiene and

safety have never been in as much focus before. Team work and

coordination as work ethics have been highlighted greatly in the

past ten months. Scientic temper and rationale have been

constantly under the limelight. All these principles have been the

forte of Intensivists long before the pandemic started. This is

probably the reason why Intensivists have been the torchbearers

in the march against the wily virus. The ISCCM has continued its endeavor to spread scientic

information and knowledge during these difcult times. As we

know, conventions and large meetings have been on hold as on date. Travel within the country is also a tricky

step. In view of this situation, the Executive Committee has resolved to defer a physical conference at

Ahmedabad as initially planned in February 2021. A full edged virtual Criticare 2021 is being organized

instead. The scientic program is getting ready and so are the logistics. As a initial exercise, a mid-term one

day meeting ( E-Criticare) was organized on the 8th of November and this was enthusiastically received.

More than three thousand members logged in into the event. The feedback received from the participants

including friends from Industry have been analysed and will be used to improve the quality during Criticare.

Intensivists have been in the forefront of the battle against COVID 19. Some of us have weathered the storm

and have become worthy survivors. There have been an unfortunate few who could not. The ISCCM wishes

to stand by the families if such martyrs. The society constituted a committee to suggest a scheme for a

benevolent fund. A mail has been circulated to all of you and the suggestions therefrom, will be implemented. The academic focus of the society has not dimmed despite challenges. The college has successfully completed

all exams and certications while starting a new teaching initiative – the STEP program. The Journal has also

established itself as a reliable source for meaningful information.

The dening moment for the society and the specialty came late in October when the department of Posts

released a postal cover acknowledging the role of ISCCM as a leading light in the Intensive Care driven ght

against the pandemic. It was indeed a recognition that was rightfully given.

Overall, the testing times have thrown up challenges which we have unitedly fought and found new ways of

engaging in our core activities. Hopefully the clouds will clear soon and the sun will shine brightly once again

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



EDITORIAL BOARD CRITICAL CARE COMMUNICATIONS 2020 - 2021

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

Head, Intensive Care Services

Sunshine Global Hospital, Surat


Mob: 7574851424

Dr. Mozammil ShafiMD, FNB, EDIC

Consultant, Critical Care Medicine

Medanta The Medicity, Gurugram


Mob: 9599557808

Dr. Vinay SinghalMD

Additional Director & Head Department of

Critical Care Medicine Fortis Hospital, Ludhiana


Mob: 9915285833

Dr. Asif AhmedDNB (Gold Medal) Anaesthesiology, IDCCM

Sr. Consultant & Head of Department

Dept of Critical Care Medicine

Tata Main Hospital, Jamshedpur


Mob: 9204657195

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

Professor, Department of Medicine,

Smt. Kashibai Navale Medical College,

Narhe, Pune, Maharashtra, India


Mob: 9822091745

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

FFICM(UK), FICCM(India)

BSE Accreditation (Transthoracic Echocardiography)

Chief of Clinical Services and Lead Consultant in

the Department of Critical Care Medicine

Manipal Hospital Whitefield, Bengaluru


Mob: 9886660477

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

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

Head of Critical Care Medicine

Head of Infection Control and

Antimicrobial Stewardship

NMC Speciality Hospital, Dubai (UAE)

Dr. Deepak GovilMD, EDIC, FCCM

Director, Critical Care, Medanta The Medicity, Gurgaon

Email: [email protected] | Mob: 9818056688

EDITOR IN CHIEF

ASSOCIATE EDITORS

EDITORIAL BOARD



EDITORIAL BOARD CRITICAL CARE COMMUNICATIONS 2020 - 2021

JOURNAL SCAN

Dr. Kapil Dev SoniMD

Additional Prof.Critical & Intensive Care

JPN Apex Trauma Centre AIIMS,New Delhi


Mob: 9718661658

Dr. Sai Saran PVMD, IDCCM, DM, EDIC

Assistant Professor,

Department of Critical Care Medicine

Superspeciality Cancer Institute & Hospital,

CG City, Lucknow, UP


Mob: 8004505719

Dr. Anand GuptaDA, IDCCM, IFCCM, EDIC

Senior Consultant,Head Surgical and

Transplant Critical Care

AIG Hospital, Gachigowli, Hyderabad


Mob: 9313392757

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

Associate Professor

Division of Critical Care Medicine

Dept of Anaesthesiology & Critical Care

IMS, BHU, Varanasi, Uttar Pradesh


Mob: 8400100128

Dr. Hrishikesh JhaDA, PGDDC

Senior Consultant and Head - Critical Care

Gurunanak Hospital and

Research Centre, Ranchi


Mob: 9471710607

Surg Ltd Cdr

(Dr) Abdul NasserMBBS, DNB (Anaesth)

Anaesthesiologist, Indian Navy

INHS Jeevanti, Goa


Mob: 9560837993

QUIZ SECTION

IMAGES SECTION



CONDOLENCE

Dr Manuj Sodhi

We are extremely saddened to announced the untimely demise of our dear friend

and colleague Dr Manuj Sodhi. Dr Manuj was an extremely hardworking,

compassionate and a noble soul with an extraordinary ability to connect with the

patients and their families. A devoted family man and intensely cordial to the

colleagues, his departure has created an eternal void which sems difcult to heal.

Dr Manuj is survived by his wife and a daughter. May the departed soul rest in

peace. Our thought and prayers are with his family.

