i s a n e w s l e tte r
TRANSCRIPT
Issue 3, September 2020
Official Monthly Newsletter of Indian Society of AnaesthesiologistsOfficial Monthly Newsletter of Indian Society of Anaesthesiologists
(Delhi Branch)(Delhi Branch)
ISA Newsletter
ISA Delhi President’s SecretariatDepartment of Anaesthesia and Intensive Care
Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi -110029, India. Email: [email protected]
Website: https://www.isawebdelhi.in
ISA Delhi SecretariatOperation theater complex, 5th Floor, Fortis Hospital Shalimar Bagh
New Delhi 110088Phone: 9810101445 | Email: [email protected]
VICE PRESIDENT
Dr G Usha
(8447795934)
SECRETARY
Dr Umesh K Deshmukh
(9810101445)
TREASURER
Dr Anuvijyant Goel
(9958895659)EDITOR
Dr Parul Mullick
(9810606262)
PRESIDENT
Dr Nikki Sabharwal
(9810774396)
TEAM ISA DELHI BRANCH2020-2021
Dr Rajiv Gupta
(9811084288)
SOUTH ZONE
Dr Ranju Gandhi
(9818941341)
NORTH ZONE
Dr Aashish Dang
(9810710458)
EAST ZONE
Dr Arvind Arya
(9871013556)
WEST ZONE
Dr Arun K Mehra
(9818134998)
GENERAL COUNCIL MEMBERS
ISA DELHI BRANCH
CENTRAL ZONE
Dr Amit Kohli
(9818073402)
ISA NATIONAL
ISA NATIONAL OFFICE BEARERS
PRESIDENT- DR MURALIDHAR JOSHI
VICE PRESIDENT- DR. SURESH KUMAR BHARGAVA
PRESIDENT ELECT- DR VENKATAGIRI K M
HONORARY SECRETARY- DR NAVEEN MALHOTRA
TREASURER- DR VIRENDRA SHARMA
EDITOR-IN-CHIEF- DR. LALIT MEHDIRATTA
PAST PRESIDENT- DR S BALA BHASKAR
PAST EDITOR-IN-CHIEF- DR. J. V. DIVATIA
GC MEMBER- DR MANOJ KUMAR (BIHAR)
GC MEMBER- DR SUKHMINDER JIT SINGH BAJWA(PUNJAB)
GC MEMBER- DR J BALAVENKATA SUBRAMANIAN (Coimbatore, TAMIL NADU)
GC MEMBER- DR S C GANESH PRABHU (Madurai, TAMIL NADU)
GC MEMBER- DR. RAJIV GUPTA (DELHI)
GC MEMBER- DR. BHARAT BHUSHAN BHARDWAJ (UTTAR PRADESH)
GC MEMBER- DR. SURAJIT GIRI (ASSAM)
GC MEMBER- DR. ASHOK VASANTA RAO DESHPANDE (MAHARASHTRA)
GC MEMBER- DR. CHINTALA KISHAN (TELANGANA)
EX OFFICIO MEMBERS
SECRETARY FAMILY BENEVOLENT FUND- DR. SUGU VARGHESE
ORG SECRETARY 68TH ISACON 2020- DR. BHADRESH ARVIND SHAH
ISA DELHI BRANCH EX OFFICE BEARERS
PRESIDENT- DR ANIL JAIN
VICE PRESIDENT- DR KK NARANI
SECRETARY- DR RAJIV GUPTA/ GIRISH CALLY
TREASURER- DR GIRISH CALLY
EDITOR- DR DEEPANJALI PANT
LIST OF ISA DELHI BRANCH OFFICE BEARERS, GOVERNING COUNCIL
MEMBERS, EXECUTIVE COMMITTEE MEMBERS, ADVISORY COMMITTEE
AND HEADS OF DEPARTMENT OF ANAESTHESIOLOGY
OFFICE BEARERS
PRESIDENT DR NIKKI SABHARWAL VMMC & SJH [email protected] 9810774396
VICE PRESIDENT DR G USHA VMMC & SJH [email protected] 8447795934
SECRETARY DR UMESH DESHMUKH FORTIS SHALIMAR
BAGH [email protected] 9810101445
