Critically Ill COVID-19 Patient with Chronic Liver Disease - Insights into a Comprehensive Liver Intensive Care.

The novel coronavirus-related coronavirus disease 2019 (COVID-19) pandemic has been relentless in disrupting and overwhelming healthcare the world over. Clinical outcomes of COVID-19 in patients with chronic comorbidities, especially in those with metabolic syndrome, are well documented. Chronic liver disease and cirrhosis patients are a special sub-group, among whom the management of COVID-19 is challenging. Understanding the pathophysiology of COVID-19 in patients with cirrhosis and portal hypertension improves our identification of at-risk patients for disease progression that will further help compartmentalize generalized and specialized treatment options in this special patient group. In this exhaustive review, we critically review the impact of COVID-19 on the liver and in chronic liver disease and cirrhosis patients. We further discuss common features associated with the pathophysiology of COVID-19 and cirrhosis, based on the renin-angiotensin system and deliberate current literature on guidelines for the treatment of COVID-19 and extrapolate the same to the cirrhosis population to provide a concise and stepwise, evidence-based management for cirrhosis patients with severe and critical COVID-19. There are no specific management guidelines for cirrhosis patients with COVID-19 and current recommendations for treatment are as per guidelines for general population. Nevertheless, specific issues like avoiding corticosteroids in decompensated patients with variceal bleeding, suspected sepsis, high grade hepatic encephalopathy and acute kidney injury, use of early mechanical ventilation strategies in those with severe ascites and hepatopulmonary syndrome, avoidance of remdesivir in advanced liver disease, and application of liver-specific severity scores for prognostication and identification of futility need to be highlighted.

Moral philosophy, pragmatism, and the larger cause: why "war" metaphors are needed during pandemics.

Coronavirus disease (Covid-19), which originated in China, is now a full-blown pandemic which has thrown governments and societies off-track in an unprecedented manner. War metaphors have been used widely to describe the scenario, but many critics decry them as harmful narratives. In this piece, we discuss the utility of the war metaphor to build solidarity and fraternity, which will be essential to get through the crisis. We also explain how concerns regarding increased authoritarianism and state excesses due to the use of these narratives are misplaced. We then tease out the colonial era concept of war that guides the arguments against the use of war metaphors in pandemics. We argue that in the post-modern world and in South Asian and African philosophies, wars are seen through the prism of the larger cause of dharma or ubuntu and that individual losses or gains in these contexts are part of a larger cause. The use of war metaphors reflects the need to get together for a societal cause. These metaphors are largely understood across societies while other alternatives are exclusionary, poetic and tangential in nature.

Keywords : Covid-19, pandemics, war metaphors, communication, philosophy, SARS-CoV-2

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Personal Protective Equipment: A Pandora's Box.

Countries all over the world writhing under the wrath of coronavirus face not only the challenge of protecting their population but the tougher challenge of protecting their healthcare workers (HCWs) dealing with the patient population. This pandemic has put unprecedented pressure on global healthcare systems, with personal protective equipment (PPE) being the most notable one. Apart from the challenge of procurement of PPE, the major challenge is rationalizing the use of PPE in this war against corona virus disease 19 (COVID19). Using PPE comes with its own set of problems such as extreme exhaustion, rashes, inability to consume food, or use washroom which can result in clouding of judgment and breach of infection barrier. Making PPE user-friendly and limiting the interaction of HCW with COVID19 patients coupled with the use of robotics, telemedicine, and other innovations is the need of the hour. HOW TO CITE THIS ARTICLE: Chawla G, Abrol N, Kakkar K. Personal Protective Equipment: A Pandora's Box. Indian J Crit Care Med 2020;24(5):371-372.

Tough times and Miles to go before we sleep- Corona warriors.

The world has changed due to COVID-19 pandemic. Global spread of COVID-19 has overwhelmed all health systems and has incurred widespread social and economic disruption. The authorities are struggling to ramp up the healthcare systems to overcome it. Anaesthesiologists are facing long duty hours, have fear of bringing disease home to their families, being companion to critically ill patients on long term life support, being on front line of this pandemic crisis, may take toll on all aspects of health of corona warriors- physical, mental, social as well as the emotional.At this juncture, we must pause and ask this question to ourselves, "Buried under stress, are we okay?"