WELCOME NEW MEMBERS



Name City Category MembershipNo

Aditya Sharma Ambala Life Members 20/S-2072

Shwethapriya R Udupi Life Members 20/R-746

Prakash Priyadarshi Patna Associate Life Member 20/P-1200

Sachin Udmale Ahmednagar Associate Life Member 20/U-77

Kapil Rastogi Lucknow Life Members 20/R-744

Manjusha Shah Sholapur Life Members 20/S-2032

Merina Thomas Bangalore Associate Life Member (Nurse) 20/T-437

Amit Panigrahi Visakhapatnam Life Members 20/P-1183

Nandita Samal Cuttack Associate Life Member (Nurse) 20/S-2031

Eliza Mahakud Associate Life Member (Nurse) 20/M-1092

Raju G Calicut Life Members 20/G-916

Vineet Kumar Rohtak Life Members 20/K-1305

Sujatha CH Guntur Associate Life Member (Nurse) 20/C-571

Niranjan H R Mumbai Life Members 20/H-178

Kedarnath Behera Cuttack Associate Life Member (Nurse) 20/B-888

Anusha R Tirupur Life Members 20/R-736

Mohammed Irfan Coimbatore Life Members 20/I-63

Asma Chouhan Thane Associate Life Member 20/C-572

Manisha Saini Sikar Life Members 20/S-2033

Santosini Panda Associate Life Member (Nurse) 20/P-1184

Jyothi Boppudi Guntur Associate Life Member (Nurse) 20/B-889

Vijaya Pagidipalli Guntur Associate Life Member (Nurse) 20/P-1185

Neinika Nayak Cuttack Associate Life Member (Nurse) 20/N-358

Sarmitha Swain Associate Life Member (Nurse) 20/S-2034

Abhishek Joshi Indore Associate Life Member 20/J-599

Nageswara Rao Yamavarapu Guntur Associate Life Member (Nurse) 20/Y-91

Avanti Purohit Mumbai Life Members 20/P-1186

Rohit Jain Jamalpur Associate Life Member 20/J-600

Tukaram Nalwad Parbhani Associate Life Member 20/N-359

Sathya Narayanan.K Vellore Life Members 20/N-360

Chennigari Ramalingam Vardhan Secunderabad Life Members 20/V-422

Rayana Prakash Hyderabad Life Members 20/P-1187

Kumaragurubaran TR Nagapattinam Life Members 20/T-438

Sindhu Baglur Bangalore Life Members 20/B-890

Annapoorani Karunanithi Chennai Life Members 20/K-1306

Arun T C Davanagere Life Members 20/T-439

Sangita Kumawat Sikar Life Members 20/K-1307

Sandhya Ravi Kochi Life Members 20/R-737

Jyotsna Mali Sindhudurg Life Members 20/M-1093

Maneesh Kumar Kanpur Associate Life Member (Nurse) 20/K-1308

Amit Mishra KANNAUJ Associate Life Member (Nurse) 20/M-1094

Amarjeet Kumar Patna Life Members 20/K-1309

Anindita Chakraborty Mumbai Life Members 20/C-573

M V Naveen Kolar Life Members 20/N-361

Saibalaji A Hyderabad Life Members 20/A-728

Sonu Jhunjhunu Life Members 20/S-2078

Saji Shanmughan Thiruvananthapuram Life Members 20/S-2035

Riya Verma PANKI Associate Life Member (Nurse) 20/V-423

Priti Jayswal Sultanpur Associate Life Member (Nurse) 20/J-601

Sachin Katkade Pune Associate Life Member 20/K-1310

Amrita Swati Faridabad Life Members 20/S-2036

WELCOME NEW MEMBERS




Michelle Fernandes Mumbai Associate Life Member 20/F-4

Yogesh Jharwal Jaipur Life Members 20/J-602

Sheikh Ilyas Sheikh Washim Associate Life Member 20/S-2037

Mohd Anas Nagaur Associate Life Member 20/A-729

Indumathi S Bangalore Life Members 20/S-2038

Banothu Neha Bangalore Associate Life Member 20/N-362

Bangari Prashanth Karimnagar Associate Life Member (Nurse) 20/P-1189

Thallapelli Anusha Adilabad Associate Life Member (Nurse) 20/A-730

Vijaymahantesh Soudri Koppal Life Members 20/S-2039

Marutheesh Mallappa Turnkur Life Members 20/M-1095

Ashwani Sharma New Delhi Life Members 20/S-2040

Karna Siva Kumar Cuddapah Life Members 20/S-2041

Ashwini Pednekar Goa Life Members 20/P-1190

Shyam Singh New Delhi Life Members 20/S-2042

Seema Bhalodia Rajkot Associate Life Member 20/B-891

Ayyappan C Madurai Life Members 20/C-580

Ankur Gupta Chandigarh Life Members 20/G-917

Vipulkumar Parmar Baroda Associate Life Member (Nurse) 20/P-1191

Suresh Kumar S Chennai Life Members 20/S-2043

Aditya Gupta Kanpur Associate Life Member 20/G-918

Banoth Vani Khammam Associate Life Member (Nurse) 20/V-424

Aleena Catherin Roy Wayanad Associate Life Member (Nurse) 20/C-574

Tesny Babu Kollam Associate Life Member (Nurse) 20/B-892

Stef Stef Alappuzha Associate Life Member (Nurse) 20/S-2044

Tushar Patel Baroda Life Members 20/P-1192

Bala Ponnuthurai Virudhunagar Life Members 20/P-1193

Jagtaran Singh Ludhiana Associate Life Member 20/S-2045

Kolluru Madhavi Hyderabad Associate Life Member (Nurse) 20/M-1096

Vrushali Patil Nashik Associate Life Member 20/P-1194

Hariom Hariom Dholpur Associate Life Member (Nurse) 20/H-179

Pooja Joshi New Delhi Associate Life Member 20/J-603

Anoop Pn Kottayam Life Members 20/P-1195

Mahesh Ohar Buldana Life Members 20/O-28

Sujata Das Bhubaneswar Associate Life Member (Nurse) 20/D-715

Navin Saxena Agra Associate Life Member (Nurse) 20/S-2046

Satyabrata Dash Bhubaneswar Life Members 20/D-723

Timal Chacko Bangalore Associate Life Member (Nurse) 20/C-575

Jinu Joseph Alappuzha Associate Life Member (Nurse) 20/J-604

Mohit Katare Indore Life Members 20/K-1311

Mayurdhwaja Rath Bhubaneswar Life Members 20/R-738

Denita DSA Udupi Associate Life Member (Nurse) 20/D-716

Malik Mohammad Calicut Life Members 20/M-1097

Nisha N Kollam Associate Life Member (Nurse) 20/N-363

Harindran N Ernakulam Life Members 20/N-364

Vivek Prasad Thiruvananthapuram Life Members 20/P-1196

Varun Rajpal Agra Life Members 20/R-739

Vettri Kkaviyan DHARMAPURI Associate Life Member (Nurse) 20/K-1312

Ramandeep Kaur Amritsar Associate Life Member (Nurse) 20/K-1313

Rajesh Verma New Delhi Associate Life Member 20/V-425

Narendra Patil Kolhapur Life Members 20/P-1197

Mariya Vincy Wayanad Associate Life Member (Nurse) 20/V-426

Suvarna Shirsekar Mumbai Associate Life Member (Nurse) 20/S-2047

WELCOME NEW MEMBERS




Anisha Jose Wayanad Associate Life Member (Nurse) 20/J-605

Mohd Akram Padiyar Sikar Associate Life Member 20/P-1188

Pasupathi Selvam Viluppuram Associate Life Member (Nurse) 20/S-2048

Ranjeet Bondar Osmanabad Life Members 20/B-893

Parth Kalaria Rajkot Associate Life Member 20/K-1314

Sunil Sorout Faridabad Life Members 20/S-2049

Anshu Thomas New Delhi Associate Life Member (Nurse) 20/T-440

Sushmita John Bhilwara Associate Life Member (Nurse) 20/J-606

Mohammed Washid Kozhikode Life Members 20/W-87

Shubham Nahar Pune Associate Life Member 20/N-365

Gaurav Arya Bhiwani Life Members 20/A-731

Sanket Panchasara Gandhinagar Life Members 20/P-1198

Shruti Patel Ahmedabad Associate Life Member 20/P-1199

Panugothu Ram Babu Naik Guntur Associate Life Member (Nurse) 20/R-740

Dhaneesh C Malappuram Life Members 20/C-576

Joby Jose Bangalore Associate Life Member (Nurse) 20/J-607

Kalavati Kalavati Bidar Associate Life Member (Nurse) 20/K-1315

Rakesh Dagar New Delhi Life Members 20/D-717

Shabbir Mulla Belgaum Life Members 20/M-1098

Unnikrishnan K P Bangalore Associate Life Member (Nurse) 20/K-1316

Irshad Lone Bangalore Associate Life Member (Nurse) 20/L-147

Sajad Manzoor Lone Bangalore Associate Life Member (Nurse) 20/L-148

Noorjahan Begum Bhubaneswar Associate Life Member (Nurse) 20/B-894

Sibnarayan Sendha Cuttack Life Members 20/S-2050

Bhoomika Barvaliya Ahmedabad Associate Life Member 20/B-895

Harphool Singh Jaipur Associate Life Member (Nurse) 20/S-2051

Narendra Choudhary Sikar Life Members 20/C-577

Dhawal Prajapati Associate Life Member 20/P-1201

Nikhil Shinde Buldhana Life Members 20/S-2052

Jaspreet Kaur Jagraon Associate Life Member (Nurse) 20/K-1317

Bilal S A Kollam Associate Life Member 20/S-2053

Deeksha Deeksha Una Associate Life Member (Nurse) 20/D-718