TREASURER DR ANUVIJAYANT GOEL FORTIS SHALIMAR
BAGH [email protected] 9958895659
EDITOR DR PARUL MULLICK VMMC & SJH [email protected] 9810606262
NATIONAL GOVERNING COUNCIL MEMBER
GC NATIONAL DR RAJIV GUPTA MAHARAJA AGRASEN
HOSPITAL [email protected] 9811084288
DELHI STATE GOVERNING COUNCIL MEMBERS
NORTH ZONE DR AASHISH DANG HINDU RAO [email protected] 9810710458
SOUTH ZONE DR RANJU GANDHI VMMC & SJH [email protected] 9818941341
WEST ZONE DR ARUN K MEHRA BHAGWATI HOSPITAL [email protected] 9818134998
EAST ZONE DR ARVIND ARYA IHBAS [email protected] 9871013556
CENTRAL ZONE DR AMIT KOHLI MAMC & LNJP [email protected] 9818073402
EXECUTIVE COMMITTEE MEMBERS
S.NO HOSPITAL NAME OF ECM CONTACT NO EMAIL ID
1 AAKASH HOSPITAL
DWARKA DR PUNEET SHARMA 9716906151 [email protected]
2 ABVIMS AND DR RMLH DR UMA HARIHARAN 9811271093 [email protected]
3 ACHARYA SHREE BHIKSHU DR RAMINDER KAUR 9717691899 [email protected]
4 AIIMS, NEW DELHI DR RAKESH KUMAR 7838043581 [email protected]
5 AIIMS DR BRAIRCH DR RAKESH GARG 9810394950 [email protected]
6 APOLLO HOSPITAL DR ANIL KUMAR
SHARMA 9810417880 [email protected]
7 ARMY HOSPITAL (R&R) DR ANURAG GARG 6284858040 [email protected]
8 BALAJI ACTION DR NEETA TANEJA 9811032535 [email protected]
9 BASE HOSPITAL DELHI
CANTT Lt Col SIDDHARTH CHAKI 9547257994 [email protected]
10 BATRA HOSPITAL DR VIVEK CHOPRA 9719962626 [email protected]
11 BHAGWAN MAHAVIR
HOSPITAL DR VIBHA PARASHAR 9650296852 [email protected]
12 BJRMH DR SUMITA
KULSHRESTHA 9868875244 [email protected]
13 BLK SUPERSPECIALITY
HOSPTAL DR MANU VARSHNEY 9811871481 [email protected]
14 CHACHA NEHRU BAL
CHIKITSALAYA DR GEETA KAMAL 8595919329 [email protected]
15
CHARAK PALIKA & PALIKA
MATERNITY HOSPITALS
(NDMC)
DR SANDEEP
BHATNAGAR 9891416684
m
16
Dr BABA SAHEB
AMBEDKAR MEDICAL
COLLEGE AND HOSPITAL
DR VANDANA CHUGH 7290095540 [email protected]
17 DDU HOSPITAL DR RITU AGGARWAL 9718990123 [email protected]
18 DHARAMSHILA
NARAYANA SSH
DR SATISH KUMAR
SINGH 9811712818 [email protected]
19 ESI FARIDABAD DR TARANG JAIN 9811827264 [email protected]
20 ESIC HOSPITAL OKHLA DR TARANG JAIN 9811827264 [email protected]
21 FORTIS LA FEMME DR GURPREET SINGH
POPLI 9871557556 [email protected]
22 FORTIS VK DR AMRISH KUMAR
TILAK 9910234015 [email protected]
23 G B PANT INSTITUTE OF
PGMER DR ANKIT SHARMA 9718592464 [email protected]
24 GURU GOVIND SINGH
HOSPITAL DR ARCHANA SINGLA 9718518038 [email protected]
25
HAMDARD INSTITUTE OF
MEDICAL SCIENCES AND
RESEARCH
DR PRATIBHA PANJIAR 9311657822 [email protected]
26 HINDU RAO NDMC MED
COLLEGE DR SUNIL KUMAR 9910279828 [email protected]
