Resilience-Need of the Hour for the "Frontliners".

Samavedam S. Resilience-Need of the Hour for the "Frontliners". Indian J Crit Care Med 2022;26(2):157-158.

Expert Consensus Statements on the Use of Corticosteroids in Non-severe COVID-19.

INTRODUCTION: There is strong evidence for the use of corticosteroid in the management of severe coronavirus disease-2019 (COVID-19). However, there is still uncertainty about the timing of corticosteroids. We undertook a modified Delphi study to develop expert consensus statements on the early identification of a subset of patients from non-severe COVID-19 who may benefit from using corticosteroids. METHODS: A modified Delphi was conducted with two anonymous surveys between April 30, 2021, and May 3, 2021. An expert panel of 35 experts was selected and invited to participate through e-mail. The consensus was defined as >70% votes in multiple-choice questions (MCQ) on Likert-scale type statements, while strong consensus as >90% votes in MCQ or >50% votes for "very important" on Likert-scale questions in the final round. RESULTS: Twenty experts completed two rounds of the survey. There was strong consensus for the increased work of breathing (95%), a positive six-minute walk test (90%), thorax computed tomography severity score of >14/25 (85%), new-onset organ dysfunction (using clinical or biochemical criteria) (80%), and C-reactive protein >5 times the upper limit of normal (70%) as the criteria for patients' selection. The experts recommended using oral or intravenous (IV) low-dose corticosteroids (the equivalent of 6 mg/day dexamethasone) for 5-10 days and monitoring of oxygen saturation, body temperature, clinical scoring system, blood sugar, and inflammatory markers for any "red-flag" signs. CONCLUSION: The experts recommended against indiscriminate use of corticosteroids in mild to moderate COVID-19 without the signs of clinical worsening. Oral or IV low-dose corticosteroids (the equivalent of 6 mg/day dexamethasone) for 5-10 days are recommended for patients with features of disease progression based on clinical, biochemical, or radiological criteria after 5 days from symptom onset under close monitoring. HOW TO CITE THIS ARTICLE: How to cite this article: Nasa P, Chaudhry D, Govil D, Daga MK, Jain R, Chhallani AA, et al. Expert Consensus Statements on the Use of Corticosteroids in Non-severe COVID-19. Indian J Crit Care Med 2021;25(11):1280-1285.

Comparison of Severity of COVID-19 Infection among Patients Using RAAS Inhibitors and Non-RAAS Inhibitors.

AIMS AND OBJECTIVES: The aim of the article was to study the safety profile of renin-angiotensin-aldosterone system (RAAS) inhibitor in COVID-19-affected Indian patients. INTRODUCTION: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for COVID-19 infection. There has been uncertainty about use of RAAS inhibitors in COVID-19. The association of RAAS inhibitors with severity of infection and clinical outcomes was addressed in this study. MATERIALS AND METHODS: This is a single-center retrospective study from Indian intensive care unit (ICU). A total of 138 were included, who were divided into group A (RAAS inhibitor) and group B (non-RAAS inhibitor). They are followed up till ICU stay during which peak levels of ferritin, D dimer, interleukin-6 were noted (primary outcome). The number of ventilator days, ICU length of stay, and ICU outcome also compared. RESULTS: Of 138 patients, 18 are included in group A and 120, in group B. There is no difference in peak levels (mean) D dimer [5,893 vs 7,710, p 0.46], ferritin [2,388 vs 3,635, p 0.56], interleukin-6 [9,597 vs 3,625, p 0.06]. There is no difference in number of ventilator days (2.2 vs 1.78, p 0.53) and ICU length of stay (6.5 vs 6.1, p 0.74). CONCLUSION: RAAS inhibitors can be safely continued in COVID-19 infection. It is not associated with an increase in severity of infection, ICU length of stay, and mortality. HOW TO CITE THIS ARTICLE: Reddy PR, Samavedam S, Aluru N, Rajyalakshmi B. Comparison of Severity of COVID-19 Infection among Patients Using RAAS Inhibitors and Non-RAAS Inhibitors. Indian J Crit Care Med 2021;25(4):366-368.

Prognostic Value of "Cycle Threshold" in Confirmed COVID-19 Patients.