Gayathri Udumbasseri Kozhikode Associate Life Member 20/U-75

P. Vishal New Delhi Associate Life Member 20/V-427

Dolma Nayal Almora Associate Life Member (Nurse) 20/N-366

Mukesh Singh New Delhi Associate Life Member 20/S-2054

Barkha Dodani Pune Life Members 20/D-719

Viraj Mohite Life Members 20/M-1099

Abhijit Telkhade Mumbai Life Members 20/T-441

Prakash T Ernakulam Associate Life Member (Nurse) 20/T-442

Mohammad Khaja Medak Associate Life Member (Nurse) 20/K-1318

Sajith S Idukki Associate Life Member (Nurse) 20/S-2055

Devang Priyadarshi Ahmedabad Life Members 20/P-1202

Jaskirat Singh Jammu Life Members 20/S-2066

Chaithra S Bangalore Associate Life Member (Nurse) 20/S-2056

Ranjith N S New Delhi Associate Life Member (Nurse) 20/N-367

Anil Kumar Jhunjhunu Associate Life Member (Nurse) 20/K-1319

Anita Anita Jaipur Associate Life Member (Nurse) 20/A-732

Grace Mathew Malappuram Associate Life Member (Nurse) 20/M-1100

Jawahar K Vellore Associate Life Member (Nurse) 20/K-1320

WELCOME NEW MEMBERS




Ananthakani Ramalingam Tiruvarur Associate Life Member (Nurse) 20/R-741

Mudasir Osmani Hyderabad Associate Life Member 20/O-29

Rajvi Patel Surat Life Members 20/P-1203

Indudipa Sinha Behala Associate Life Member 20/S-2057

D. Nithya D Perambalur Associate Life Member (Nurse) 20/D-720

Sandeep Kumar Sharma Mumbai Life Members 20/S-2058

Ashok Sehgal Jalandhar Life Members 20/S-2059

Prerna Bedi Panchkula Life Members 20/B-896

Kamna Kakkar Gurugram Life Members 20/K-1321

Chintha Sriram Nellore Life Members 20/S-2060

Kanaga Pv Thiruvallur Associate Life Member (Nurse) 20/P-1204

Dundigala Kumar Nalgonda Associate Life Member (Nurse) 20/K-1322

Varun Chalil Navi Mumbai Life Members 20/C-578

Lavanya K Hyderabad Life Members 20/K-1323

Sathya S Chittoor Associate Life Member (Nurse) 20/S-2061

Sunil Kuldeep Jaipur Life Members 20/K-1324

Danish Siddiqui Mumbai Associate Life Member 20/S-2062

Tarique Anwar Sayyed Nashik Associate Life Member 20/S-2063

Abhishek Badave Pune Life Members 20/B-897

Sarita Yadav Jaipur Associate Life Member (Nurse) 20/Y-92

Prarabdha Agrawal Raipur Associate Life Member 20/A-733

Mohammed Naseem Khan Mumbai Associate Life Member 20/K-1325

Prashant Choudhary Ghaziabad Life Members 20/C-579

Kevin Bora Pune Life Members 20/B-898

Manasi Shahane Pune Life Members 20/S-2064

Sagar Pithiya Rajkot Life Members 20/P-1205

Karthi Keyan Tirupur Associate Life Member (Nurse) 20/K-1326

Chirasmita Mahanta Sundargarh Associate Life Member (Nurse) 20/M-1101

Padmaja Pallavi Patna Life Members 20/P-1206

Priyanka K Vellore Associate Life Member (Nurse) 20/K-1327

Dayana V Viluppuram Associate Life Member (Nurse) 20/V-428

Rajalakshmi U Thoothukudi Associate Life Member (Nurse) 20/U-76

Rooba Krishnan Vandavasi Associate Life Member (Nurse) 20/K-1328

Nikita Trehan New Delhi Life Members 20/T-443

Saritha Joseph Wayanad Associate Life Member (Nurse) 20/J-608

Haritha P Kozhikode Associate Life Member (Nurse) 20/P-1207

Ayisha A S Kozhikode Associate Life Member (Nurse) 20/A-734

Jasteena James Kasaragod Associate Life Member (Nurse) 20/J-609

Satbir Malik Pune Life Members 20/M-1102

Raj Shukla Allahabad Life Members 20/S-2073

Puneeth J Bangalore Life Members 20/J-610

Sourabh Kumar Ranchi Life Members 20/K-1329

Smriti Sinha Mangalore Life Members 20/S-2065

Shubham Kumar New Delhi Life Members 20/K-1330

Abhinob Roy Gurugram Life Members 20/R-742

Anisha Beniwal Churu Life Members 20/B-899

Rohit Patnaik Bhubaneswar Life Members 20/P-1210

Taher Ahmed Hyderabad Life Members 20/A-735

Nitin Rai New Delhi Life Members 20/R-743

Balasubramaniaguhan Vivekanandan Tiruchirapalli Associate Life Member 20/V-429

Sai K.N Tirupathi Life Members 20/K-1334

Raj Singh Patna Life Members 20/S-2067

WELCOME NEW MEMBERS




Saurav Shekhar Patna Life Members 20/S-2068

Priyanka Bansal Rohtak Life Members 20/B-900

Ritu Dave Udaipur Life Members 20/D-721

Lizy Vincent Thiruvananthapuram Associate Life Member 20/V-430

Abhishek Bharadwaj Bargarh Life Members 20/B-901

Prakhar Agarwal Bhopal Life Members 20/A-737

Arti Singh Kanpur Life Members 20/S-2069

Arul Selvan.U Chennai Life Members 20/S-2070

Sudheesh Kannan Bangalore Life Members 20/K-1331

Sunil Agarwal Raurkela Associate Life Member 20/A-736

Priyanka Dwivedi Gorakhpur Life Members 20/D-722

Arnab Choudhury Kolkata Life Members 20/C-581

Akash Singhal New Delhi Life Members 20/S-2071

Mahendra Meena Rishikesh Life Members 20/M-1103

Sachin Jadhav Bangalore Life Members 20/J-611

Mandeep Kaur Bhatia Hoshiarpur Life Members 20/B-904

Kamal Singh Jalandhar Life Members 20/S-2076

Professor Manisha New Delhi Life Members 20/M-1104

Ravindra Rahangdale Nagpur Life Members 20/R-745

Anirban Karmakar Kolkata Life Members 20/K-1332

Bharat Kheria Unnao Life Members 20/K-1333

Reena Singh Kanpur Life Members 20/S-2074

Satish Kumar Farrukhabad Life Members 20/K-1337

Shivendra Singh New Delhi Life Members 20/S-2075

Prashant Srivastava Kanpur Associate Life Member 20/S-2077

Diana PBS Ongole Associate Life Member 20/P-1208

Afreen Banu Hyderabad Life Members 20/B-902

Neha Patil Satara Associate Life Member 20/P-1209

Deepak Bansal Jalandhar Life Members 20/B-903

Sudeep Kumar Agra Life Members 20/K-1335

Kumar Abhinandan Bhubaneswar Associate Life Member 20/A-738

Mohammed Kadiyawala Kadi Associate Life Member 20/K-1336

Syed Ahmed Hyderabad Life Members 20/A-739

Mousumi Majumdar Kolkata Life Members 20/M-1105

Md Golam Ahamad Reza Bhadrak Associate Life Member 20/R-747

CORONA WARRIORS AWARD



Dr Dhruva Chaudhry, President ISCCM, receiving Corona Warriors Appreciation

award by honorable Shri Anil Vij, Home and Health Minister, Haryana Govt



ISCCM POSTAL COVER RELEASE

Ist Special postal cover to commemorate ISCCM day was released by Prof OP Kalra Vice Chancellor,

Pt B. D. Sharma University of Health Sciences, Rohtak and Mr S S Saini , Senior Supdt Post, Rohtak in

presence of Dr Dhruva Chaudhry, President ISCCM & Other dignitaries of the university

Dr Dhruva Chaudhry, President ISCCM, presenting the

1st day cover to honorable Shri Anil Vij, Home and Health Minister, Haryana Govt

ISCCM POSTAL COVER RELEASE



COVID-19 ARDS: TIMING OF INTUBATION- AN INTENSIVIST’S DILEMMA



Introduction

The novel Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection, and its clinical manifestation as Coronavirus Disease

2019 (COVID-19) presents an unparalleled worldwide public health problem [1]. Globally, as of 5:05pm CEST, 24 September 2020, there

have been 31,798,308 conrmed cases of COVID-19, including 973,653 deaths, reported to WHO [2]. The disease introduces a unique

pathophysiology and clinical course that puzzles the efcacy of the currently existing therapeutic approaches. This pandemic has to date

caused considerable social, economic, and political disruption globally with many countries adapting unprecedented social distancing

policies that have paralyzed economic activity [8]. About 5% of patients have severe disease. Some of these patients require ICU admission

and many of them will need mechanical ventilation. Mortality remains high in ventilated patients. It is not clear if timing of intubation has any

impact on outcomes. In this article we will be discussing the pathophysiology of COVID-19 ARDS and evidence related to timing of

ventilation.