27 IHBAS, DELHI DR ARVIND ARYA 9871013556 [email protected]
28 ILBS DR LALITA GOURI MITRA 9971792343 [email protected]
29 JAIPUR GOLDEN DR ABHA AGGARWAL 9811091792 [email protected]
30 LHMC AND ASSOC.
HOSPITALS DR ANSHU GUPTA 9871158433 [email protected]
31 LAL BAHDUR SHASTRI
HOSPITAL DR PREM KUMAR SINGH 9582500337 [email protected]
32 MAMC AND LNJP DR MONA ARYA 9968604412 [email protected]
33 MANIPAL HOSPITAL
DWARKA DR LALIT SEHGAL 9910256127 [email protected]
34 MATA CHANAN DEVI
HOSPITAL DR KAPIL LAMBA 9811153757 [email protected]
35 MAX LAP AND BARIATRIC DR APARNA SINHA 9810035503 [email protected]
36 MAX SSH, SAKET DR RAHUL CHOPRA 7872835168 [email protected]
37 MAX SMART, SAKET DR MUKUL KAPOOR 9971888773 [email protected]
38 MAX SSH, PATPARGANJ DR RAVI BHASKAR 9582329720 [email protected]
39 MAX SSH, VAISHALI DR VICKY JAISWAL 9582265897 [email protected]
40 MAX SSH, SHALIMAR
BAGH DR ROHIT JASWAL 9811837096 [email protected]
41 MEDANTA, THE MEDICITY DR HIMANSHU SURI 9891789001 [email protected]
42 NORTHERN RAILWAY
CENTRAL HOSPITAL DR RAKESH KUMAR 9717630521 [email protected]
43 PGIMSR-ESI
BASAIDARAPUR DR TARANG JAIN 9811827264 [email protected]
44 RAJIV GANDHI CANCER
INSTITUTE, ROHINI DR NITESH GOEL 9717773292 [email protected]
45 SANJAY GANDHI
MEMORIAL HOSPITAL DR NYMPHIA KAUL 8447734430 [email protected]
46 SANT PARMANAND
HOSPITAL DR B N SETH 9810392574 [email protected]
47 SARDAR VALLABH BHAI
PATEL HOSPITAL DR SURABHI MOHANTY 9810233218 [email protected]
48 SAROJ HOSPITAL DR VIVEK GUPTA 9810020953 [email protected]
49 SHANTI MUKAND
HOSPITAL DR ROSHAN GARG 9810162887 [email protected]
50 SIR GANGA RAM
HOSPITAL DR ARCHNA KOUL 9958892622 [email protected]
51 SWAMI DAYANAND
HOSPITAL DR RANAJIT CHATTERJEE 9891257572 [email protected]
52 UCMS AND GTBH DR ASHA TYAGI 9818606404 [email protected]
53 VENKATESHWAR
HOSPITAL DR KALPANA GOYAL 9891682605 [email protected]
ADVISORY COMMITTEE
DR MANORAMA MITTAL PAST PRES ISA-NATIONAL 9810168297
DR VP KUMRA PAST VICE PRES ISA- NATIONAL 981113221
DR BALJEET SINGH PAST VICE PRES ISA- NATIONAL 9810131295
DR ASHOK SAXENA PAST PRES ISA- DELHI 9868399703
DR ANIL JAIN IMM. PAST PRES ISA DELHI 9811005826
DR GIRISH CALLY IMM. PAST SECRETARY & TREASURER ISA DELHI 9810031679
HEADS OF THE DEPARTMENT OF ANAESTHESIOLOGY
S.NO HOSPITAL NAME OF HOD MOBILE NO E MAIL ID
1 AAKASH HOSPITAL DWARKA DR. PUNEET SHARMA 9716906151 [email protected]
2 ABVIMS AND DR RMLH DR MOHANDEEP KAUR 9868952253 [email protected]
3 ACHARYA SHREE BHIKSHU
GH DR RITU ARORA 9650296851 [email protected]
4 AIIMS, NEW DELHI DR. RAJESHWARI SUBRAMANIAM