Objective: To study the correlation between the cycle threshold (CT) of reverse transcription-polymerase chain reaction (RT-PCR) test in confirmed COVID-19 patients and the severity of disease. Background: RT-PCR test is a standard method for the diagnosis of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infections. This test is based upon the amplification of the fluorescent signal. The number of cycles that the fluorescent signal undergoes to reach the threshold is called "cycle threshold." It is inversely related to the nucleic acid content of the sample. Patients and methods: This is a single-centered, retrospective observational study. We have included a total of 192 patients. SARS-CoV-2 infection was confirmed by the RT-PCR test. Entire data have been collected from the electronic medical records. The primary outcome was 28-day mortality, whereas the secondary outcomes were intensive care unit (ICU) admission, invasive ventilation, acute kidney injury, renal replacement therapy (RRT), shock, and COVID-19 reporting and data system (CO-RADS) score on high-resolution computed tomography of the chest, total length of stay in the hospital, and the number of ICU days and ventilator days. Results: We have calculated the mean CT value for all groups and calculated the p-value for statistical significance. For the total length of stay in the hospital and the number of ICU days and ventilator days, we applied the Pearson correlation coefficient. The p-value was statistically significant for mortality, ICU admission, and shock groups. The CT values and the length of ICU stay were inversely correlated with the statistically significant p-value. Conclusion: Low CT value is associated with increased ICU admission, high mortality, shock, and increased length of ICU stay. How to cite this article: Rajyalakshmi B, Samavedam S, Reddy PR, Aluru N. Prognostic Value of "Cycle Threshold" in Confirmed COVID-19 Patients. Indian J Crit Care Med 2021;25(3):322-326.

"Physical" Aspect of COVID Nursing.

The use of personal protection equipment (PPE) is associated with physical and physiological derangements. Healthcare workers are at the forefront of the fight against COVID-19 and are continuously exposed to PPE. This editorial discusses a survey carried out by Jose et al. capturing the physical problems associated with PPE use. How to cite this article: Samavedam S. "Physical" Aspect of COVID Nursing. Indian J Crit Care Med 2021;25(2):109-110.

Infection Prevention and Control for ICU during COVID-19 Pandemic: Position Paper of the Indian Society of Critical Care Medicine.

Coronavirus disease-2019 (COVID-19) has very high rates of hospital-related transmission among healthcare workers (HCWs), mandating the need for careful intensive care unit (ICU) designing, optimization of staff resources, implementation of vigorous infection control practices, environmental disinfection, meticulous sample collection, and criteria for staff quarantine. Most of the ICUs are not designed to deal with airborne viral infections and require redesigning for the safety of HCWs and patients. Infection control practices related to the prevention of spread of COVD-19 are unique and are well described. The training of staff on infection control practices reduces the infection rate among HCWs significantly. Adequate staffing not only helps in infection control but also prevents burnout of the staff. In case of infection to HCW, the staff must be assessed systematically, and institute's infection control committee should guide for isolation period as well as return to work based upon standard recommendations. This article focuses on infection control and prevention measures required in ICU during the COVID-19 pandemic. How to cite this article: Sharma J, Nasa P, Reddy KS, Kuragayala SD, Sahi S, Gopal P, et al. Infection Prevention and Control for ICU during COVID-19 Pandemic: Position Paper of the Indian Society of Critical Care Medicine. Indian J Crit Care Med 2020;24(Suppl 5):S280-S289.

Airway Management and Related Procedures in Critically Ill COVID-19 Patients: Position Statement of the Indian Society of Critical Care Medicine.

The coronavirus disease (COVID-19) pandemic has affected nearly all nations globally. The highly contagious nature of the disease puts the healthcare workers at high risk of acquiring infection, especially while handling airway and performing aerosol-generating procedures. The Indian Society of Critical Care Medicine, through this position paper, aims to provide guidance for safe airway management to all healthcare workers dealing with airway in COVID-19 patients. HOW TO CITE THIS ARTICLE: Praveen Kumar G, Kulkarni AP, Govil D, Dixit SB, Chaudhry D, Samavedam S, et al. Airway Management and Related Procedures in Critically Ill COVID-19 Patients: Position Statement of the Indian Society of Critical Care Medicine. Indian J Crit Care Med 2020;24(8):630-642.