Pathophysiology

Even though it can meet the ARDS Berlin denition [4, 5], the COVID-19 pneumonia is a specic disease with peculiar phenotypes. Its main

characteristic is the dissociation between the severity of the hypoxemia and the maintenance of relatively good respiratory mechanics [6].

Two phenotypes associated with the COVID-19 infection were observed in several observational studies carried out at various centers.

Type 1: Near normal pulmonary compliance with isolated viral pneumonia

In these patients, severe hypoxemia is associated with respiratory system compliance > 50 ml/cmH2O. The lung’s gas volume is high, the

recruitability is minimal, and the hypoxemia is likely due to the loss of hypoxic pulmonary vasoconstriction and impaired regulation of

pulmonary blood ow. Therefore, severe hypoxemia is primarily due to ventilation/perfusion (VA/Q) mismatch. High PEEP and prone

positioning do not improve oxygenation through recruitment of collapsed areas, but redistribute pulmonary perfusion, improving the VA/Q

relationship. Lung CT scans in those patients conrm that there are no signicant areas to recruit, but the right-to-left venous admixture is

typically around 50% [6].

Type 2: Decreased pulmonary compliance

In 20–30% of these COVID-19 patients admitted to the intensive care unit (ICU), severe hypoxemia is associated with compliance values <

40 ml/cmH2O, indicating severe ARDS [9]. It is certainly possible that their lower compliance (i.e., lower volumes and increased

recruitability) is due to the natural evolution of the disease, but could be the damage caused by the initial respiratory management. Many of

these patients receive CPAP or non-invasive ventilation before ICU admission and are subjected to very high respiratory drives, vigorous

inspiratory efforts, and highly negative intrathoracic pressures. Therefore, in addition to viral pneumonia, this self inicted ventilator-

induced lung injury leads to a decreased pulmonary compliance [10].

Management of ARDS

Invasive ventilation: timing and management of mechanical ventilation

Generally, in ARDS, the timing of intubation is related to clinical outcomes. Studies have shown that ARDS patients undergoing late

intubation have markedly higher mortality rates compared to those who were intubated early in the course of the illness [11].

The near universal approach to early mechanical ventilation at the onset of the COVID-19 pandemic was driven by early data from China

describing rapid deterioration with severe hypoxia, fears of patient self-induced lung injury and infection control measures [12].

Continuous monitoring and preparedness for urgent intubation are cornerstones in the treatment of COVID-19 patients with respiratory

failure. It is still not clear if early intubation is benecial in these patients. A delay of intubation in patients failing NIV worsens outcome [13].

However mortality remains high in ventilated patients. As the main issue in COVID-19 is hypoxia, adequate oxygenation by any other means

may give enough time for the lungs to heal thereby reducing the need for intubation and consequent increased mortality.

Dr. Shruti Krishnan MBBS, MD (KU) Internal Medicine

Senior Registrar, Internal Medicine and Health Check

Manipal Hospital Whiteeld

[email protected]

Mob:9886606621




Gattinoni et al. proposed tailored modications to the usual ARDS principles based on the phenotype of the COVID-19 pneumonia.

Authors proposed a modication in ventilation strategy based on timing. In intubated type 1 phenotype patients, the management of

hypoxemia should be directed to improve the ventilation/perfusion mismatch by liberalized tidal volumes (7-8 ml/kg ideal body weight, to

avoid resorption atelectasis), limited PEEP levels (8-10cmH2O) and keeping the respiratory rate < 20 breaths per minute [17, 6, 18].

As lung damage progresses, type 2 phenotype arises following a similar pattern of a “typical” ARDS (bilateral inltrates, decreased

respiratory system compliance and increased lung weight) [17]. The standard approach of lung protective ventilation through low tidal

volumes (6ml/kg ideal body weight), PEEP levels (




References

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SPIRITUAL CARE IN HEALTHCARE



Dr. Shreya E.

MBBS.

Resident in department of Critical Care Medicine.

Manipal hospital Whiteeld.

Mail id: [email protected]

With the arrival of scientic and technological era the focus on holistic care had begun to wane. Fortunately, in the recent times there is

increased awareness about importance of spiritual care in the healthcare and there is a resurgence in incorporating provisions exclusively

for spiritual care in the hospital setting. Hospitals are a stressful environment especially in the critical care and palliative care departments.

Even though recuperation and recovery transpire every day at a hospital, but so does illness, uncertainty and death. These tragedies not only

leave the patient and their family vulnerable but has huge impact on other aspects of patient and family’s life. Illnesses may interrupt

routines, drain nances, separate families create situations of dependency, and lead to an existential and spiritual concern. In this kind of

situation there is a requirement for emotional and spiritual support. This is where the role of spiritual care in hospitals become essential in

helping to navigate through these difcult times.

What is spiritual care?

Many a time people misconstrued that spirituality and religion are identically tantamount. There may be an overlap as religion can be a form

of spirituality, but they are not the same. Spirituality is a fundamental human experience which gives us meaning, hope and purpose in life;

these purposes can vary among individuals, like for some it can be their loved ones, work, music, art, day to day activities, pets, etc. From an

historical perspective there’s always been close association of religion, spirituality and medicine. Ayurveda, the Indian system of medicine,

which had its roots since ancient times, which incorporated the healing of the physical body in addition to the mind.

What are the benets of spiritual care?

Lately there has been growing disconnect between doctor-patient relationship, despite the easier access and newer means of

communication. 1In practice, many practitioners develop apathy and become sceptical due to burnout. We are becoming an individualistic

society. There is a huge demand on us to keep busy, achieve more patient targets, develop our practice, which can sometimes take us away

from our patients. When a patient and their family want to discuss about their anxieties and worries, we usually tend to think it would be

cumbersome or time consuming or wouldn’t know how to respond or that the answer has to be something deep and philosophical. But

research shows that, this is not the case. It is all about the basics – listening, connecting and communication which can be done in the limited

time we have. 2The most basic thing a physician can do is to listen compassionately. Regardless of whether patients are devout in their

spiritual traditions, their beliefs are important to them. By listening, physicians signals their care for their patients, as empathetic listening can

be all the support a patient requires.

On the downside religious involvement and spirituality may adversely affect an individual too. 3For example, religious beliefs may adversely

affect a person’s health by encouraging avoidance or discontinuance of treatments, failure to seek timely medical care, avoidance of effective

preventive health measures and religious abuse. But comparatively the association between spiritual involvement have better health

outcomes. 4 Assessing and integrating patient spirituality into the health care can build trust and rapport, broadening the physician-patient

relationship

Provision of spiritual care in the ICU setting

5Spiritual care is one of the component of palliative care and contributes to the quality of life, 6as per the National Consensus Project and

World health Organization. Many western hospitals have incorporated provisions exclusively for spiritual care in ICU and palliative care. In

the USA there are board certied representatives called Chaplin who are associated with the Institute to provide clergy and other services

irrespective of one religious beliefs. One such model is briey discussed below.