9810079229 [email protected]
5 AIIMS DR BRAIRCH DR SUSHMA BHATNAGAR 9811326453 [email protected]
6 AIIMS CARDIAC ANESTHESIA PROF SANDEEP CHAUHAN 9873729366 [email protected]
7 AIIMS NEUROANESTHESIA DR ARVIND CHATURVEDI 9871045824 [email protected]
8 APOLLO HOSPITAL DR SANJEEV ANEJA 9810511510 [email protected]
9 ARMY HOSPITAL (R&R) DR VIKAS KR SHANKHYAN 9418865691 [email protected]
10 BALAJI ACTION DR. NEETA TANEJA 9811032535 [email protected]
11 BASE HOSPITAL DELHI
CANTT DR D K SREEVASTAVA 9560753335 [email protected]
12 BATRA HOSPITAL DR PAVAN GURHA 9811088632 [email protected]
13 BHAGWAN MAHAVIR
HOSPITAL DR VIBHA PARASHAR 9650296852 [email protected]
14 BJRMH DR SUMITA KULSHRESTHA 9868875244 [email protected]
15 BLK SUPERSPECIALITY
HOSPTAL DR U K VALECHA 9810001903 [email protected]
16 CHACHA NEHRU BAL
CHIKITSALAYA DR GEETA KAMAL 8595919329 [email protected]
17 CHARAK PALIKA & PALIKA
MATERNITY HOSPITALS (NDMC)
DR. SANDEEP BHATNAGAR 9891416684 [email protected]
18 Dr BABA SAHEB AMBEDKAR
MEDICAL COLLEGE AND HOSPITAL
DR NIDHI P SEHGAL 7290095549 [email protected]
19 DDU HOSPITAL DR. VATSALA AGGARWAL 9718990112 [email protected]
20 DHARAMSHILA NARAYANA SUPERSPECIALITY HOSPITAL
DR. MANISH TANDON 9871437478 [email protected]
21 ESI FARIDABAD DR. SUVIDHA SOOD 9999302616 [email protected]
22 ESIC HOSPITAL OKHLA DR ARCHANA LAKRA 9871107058 [email protected]
23 FORTIS LA FEMME DR UMESH DESHMUKH 9810101445 [email protected]
24 FORTIS SB DR. UMESH DESHMUKH 9810101445 [email protected]
25 FORTIS VK DR AMRISH KUMAR TILAK 9910234015 [email protected]
26 GB PANT INSTITUTE OF
PGMER DR PRAGATI GANJOO 9718599407 [email protected]
27 GIRDHARILAL HOSPITAL DR RASHMI DUGGAL 9810138257 [email protected]
28 GURU GOVIND SINGH
HOSPITAL DR RAJESH BILALA 9891551152 [email protected]
29 HAMDARD INSTITUTE OF MEDICAL SCIENCES AND
RESEARCH
PROF KHARAT MOHD BATT
9622457554 [email protected]
30 HINDU RAO NDMC MED
COLLEGE DR ALKA CHANDRA 9560044454 [email protected]
31 IHBAS DR ARVIND ARYA 9871013556 9867396825
32 ILBS PROF M K ARORA 9811365293 [email protected]
33 JAIPUR GOLDEN DR. SWARAN BHALLA 9811689549 [email protected]
34 LHMC AND ASSOCIATED
HOSPITALS DR MAITREE PANDEY 9810570515 [email protected]
35 LAL BAHDUR SHASTRI
HOSPITAL DR. SANJEEV KUMAR 9582500336 [email protected]
36 MAHARAJA AGRASEN
HOSPITAL DR. RAJIV GUPTA 9811084288 [email protected]
37 MAMC AND LNJP DR KIRTI NATH SAXENA 9968604215 [email protected]
38 MANIPAL HOSPITAL
DWARKA DR. LALIT SEHGAL 9910256127 [email protected]
39 MATA CHANAN DEVI
HOSPITAL DR PRAMOD MANGWANA 9810956411 [email protected]