Basic Critical Care for Management of COVID-19 Patients: Position Paper of Indian Society of Critical Care Medicine, Part-I.

With more than 23 million infections and more than 814,000 deaths worldwide, the coronavirus disease-2019 (COVID-19) pandemic is still far from over. Several classes of drugs including antivirals, antiretrovirals, anti-inflammatory, immunomodulatory, and antibiotics have been tried with varying levels of success. Still, there is lack of any specific therapy to deal with this infection. Although less than 30% of these patients require intensive care unit admission, morbidity and mortality in this subgroup of patients remain high. Hence, it becomes imperative to have general principles to guide intensivists managing these patients. However, as the literature emerges, these recommendations may change and hence, frequent updates may be required. How to cite this article: Juneja D, Savio RD, Srinivasan S, Pandit RA, Ramasubban S, Reddy PK, et al. Basic Critical Care for Management of COVID-19 Patients: Position Paper of Indian Society of Critical Care Medicine, Part-I. Indian J Crit Care Med 2020;24(Suppl 5):S244-S253.

Immunomodulation and COVID-19: Is There a Winning Combination?

Coronavirus disease-2019 (COVID-19) has been testing the boundaries of science on several fronts. Pharmacotherapy has seen the highs of several drugs being tried as the best option as well as the lows of no drug proven to be effective. In this edition of the Indian Journal of Critical Care Medicine, Mahale et al. retrospectively evaluated a combination of drugs targeted at immunomodulation. HOW TO CITE THIS ARTICLE: Samavedam S. Immunomodulation and COVID-19: Is There a Winning Combination? Indian J Crit Care Med 2020;24(11):1015-1017.

Critical Care for COVID-19 Affected Patients: Updated Position Statement of the Indian Society of Critical Care Medicine.

The management of coronavirus disease-2019 (COVID-19) is witnessing a change as we learn more about the pathophysiology and the severity of the disease. Several randomized controlled trials (RCTs) and meta-analysis have been published over the last few months. Several interventions and therapies which showed promise in the initial days of the pandemic have subsequently failed to show benefit in well-designed trials. Understanding of the methods of oxygen delivery and ventilation have also evolved over the past few months. The Indian Society of Critical Care Medicine (ISCCM) has reviewed the evidence that has emerged since the publication of its position statement in May and has put together an addendum of updated evidence. How to cite this article: Mehta Y, Chaudhry D, Abraham OC, Chacko J, Divatia J, Jagiasi B, et al. Critical Care for COVID-19 Affected Patients: Position Statement of the Indian Society of Critical Care Medicine. Indian J Crit Care Med 2020;24(Suppl 5):S225-S230.

Procedures in COVID-19 Patients: Part-II.

Critical care in the era of novel coronavirus disease-2019 (COVID-19) infection has multiple challenges including management of the patient, underlying comorbidities, and the complications. With no end in sight to the pandemic, intensive care unit (ICU) practitioners and hospital administrators have to join hands to prepare for the long battle ahead. Critically ill COVID-19 patients need imaging or image-guided interventions in one form or the other including X-rays, ultrasonography (USG), echocardiography (ECHO), and CT scan. These patients often require renal replacement therapy (RRT) for either the preexisting chronic renal insufficiency or acutely developing kidney injury. Another important component of care is transfer of the patient to and fro from the ICU or to higher care centers. Most of the ICUs are equipped with modern facilities but with increasing number of patients a large number of makeshift arrangements are being made for managing these patients. This position paper outlines important tips to formulate protocols and procedures for critically ill patients, who are managed in the ICU. How to cite this article: Pande RK, Bhalla A, Myatra SN, Yaddanpuddi LN, Gupta S, Sahoo TK, et al. Procedures in COVID-19 Patients: Part-II. Indian J Crit Care Med 2020;24(Suppl 5):S272-S279.

Procedures in COVID-19 Patients: Part-I.