7Spiritual care team (SCT) The model described was developed at Duke University’s Centre for Spirituality, Theology and Health for

implementation in the Adventist Health System:

The goals of a SCT:

1) To identify the spiritual needs of a patient related to medical illness.

2) Competently address those needs.

3) Create an atmosphere where patient’s feel comfortable talking about the spiritual needs to the physician.




4) To address the whole person need of healthcare team member related to the patient care.

5) To provide a whole person healthcare to all patients they serve.

8All category of patients may benet from spiritual assessment. Examples are- patients with serious, life threatening condition; patients with

chronic disabling medical illnesses; patient with depression or signicant anxiety; patients newly admitted to the hospital or to a nursing

home; and patience being seen for a follow-up out-patient appointment when time is available to address social issues

9Structure of SCT:

1)Physician : is responsible to conduct a brief spiritual assessment in order to identify the spiritual needs.

10Faith, Importance and Inuence, Community, and Address (FICA) Spiritual History Tool, 11HOPE Questions for Spiritual Assessment,

The Open Invite Mnemonic are some of the tools used in Spiritual assessment needs.

The spiritual assessment consist of 3 questions

-Do you have any religious or spiritual support system to help you in the times of need?

-Do you have a religious beliefs that might inuence your medical decision?

-Do you have any other spiritual concern that you would like someone to address?

If the response is yes then the physician will alert the spiritual care coordinator.

2) Spiritual care coordinator: is often a nurse or clinical manager. They review the spiritual assessment and identify and prioritise the spiritual

needs that require addressing. They refer the patient to the Chaplain and later follow up.

3) Chaplain: is a comprehensively trained personnel, to assess and address spiritual need of the patient and develop a spiritual care plan

addressing them along with the type of intervention required. Chaplin also engage in various activities such as listening, counselling, praying,

providing spiritual emotional support to the family members. One of the study in Mayo clinic suggested that over 80% of the patients visited

by a chaplain found the experience signicantly helpful.

The addition of a spiritual care team structure would be difcult in an Indian scenario and would require time. This can be achieved by

education of the trainees and staff. The art of spiritual history taking and on how to handle situation with compassion and care, can be

instilled at medical college level. Without any changes in the structure of educational program it can be established, by teaching medical

students about how to anticipate and be respectful towards others and their religious views despite one's own conviction and beliefs.

Review of evidence of benets with spiritual care

Religious and spiritual coping may have prognostic importance. There are very few studies which have been conducted to evaluate the

benets of Spiritual care. 12Studies have shown that religious and spiritual coping are associated with less depression during illness. One of

the study conducted in Mayo clinic examined the relationship between religious coping and depression among 850 men (aged>65 years)

with no history of mental illness and were hospitalized for a medical illness. Results showed that depressive symptoms were inversely

related to spiritual and religious coping. In addition, spiritual and religious coping was the only baseline variable that predicted less

depression six months later and shown to lessen the ill effects of a stressful life event

Summary

Recently there has been increased awareness about importance of spiritual care in the healthcare. Studies have shown that religious and

spiritual coping are associated with less depression during illness. Many western hospitals have incorporated provisions exclusively for

spiritual care in ICU and palliative care. The addition of a spiritual care team structure would be difcult in an Indian scenario and would

require time. This can be achieved by education of the trainees and staff. The art of spiritual history taking and on how to handle situation

with compassion and care, can be instilled at medical college level. Spiritual care should be a component of comprehensive care provided to

our patients. This may help our patients and their family to endure the impact of illness because sometimes the smallest change can make a

huge difference and enable us to provide holistic care in pursuit of a best medical practice.

Acknowledgements

My sincere gratitude to Dr. Rajesh Mohan Shetty (MHW, Bangalore) for the valuable help and encouraging support.




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http://www.spiritualityandhealth.duke.edu/ (accessed on 15 September 2014).

IMPACT OF COVID-19 PANDEMIC ON FAMILY EQUATIONS OF HEALTH-CARE WORKERS



The pandemic of coronavirus disease 2019 (COVID-19) has affected the healthcare system and healthcare workers (HCWs) in

unprecedented manner. When the news of this novel coronavirus rst appeared in January, the HCWs all over the world were more

intrigued by it, yet today almost all countries have been battling it with ebbs and ows. The healthcare systems globally are struggling to put

enough workforce for treatment of increasing number of patients. The stafng problem was further exacerbated due to signicant

proportion of HCWs themselves being infected and unable to work. Lack of enough trained and motivated manpower can be a direct factor

which is linked to higher mortality in case of surge. Furthermore, inadequate manpower leads to sharing of work with remaining HCWs

and/or longer working hours which increases the risk of cross-transmission of infection and burnout among staff. Therefore, provision of an

adequate workforce has been one of the top priorities of healthcare during this pandemic.

The pandemic of COVID-19 has signicant impact on frontline HCWs and their family members. The frontline HCWs went through cycle of

grief with the initial shock and denial to acceptance of the situation. The pandemic was not only a professional challenge for many HCWs, it

involved personal and social sacrices or psychological makeover at many levels. The unrecognised role of HCWs as children to their

parents, or as a spouse or a parent is usually overlooked both by government ofcials and public. Many HCWs have put their profession rst

in this time of need, however at great cost to their personal and family life. The emotional, psychological and mental wellbeing of self and the

family members has additionally been challenged during this time of crisis.

During the start of pandemic, the frontline HCWs, doctors or nurses tried to self-quarantine from their family members to protect them

from exposure. The isolation was not just physical but, in most cases, psychological too because of increased work pressure and distress due

to rapid increase in number of patients and mortality. The hospitals tried to build on infrastructure with increased number of isolation

rooms, and equipment but human resource to manage these increased beds could not be hired and trained on the same scale. This caused

disproportionate increased work with inadequate resources either manpower or PPE. The initial uncertainty in treatment and infection

control aspect of new disease adds to the stress and dilemma. The physical and social distancing took a toll on communication. The

communication failure was not only seen in hospitals but also among HCWs and family or friends. The psycho-social support by family

members is strength in time of crisis, however, social distancing, lockdown and self-quarantine snatched that support to HCWs.

Work-family balance is always challenging for primary caregivers especially working in emergency and intensive care unit (ICU) and this

pandemic has further exacerbated this crisis. There are various aspects unique to this pandemic which challenged the pendulum of work-

family balance of HCWs.

Risk of cross transmission: The frontline HCWs are always at higher risk of cross-transmission because of the virtue of their work and

prolonged exposures with patients of COVID-19. The risk is not limited to HCWs themselves, but also to their close contacts like family

members especially high- risk contacts. The quantication of this risk is difcult which depends on HCWs (like place of work in hospital, and

availability and quality of PPE) and their households (degree of contact and risk factors among family members). Most, studies reported a

higher risk of transmission among frontline HCWs. In a large cohort of 158445 HCWs, the absolute risk of such infections was found low.

However, frontline HCWs and their households had threefold, and twofold increased risk respectively as compared to general population.

The HCWs in intensive care unit (ICU) are not found to have increased risk because of factors like patients admitted in ICU in late phase of

illness with decreasing infectivity and/or better compliance with usage of PPE.

Dr Prashant Nasa

NMC Speciality Hospital, Dubai

Dr Ruchi Nasa

NMC Speciality Hospital, Dubai

IMPACT OF COVID-19 PANDEMIC ON FAMILY EQUATIONS OF HEALTH-CARE WORKERS



Stigma of Contagion: The HCWs and family members have also faced acts of violence due to the COVID-19 pandemic against the backdrop

of growing social stigma and discriminatory behaviours. There was a false perception and misbelief of public for HCWs their family members

as “vectors of contagion”. The initial lack of reliable information and misinformation especially through social media channels (infodemic)

shaped such beliefs and behaviours among public. This mistrust comes as a further risk to HCWs, who were at frontlines in this public health

emergency.