40 MAX LAP AND BARIATRIC DR APARNA SINHA 9810035503 [email protected]
41 MAX SSH, SAKET DR KAMAL KUMAR
FOTEDAR 9873003832 [email protected]
42 MAX SMART, SAKET DR MUKUL KAPOOR 9971888773 [email protected]
43 MAX SUPER SPECIALITY HOSPITAL PATPARGANJ
DR ARUN PURI 9811074379 [email protected]
44 MAX SUPER SPECIALITY
HOSPITAL VAISHALI DR ARUN PURI 9811074379 [email protected]
45 MAX SUPERSPECIALITY
HOSPITAL, SHALIMAR BAGH DR ROHIT JASWAL 9811837096 [email protected]
46 MEDANTA, THE MEDICITY DR SURINDER.M. SHARMA 9811082995 [email protected]
47 NORTHERN RAILWAY CENTRAL HOSPITAL
DR ANIL KUMAR SHARMA 9717630508 [email protected]
48 PGIMSR-ESI BASAIDARAPUR DR. MADHU GUPTA 9873581030 [email protected]
49 RAJIV GANDHI CANCER
INSTITUTE, ROHINI DR RAJIV CHAWLA 9718599404 [email protected]
50 SANJAY GANDHI MEMORIAL
HOSPITAL DR NYMPHIA KAUL 8447734430 [email protected]
51 SANT PARMANAND
HOSPITAL DR B N SETH 9810392574 [email protected]
52 SARDAR VALLABH BHAI
PATEL HOSPITAL DR NIDHI MATHUR 9873143460 [email protected]
53 SAROJ HOSPITAL DR. VIVEK GUPTA 9810020953 [email protected]
54 SHANTI MUKAND HOSPITAL DR RAJESH DHALL 9810110405 [email protected]
55 SIR GANGA RAM HOSPITAL PROF JAYASHREE SOOD 9811294608 [email protected]
56 SWAMI DAYANAND
HOSPITAL DR RAKESH SINGHAL 9811111388 [email protected]
57 UCMS AND GTBH PROF AK SAXENA 9810431367 [email protected]
58 VENKATESHWAR HOSPITAL DR KALPANA GOYAL 9891682605 [email protected]
59 VMMC AND SJH DR. G. USHA 8447795934 [email protected]
EDITORIAL TEAM
EDITOR DR PARUL MULLICK VMMC & SJH [email protected] 9810606262
EBM DR MAHESH CHANDRA VMMC & SJH [email protected] 7291061045
EBM DR ARIN CHOUDHURY VMMC & SJH [email protected] 7838756566
EBM DR IRA BALAKRISHNAN M VMMC & SJH [email protected] 7838867927
EBM DR NIKHILESH CHANDRA VMMC & SJH [email protected] 8989792136
EBM DR AMANDEEP JASWAL VMMC & SJH [email protected] 9582142904
President’s Message
Respected members of ISA Delhi
Greetings to one and all!
With the second surge of the covid -19 cases overwhelming our medical facilities in this month
of September 2020, all hopes of bidding goodbye to this ongoing pandemic came crashing
down. Still, we must carry on with our crusade against covid! Many more doctors, nurses and
paramedics have been afflicted by this deadly virus and though several covid warriors could
succeed in their battle against covid, many young bright lives succumbed to it. I pay my most
respectful homage to each one and pray to the almighty for taking them in his immortal and
blissful fold of divine light.