The number of cases with novel coronavirus disease-2019 (COVID-19) infection is increasing every day in the world, and India contributes a substantial proportion of this burden. Critical care specialists have accepted the challenges associated with the COVID-19 pandemic and are frontline warriors in this war. They have worked hard in streamlining workflow isolation of positive patients, clinical management of critically ill patients, and infection prevention practices. With no end in sight for this pandemic, intensive care unit (ICU) practitioners, hospital administrators, and policy makers have to join hands to prepare for the surge in critical care bed capacity. In this position article, we offer several suggestions on important interventions to the ICU practitioners for better management of critically ill patients. This position article highlights key interventions for COVID-19 treatment and covers several important issues such as endotracheal intubation and tracheostomy (surgical vs PCT), nebulization, bronchoscopy, and invasive procedures such as central venous catheters, arterial lines, and HD catheters. How to cite this article: Pande RK, Bhalla A, SN Myatra, Yaddanpuddi LN, Gupta S, Sahoo TK, et al. Procedures in COVID-19 Patients: Part-I. Indian J Crit Care Med 2020;24(Suppl 5):S263-S271.

Basic Critical Care for Management of COVID-19 Patients: Position Paper of the Indian Society of Critical Care Medicine, Part II.

In a resource-limited country like India, rationing of scarce critical care resources might be required to ensure appropriate delivery of care to the critically ill patients suffering from COVID-19 infection. Most of these patients require critical care support because of respiratory failure or presence of multiorgan dysfunction syndrome. As there is no pharmacological therapy available, respiratory support in the form of supplemental oxygen, noninvasive ventilation, and invasive mechanical ventilation remains mainstay of care in intensive care units. As there is still dearth of direct evidence, most of the data are extrapolated from the experience gained from the management of general critical care patients. How to cite this article: Juneja D, Savio RD, Srinivasan S, Pandit RA, Ramasubban S, Reddy PK, et al. Basic Critical Care for Management of COVID-19 Patients: Position Paper of the Indian Society of Critical Care Medicine, Part II. Indian J Crit Care Med 2020;24(Suppl 5):S254-S262.

Current Approaches to COVID-19: Therapy and Prevention.

The coronavirus disease-2019 (COVID-19) pandemic has affected millions of people worldwide. As our understanding of the disease is evolving, our approach to the patient management is also changing swiftly. Available new evidence is helping us take radical decisions in COVID-19 management. We searched for inclusion of the published literature on treatment of COVID-19 from around the globe. All relevant evidences available till the time of submission of this article were briefly discussed. Once advised as blanket therapy for all patients, recent reports of hydroxychloroquine with or without azithromycin indicated no potential benefit and use of such combination may increase the risk of arrhythmias. Clinical evidence with newer antivirals such as remdesivir and favipiravir is promising that can hasten the patient recovery and reduce the mortality. With steroids, evidence is much clear in that it should be used in low dose and for short period not extending beyond 7 days in moderate to severe hospitalized patients. Low-molecular-weight heparin should be initiated in all hospitalized COVID-19 patients and dose should be based on the coagulation profile and risk of thromboembolism. Immunomodulatory drugs such tocilizumab may be considered for severe and critically ill patients to improve the outcomes. Though ulinastatin can be a potential alternative immunomodulator, there is lack of clinical evidence on its usage in COVID-19. Convalescent plasma therapy can be potentially lifesaving in critically ill patients. However, there is need to generate further evidence with various such therapies. Though availability of a potent vaccine is awaited, current treatment of COVID-19 is based on available therapies, which is guided by the evidence. In this review, we discuss the potential treatments available around the globe with current evidence on each of such treatments. How to cite this article: Dixit SB, Zirpe KG, Kulkarni AP, Chaudhry D, Govil D, Mehta Y, et al. Current Approaches to COVID-19: Therapy and Prevention. Indian J Crit Care Med 2020;24(9):838-846.

Critical Care for COVID-19 Affected Patients: Position Statement of the Indian Society of Critical Care Medicine.

The global pandemic involving severe acute respiratory syndrome-coronavirus-2 (SARS-COV-2) has stretched the limits of science. Ever since it emerged from the Wuhan province in China, it has spread across the world and has been fatal to about 4% of the victims. This position statement of the Indian Society of Critical Care Medicine represents the collective opinion of the experts chosen by the society. HOW TO CITE THIS ARTICLE: Mehta Y, Chaudhry D, Abraham OC, Chacko J, Divatia J, Jagiasi B, et al. Critical Care for COVID-19 Affected Patients: Position Statement of the Indian Society of Critical Care Medicine. Indian J Crit Care Med 2020;24(4):222-241.