Psychological distress: The HCWs have faced multiple challenges on working front like inundated systems, shortage of resources like beds,

equipment like ventilators or PPE. There is also psychological impact of this pandemic besides physical challenges. Several studies had

demonstrated, an increased risk of acquiring post traumatic -stress disorder, depression and anxiety among HCWs. Nurse and female

gender were conferred with higher risk of psychological distress. There are various reasons of psychological distress including continuous

exposures to high pressure job, stigma from family members and society, limited social support due to lockdown and lack of psychosocial

help. This distress further threatens the work-family balance of HCWs.

Parenting: Parenting of children in absence of school, group activities, team sports has been a major challenge for parents, with no clarity on

how long the situation will last. The challenges multiply when parents themselves are also caregivers. The children of HCWs, besides the

negative effects of home connement due to school closures, also face lack of emotional support because of working parents. Marriage

among working HCWs is common and crisis multiplies when spouses of HCWs are also on frontline. In most cases, children were left alone

to tend for themselves as the support from day-care centre and schools were disrupted. The relatives or housemaids were also unavailable

during this crisis because of quarantine and lockdown. The effect on children of working HCWs are so far unspoken but likely to be worse

because of added fears and unspoken worries. The old aged parents were similarly isolated in order to reduce the risk of cross-infection and

putting their lives in danger. These all situations were additional mental trauma for the already burdened healthcare professionals.

In conclusion, COVID-19 pandemic is likely to cause long term psychological distress among HCWs and their family members. The balance

of work and family life can only create a motivated workforce which can deal with menace of second or more waves of this pandemic. There

is urgent attention required by government ofcials and healthcare systems on support system of their own staff and their households.

References:

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2020 Jul 20;13(1):40. doi: 10.1186/s12245-020-00299-5.

AN ODE TO TRANSCRANIAL DOPPLER SONOGRAPHY



Dr. Munta Kartik MD.,IDCC.,EDIC

Sr. Consultant intensivist

Yashoda Hospital,Somajiguda,Hyderabad,Telangana

Transcranial Doppler (TCD) ultrasonography has been described in the literature as an inexpensive, noninvasive method of measuring

blood ow within the cerebral circulation. In modern era it could be described as the doctor’s stethoscope of the brain. Rune Aaslid had

introduced TCD in 1982, which has re invented itself since then to be a reliable diagnostic, monitoring, and therapeutic tool.[1]

Doppler sonography is all about obtaining information regarding blood ow velocities without any structural imaging , but with addition of

tissue imaging it is termed as duplex sonography. Transcranial Doppler is mainly helpful in clinical situations such as assessment of vasospasm,

detection of stenosis of the intracranial arteries, evaluation of cerebrovascular autoregulation, non-invasive estimation of intracranial

pressure and assessment of brain death. [2]

Physics behind Cerebrovascular Hemodynamics:

Ohms law describes the relationship between the three parameters namely Flow, Resistance and Pressure. Flow = Pressure/Resistance

Cerebral blood ow = Cerebral perfusion pressure/Cerebrovascular resistance (CBF = CPP/CVR).[3]

CPP can be obtained from the mean arterial blood pressure and the intracranial pressure (CPP = MAPB-ICP). CVR aids in autoregulation of

blood ow by constriction and dilatation of the arterioles in the cerebral circulation. The Cerebral autoregulation helps in maintaining CBF

stable despite alterations in CPP and CVR, by lowering resistance by inducing vasodilatation to maintain CBF when CPP is decreased and

increasing resistance by vasoconstriction when CPP increases.

Mean ow velocity is directly proportional to ow and inversely proportional to the section of the vessel. Any conditions that leads to a

change in one of these factors can thus affect mean velocity.

Accoustic windows:

Acoustic windows are the specic points of the skull where the cranial bone is thin enough to allow penetration of ultrasound waves. The

main acoustic windows are namely the transtemporal, transorbital, suboccipital windows.

Therefore, familiarity with the anatomic location of cerebral blood vessels relative to the acoustic windows is paramount for measurement

of accurate blood ows.

Figure 1: Accoustic windows and various angles of insonation.




Preparing to do an Transcranial ultrasound:

The TCD examination can be performed using a 2 MHz frequency ultrasound probe (Figure 2) through the thinner regions of the skull,

termed acoustic windows.

The insonation of cerebral blood vessels can be performed only through these regions of interest.

Specic arteries of the circle of Willis are identied using the following criteria: [4]

(1) relative direction of the probe within a specic acoustic window

(2) direction of blood ow in the interested blood vessel relative to the probe

(3) depth of insonation

Figure 2: Transcranial doppler probe and transtemporal window for insonation.

Trans temporal window:

The transtemporal window is usually the most useful accoustic window. Through this window the Circle of willis can be visualised anterior

to the cerebral peduncles as shown in the gure (gure 3). Cerebral peduncle is visualised as an buttery shaped structure on the ulrasound

image. Through this accoustic window the ICA bifurcation can be identied at depths of 55 to 65 mm.

Figure 3: Trans temporal gray-scale image showing the cerebral peduncles (P) with the echogenic basilar cistern located just anteriorly.




The MCA, is visualised at depths of 35 to 55 mm, its course runs laterally and slightly anterior from the origin of ICA. Flow in the MCA is

always toward the probe until bifurcation where ow becomes bidirectional.(Figure 4)

The ACA, which can be viewed at depths of 60 to 70 mm, it courses medially and then anteriorly after the ICA bifurcates. The ow in ACA is

always away from the probe.

The PCA can be found at a depth of ~60 to 70 mm. PCA is located usually 1 to 2 cm posterior to the ICA bifurcation, in the same plane as the

circle of Willis. Flow in the proximal PCA (P1 segment) is toward the probe and in the distal PCA (P2 segment) away from the probe. The

velocities in PCA is lower than the velocities of MCA.[5]

Figure 4: Anatomic visualisation of intracranial arteries through the transtemporal window.

Transorbital window

The transorbital window insonates mainly the carotid siphon and the ophthalmic artery. The probe is placed over the closed eyelid after

taking due precautions. The Sonar beam is directed toward the optic canal to insonate the carotid siphon at a depth of 55 to 70 mm. Flow

direction signies the different segments of the siphon. Flow in the ophthalmic artery is always towards the probe.

Suboccipital window

The suboccipital window can be helpful in examination of posterior circulation. It is performed with the neck exed, and can be helpful to

insonate the basilar and vertebral arteries. The basilar artery is typically found at depths of 60 to 70 mm.

Main Clinical Applications:

1. Acute Ischemic Stroke

TCD can detect acute MCA occlusions with high (> 90%) sensitivity, specicity, and positive and negative predictive values.TCD can also

detect occlusion in the ICA siphon, vertebral, and basilar arteries with reasonable (70 to 90%) sensitivity and positive predictive value and

excellent specicity and negative predictive value (> 90%).[6]

TCD ndings play an important role in prognosticating in patients presenting with acute ischemic stroke. CD in acute ischemic stroke can be

helpful where repeated TCD studies can be used to monitor the course of an arterial occlusion before and after performing

thrombolysis.[7]

TCD provides real-time information regarding the direction and the velocity of ow of blood in collateral branches, which are active in acute

and/or chronic steno-occlusive cerebrovascular diseases. It has been observed in studies that the degree of collateral ow is correlated with

infarct volume and clinical outcome in patients with stroke.[8]




2. Subarachnoid hemorrhage and Vasospasm:

Angiography of the vessels of the brain still remains gold standard for the diagnosis of cerebral vasospasm. However, this procedure is

invasive, requires the availability

of signicant resources.TCD evaluation has been recommended as a screening tool in high-grade WFNS (World Federation of Neurological

Surgeons) scale patients to recognise high risk patients for devoloping vasospasm .[9]

Vasospasm results in elevations of the mean ow velocities in cerebral arteries without any increase in the ow velocities of supplying

extracranial blood vessels.