The month of September belonged to Lady Hardinge Medical College; whose motto is “Per
Ardua Ad Astra” which is Latin for “Through Adversity to Stars”! The team of LHMC ably led by
Dr Maitree Pandey lived up to this motto by putting together two intellectually stimulating
academic programmes for ISA Delhi, within a span of one week. On 11th September 2020, the
department of Anaesthesia and Critical care, Lady Hardinge Medical College & Smt. Sucheta
Kripalani Hospital, organized the second clinical meeting of ISA Delhi branch. It was well
attended and generated a fair amount of fruitful discussion. Continuing with our series of
webinars, LHMC held a CME on” Hypertensive disorders in Pregnancy” on 18th September
2020.This was an excellent and very exhaustive update of the topic, showcasing the high-
quality work being done in their institute for this group of patients. Dr Maitree and her very
accomplished faculty have set a very high benchmark for the subsequent CMEs to be held by
other institutes and I complement them for the same. It is a matter of pride for us all, especially
the women office bearers of ISA Delhi branch, all of whom are Hardonions! We salute our Alma
Mater.
Team ISA Delhi branch 2019-2020 led by the very diligent Dr Anil Jain, along with the unstinted
support of the present office bearers, is making tremendous efforts to ensure that the ISACON
2020 virtual conference, to be held from 2nd to 4th October is an academic feast and that it gets
conducted smoothly. This is a first of its kind annual conference of ISA Delhi branch to be held
on a virtual platform. We solicit your cooperation in making this, your own annual conference,
a grand success.
Soon after our annual conference, we shall be celebrating the World Anaesthesia Day on 16th
October. I earnestly request you all to please participate actively in this event, also to be
celebrated on the e platform. I suggest that all our members should in addition to the traditional
cake cutting ceremony, plan to have a collective prayer meeting in each institution, where we
pray for the eradication of the corona virus and this pandemic, from the face of this world. I do
believe that there is a lot of power in our prayers and we must strive to seek the grace of the
almighty for ridding our planet of the covid curse and to restore peace and divinity.
Our editorial team, ably led by our very sincere and enthusiastic editor Dr Parul Mullick, has
brought out the third e news bulletin of ISA Delhi branch which is full of all the regular features.
Dr Arun Mehra, our expert on ethics has elaborated on the ‘Unprecedented Challenges’ in
Covid times. In addition we bring to you the guidelines of the Indian Resuscitation Council of
ISA pertaining to the modifications in suspected and confirmed cases of covid, to commemorate
the “Start a Heart Day”.
Thank you
Stay safe
Long live ISA National & ISA Delhi!
Jai Hind!
Nikki Sabharwal
President ISA Delhi (2020-2021)
Vice President’s Message
Dear Members
The entire academic activity of the ISA Delhi branch for this month was conducted by Lady
Hardinge Medical College and Associated Hospitals under the able leadership of Dr Maitree
Pandey. I extend my heartiest congratulations to Dr Maitree Pandey and her team for
conducting such a wonderful academic program that has benefitted many of us. I request you
all to please attend these programs in greater numbers for a greater benefit.
The month of October is very exciting for all of us as this month we celebrate the World
Anaesthesia Day. I urge you all to please come up with ideas and showcase your talent. Let us
get together and celebrate on a virtual platform this time. Let us make memories.
So please gear up and stay Safe!
Long Live ISA!
Dr G Usha Vice President, ISA Delhi Branch
Secretary’s Message
Dear Friends,
The onset of autumn (Sharad Ritu) is the best time to venturing outdoors in Delhi. The clear
skies, Chirpy birds and flowers everywhere are so inviting after the cloudy humid days of the
Varsha Ritu.
It’s a great time to meet and greet and we are all going to miss the physical conference but our
ISACON 2020- Delhi team has ensured that we will have an experience comparable to the
actual conference. The SGRH team has done a commendable job under the leadership of our
ex-President Dr. Anil Jain and with the support of our current President Dr.Nikki Sabharwal. I
am looking forward to the Virtual conference which has been organized in place of the ISACON
2020 Delhi which was scheduled April 2020. I urge you all to attend and experience the wonder
of technology.
Looking forward to see you all there.
Have a great time.