The utilisation of Lindegaard ratio (LR) to dene the severity of vasospasm by caliculating the ratio between the average mean (Vmean)

velocity of the MCA to ICA helps in differentiating hyperemia from Vasospasm. [10] Hyperemia is diagnosed by incresase in ow velocities in

both the MCA and ICA and result in an LR < 3, whereas Vasospasm usually elevates the MCA ow over the ICA with LR > 6.

TCD is one of the most signicant modalities in monitoring the temporal course of angiographic vasospasm following SAH. It is useful in

timing of diagnostic and therapeutic angiographic interventions.

3. Cerebral Circulatory Arrest

Cerebral ow patterns can be observed and monitored regularly bedside in critically ill neurological patients who are having impending

Cerebro circulatory arrest situations with help of transcranial ultrasound. When the cerebral compliance decreases, ICP increases to match

the diastolic perfusion pressure. It reaches a critical point where diastolic cerebral blood ow approaches zero. With any further rise rise in

ICP, diastolic blood ow starts to reverse in opposite direction, which can be visualized as retrograde ow.[11]

Figure 5: Ultrasound image depicting the reversal of ow pattern in cerebrovascular arrest patient.

The presence of such retrograde or oscillatory diastolic ow along with systolic spikes, is taken as conrmatory sign of cessation of forward

cerebral blood ow and are depictive of CCA.(Figure 5) TCD has very high sensitivity (96.5%) and specicity (100%) in the diagnosis of

cerebral circulatory arrest.

Disadvantages of TCCD:

1. It is operator dependent

2. Sensitivity is 80% when compared to angiography which is around 89-98% for MCA.

3. Viewing structures may prove to be difcult in thick skull individuals.

4. Potential confounders may interfere in appropriate conclusions like the hypo/hypercapnea, Hematocrit, Hypotension etc




References:

1. Sharma AK, Bathala L, Batra A, Mehndiratta MM, Sharma VK. Ann Indian Acad Neurol. 2016 Jan-Mar; 19(1):102-7.

2. Tsivgoulis G, Alexandrov AV, Sloan MA. Advances in transcranial Doppler ultrasonography. Curr Neurol Neurosci Rep. 2009 Jan;9(1):46-

54.

3. Vriens EM, Kraaier V, Musbach M, Wieneke GH, van Huffelen AC. Transcranial pulsed Doppler measurements of blood velocity in the

middle cerebral artery: reference values at rest and during hyperventilation in healthy volunteers in relation to age and sex. Ultrasound Med

Biol. 1989;15(1):1–8.

4. Tegeler CH, Babikian VL, Gomes CR, editors. Neurosonology. St. Louis, MO: Mosby-Year Book; 1996.

5. Ringelstein EB, Kahlscheuer B, Niggemeyer E, Otis SM. Transcranial Doppler sonography: anatomical landmarks and normal velocity

values. Ultrasound Med Biol. 1990;16(8):745–761.

6. Rasulo FA, De Peri E, Lavinio A. Transcranial Doppler ultrasonography in intensive care. Eur J Anaesthesiol Suppl. 2008;42 (42):167–173.

7. Camerlingo M, Casto L, Censori B, Ferraro B, Gazzaniga GC, Mamoli A. Transcranial Doppler in acute ischemic stroke of the middle

cerebral artery territories. Acta Neurol Scand. 1993;88(2):108–111.

8. Zanette EM, Fieschi C, Bozzao L, et al. Comparison of cerebral angiography and transcranial Doppler sonography in acute stroke. Stroke.

1989;20(7):899–903.

9. Lysakowski C, Walder B, Costanza MC, Tramèr MR. Transcranial Doppler versus angiography in patients with vasospasm due to a

ruptured cerebral aneurysm: A systematic review. Stroke. 2001;32 (10):2292–2298.

10. Lindegaard KF, Nornes H, Bakke SJ, Sorteberg W, Nakstad P. Cerebral vasospasm diagnosis bymeans of angiography and blood velocity

measurements. Acta Neurochir (Wien) 1989;100(1–2):12–24.

11. Tsivgoulis G, Alexandrov AV, Sloan MA. Advances in transcranial Doppler ultrasonography. Curr Neurol Neurosci Rep.

2009;9(1):46–54.

POCUS IN ACUTE KIDNEY INJURY-LEST WE FORGET



Dr Arjun Alva, MBBS,MDAdministrative Head and Consultant Critical Care Medicine,

Medical Intensive Care Unit,

Consultant incharge Covid ICU, Head of the department,Respiratory therapy care services,

NH-Mazumdar Shaw Multispeciality Hospital,Bangalore.

Email:[email protected] | Mobile:9108026001

Acute Kidney injury has been one of the most common complication in the intensive care unit. There are plethora of factors responsible for

the onset of acute kidney injury (AKI) in the critical care unit. The few of the common causes of acute kidney injury in the ICU include septic

shock, hemodynamically mediated prerenal dysfunction, nephrotoxic drugs, urinary tract obstruction, use of vasopressors and also the

amount and quantity of uids that are used as maintenance or bolus uids. Incidence of acute kidney injury in the intensive care unit is as high

as 60% raising concern regarding Acute kidney injury in the ICU globally with extremely high morbidity. It is also an independent predictor

of mortality.1

We are living in an age of ultrasound and we have spent a lot of time in researching and implementing protocols for evaluation of heart and

lungs. The use of Point of care Ultrasound (POCUS) in evaluating the renal system by intensivists has not been given its due importance.

The pertinent questions which one can get answers through the utility of POCUS in AKI are

1. What mean arterial blood pressure (MAP) is ideal for renal perfusion?

2. Is the patient hypovolemic or hypervolemic?

3. Is renal autoregulation maintained.

4. When do we stop uid resuscitation?

5. Is the patient developing an acute kidney injury?

This article will give a brief into the questions above, which can lay a basic foundation for further research and possible POCUS protocol for

Acute Kidney Injury by discussing the role of ultrasound in calculating Renal Resistive Index and venous excess ultrasound score.

POCUS role in dening intrarenal hemodynamics (RRI)

The renal resistive index (RRI), derived from the doppler spectrum of intrarenal (segmental interlobar) arteries, is obtained by the

difference between maximum and minimum (end-diastolic) ow velocity to maximum ow velocity. RRI = (maximum velocity - minimum

velocity) /maximum velocity. RRI is dependent on the vascular compliance and uid shifts specic to renal system and hence it might give a

true picture of intrarenal hemodynamics.

Renal Resistive index was introduced by Gosling et al in 1974 and has found its utility in prognosis of postrenal transplant patients. Although

the role of RRI has been well documented in critical care areas its clinical application at bedside is yet to gain popularity.

Renal resistive index of more than 0.75 can help in diagnosing onset of acute kidney injury 2 to 3 days before its onset.2 It can also be used to

determine what MAP to be maintained to facilitate renal perfusion.3 As it gives a dynamic index for renal perfusion it is worth pondering on

future studies. In a study done by song et al in septic patients; combining CVP with RRI had a higher prediction of sepsis induced acute kidney

injury.4

Figure 1: The renal resistive index (RRI) is measured by Doppler sonography in an intrarenal interlobar artery, and is the difference between

the peak systolic (PSV) and end diastolic (EDV) blood velocities divided by the peak systolic velocity (PSV)




Figure 2.5 Different renal and extrarenal determinants concur to determine RRI

Low Renal resistive index i.e IR0.70 in native kidneys are associated with renal dysfunction and adverse cardiovascular issues. In Renal

transplant recipients they are associated with increased risk of graft loss and death.5

POCUS in dening volume status of the patient (VEXUS)

Monitoring the volume status of a patient continues to be a challenge in the critical care units. Peripheral hypervolemic signs have limitations

to the extent that it correlates to only about 52% of the probability of diagnosing volume status. Venous excess ultrasound score (VEXUS)

has been designed with a physiological concept that kidneys being an encapsulated organ, the back-pressure effects are quite prominent.

The hypothesis behind the scoring system is that the IVC gets distended with less than 20% of respiratory variability followed by alteration

of hepatic venous waveform and appearance of portal venous pulsatality.

Ultrasound Assessment:7 Ultrasound assessment is performed bedside using a curvilinear abdominal probe of 8–3 MHz by intensivist who

is experienced in ultrasound examination. The Patients are positioned in the dorsal decubitus position with headend of bed elevated

between 0° and 30°. Hepatic Doppler visualizing either the middle hepatic vein in the subxiphoid area or the right hepatic vein from a lateral

angle is done. Similarly, the portal vein Doppler is interrogated from a lateral approach. As for all Doppler examinations, the waveforms are

traced during a respiratory pause, if respiratory liver movement prevented proper trace generation. The Inferior vena cava(IVC) is

interrogated in long and short axis along the intrahepatic segment and a visual average is done. Respiratory variation is dened as a 20% or

more change in surface area in the short axis.

Grade 0: 20 mm with respiratory variation

Grade IV: >20 mm with minimal or no respiratory variation

Hepatic vein (HV): interrogation by pulsed wave Doppler, identication and analysis of A, S, and D waves:

Grade 0: normal S > D

Grade I: S < D with antegrade S

Grade III: S at or inverted or biphasic trace

S wave is normally the larger of the two negative deections.




Portal vein Doppler (PD)

Portal vein (PV) interrogation

Grade 0:




Flowchart for approach to AKI patient 7

In a study done by Beaubien- Souligny et al. in postoperative cardiac surgery patients where a signicant association was found between an

elevated VEXUS score and the development of AKI.6

In a study done by Bhardwaj et al showed that combined imaging of IVC, Hepatic vein and portal vein (VEXUS score) might reliably

demonstrate venous congestion and aid clinical decision-making process in cardiorenal syndrome patients. In this study 87% patients

correlated with resolving AKI and improving VEXUS score.7 This might answer the question whether to aggressively give uids or to give

diuresis more reliably.

In conclusion there is a need for AKI POCUS protocol and a greater emphasis on potential research encompassing renal resistive index and

venous excess ultrasound score to answer some of the key clinical questions by the bedside in management of patients with the risk of acute

kidney injury.

References

1. Maria Boddi et al, Renal Resistive Index and mortality in critical patients with acute kidney injury. Eur J Clin Invest 2016; 46 (3): 242–251

2. Matthieu Le Dorze et al. Renal Doppler Ultrasound: A new tool to assess renal perfusion in critical illness. SHOCK, Vol. 37, No. 4, pp.

360Y365, 2012

3. Nicolas Lerolle et al ,Renal failure in septic shock: predictive value of Doppler-based renal arterial resistive index. Intensive Care Med

(2006) 32:1553–1559 DOI 10.1007/s00134-006-0360-x

4. Ming Zhong, Jieqiong Song et al, Value of the combination of renal resistance index and central venous pressure in the early prediction of

sepsis-induced acute kidney injury. YJCRC (2017) 52885, doi:10.1016/j.jcrc.2018.03.016.

5. Maria Boddi et al , The internist and the renal resistive index: truths and doubts Intern Emergency Med DOI 10.1007/s11739-015-1289-2

6. Beaubien-souligny W,Eliaiek R,Fortier A, Lamarche Y, Liszkowski M, Bouchard J, et al.The association between pulsatile portal ow and

acute kidney injury after cardiac surgery:a retrospective study. J Cardiothoracic Vascular Anesth 2018;32(4):1780-

1787.DOI:10.1053/jvca.2017.11.030

7. Bhardwaj V et al ,Combination of Inferior Vena Cava Diameter, Hepatic Venous Flow, and Portal Vein Pulsatility Index: Venous Excess

Ultrasound Score (VEXUS Score) in Predicting Acute Kidney Injury in Patients with Cardiorenal Syndrome: A Prospective Cohort Study.

Indian J Crit Care Med 2020; https://www.ijccm.org/doi/ IJCCM/pdf/10.5005/jp-journals-10071-23570.

8. Doppler resistive index to reect regulation of renal vascular tone during sepsis and acute kidney injury. Dewitte et al. Critical Care 2012,

16:R165 http://ccforum.com/content/16/5/R165



Dr Deepak Kumar Nirala

MD. PDCC(Critical care medicine)

Department of Critical Care Medicine, RIMS, Ranchi

Dr Mohd Saif Khan

MD, DNB, PDF (CCM), DM (CCM)

Associate professor

Department of Critical Care Medicine,

RIMS, Ranchi

CRITICAL APPRAISAL:

1. Are the Title and Objectives appropriate?

• Yes, the title is clear and appropriate.

• Objectives of the study are clearly stated.

2. What is the clinical importance of that objective?

• Pregnancy related acute kidney injury (PRAKI) is one of the most important causes of feto-maternal morbidity and mortality.

• In India, PRAKI requiring dialysis was 15% in 1982–1991 and was 10% in 1992–2002.

• The timing of initiation of renal replacement therapy (RRT) for better patient outcome is still debatable with conicting data from different

randomized controlled trials. It will be interesting know the impact of early RRT on fetomaternal outcome.

Was it studied previously and what were the results?

• Wierstra et al. did a Meta analysis on 1042 patients of 9 different studies. Their results were, in “early” RRT group mortality rate was 34.6

% compared with 40.2 % in “late” RRT group. No mortality benet with “early” versus “late” RRT, with an OR of 0.665 (95 % CI

0.384–1.153, p = 0.146). They concluded that “early” initiation of RRT in critical illness complicated by AKI does not improve patient

survival or confer reductions in ICU or hospital LOS.

• Meta-analysis conducted by Bhatt et al. of 10 randomised controlled trials with 1,636 participants, showed no signicant benet of early

RRT on day 30 mortality; day 60 mortality; day 90 mortality [3 trials; 555 participants; RR,0.94];Overall ICU or hospital mortality; dialysis

dependence on day 90. There was no signicant difference between length of ICU or hospital stay and recovery of renal functions.

• Meta-analysis performed by Feng et al. of 9 RCTs with a total of 1636 participants, demonstrated no differences between the early RRT

group and the late RRT with respect to mortality (38% vs 41.4%; relative risk, 0.93). There were no ndings of benets in terms of

reduction in the ICU LOS and hospital LOS.

• In another meta-analysis by Lai et al. showed earlier RRT was not associated with benets in terms of mortality and RRT dependence.

There were also no signicant differences in the ICU and hospital LOS.

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

compared? If so how?

• This is a prospective comparative study in which patients were screened at a multispecialty tertiary-care hospital. RIFLE criteria were

used to dene AKI.

• The demographic prole and clinical characteristics of the patients in terms of age, parity, access to antenatal care, fetal outcome, urine

output, hematological and biochemical proles, RRT, duration of hospitalization, recovery of renal function, and patients survivalwere

recorded.

• The patients were divided into two groups:

• Early RRT (RRT done in 0.05 and signicant if



5. What were the results?

• This prospective study included 13 patients in the early RRT group and 23 patients in the standard group.

• The age and the weight between the two groups were statistically nonsignicant. The mea

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