Dr Umesh Deshmukh
Hong, Sec. ISA Delhi Branch
From the Editor’s Desk
Dear Members,
I feel blessed to have wonderful teachers who have always guided me through all my
endeavours. I take this opportunity to wish them a very Happy teachers’ day!
The current pandemic has posed endless challenges to each one of us. The healthcare
providers are exposed to a considerable risk of acquiring Covid-19 infection while providing
cardiopulmonary resuscitation. The resuscitation councils across the world have thus created
guidelines to make the intervention safe for both victim and the caregiver. In this issue, Smita
Das, Rakesh Garg, et al. have compared the resuscitation guidelines created by various
professional bodies in their manuscript “Cardiopulmonary resuscitation in confirmed or
suspected COVID-19 victim: A global view”. I am sure our readers will find this extremely useful.
Dr Arun K Mehra, has contributed an article, “The unprecedented challenges” to the series -
“Ethics in Covid Times” in which he has enumerated the various challenges faced by us. Dr
Rohan Khandelwal, one of our frontline doctors while treating Covid positive patients had got
infected with corona virus, has penned down his experience. The amazing art gallery, poetry
and crossword will surely cheer you up.
We have also added a calendar of ISA activities from the month of September onwards. This
is to facilitate our members to plan their activities in advance so that they can attend these
programs and enrich their knowledge.
Looking forward to your wholehearted contribution for the newsletter. These could be in the
form of interesting photographs, drawings, cartoons, jokes, poetry, prayers, your experiences
etc. You may send these to us by email at [email protected]
I request all the anaesthesiologists who are not yet ISA members to become life members.
For membership form, please log in to website:
https://www.isaweb.in/webpages/MembersRegistration.aspx
I pray that we all stay safe and in good health.
Please follow the 3 W’s – Watch distance, Wear mask and Wash hands
Enjoy Reading!
LONG LIVE ISA!
Dr Parul Mullick
Editor, ISA Delhi Branch
Calendar of ISA Activities from September 2020
September 2020
1. 11th Sept Friday 4-6 pm Clinical mtg, LHMC
2. 18th Sept. Friday 4.30 - 6.30 pm, CME, LHMC, Hypertensive disorders in pregnancy'
October 2020
1. 2nd to 4th Oct. ISACON 2020, SGRH
2. 16th Oct. Friday 5 - 7.30 pm World Anaesthesia Day celebrations by all ISA Delhi members
3. 30th Oct. Friday, 5-7 pm clinical mtg by ESIC group of Hospitals
November 2020
1. 7th Nov. Saturday, 5-7 pm clinical mtg by Max Smart Hospital, Saket
2. 20th Nov. Friday 5-7 pm, clinical mtg by MAMC
3. 27th Nov. Friday, 5-7 pm, clinical mtg, Dr RMLH
December 2020
1.4th Dec. Friday 5-7 pm, clinical mtg by UCMS
2. 11th Dec Friday, 5-7 pm, webinar on NIV by m/s Teamed
3. 18th Dec.Friday,5-7 pm, CME, Hindu Rao hospital
4. 28th Dec Monday, 5-7 pm clinical mtg Apollo hospital
January 2021
1. 8th Jan Friday, 5-7 pm, clinical mtg, Army hospital
2. 15th Jan. Friday, 5-7 pm, CME Bariatric, MAX Saket
3. 22nd Jan. Friday, 5-7 pm clinical mtg DDU
February 2021
1. 5th Feb Friday 5-7pm, clinical mtg, Hindu Rao hospital
2. 19th Feb. Friday clinical mtg by Dwarka group ie Akash, Venkateshwar and Balaji Action
hospitals
March 2021
1. 5th March, Friday, 5-7 pm, clinical mtg AIIMS
2. 12th March Friday 5 -7 pm clinical mtg by Ambedkar and Sanjay Gandhi hospital.
Clinical Meet (11/09/2020)
The second clinical meet of ISA Delhi chapter was hosted by Lady Hardinge Medical College
and associated hospitals on the 11th September 2020 from 4 pm onwards.
I take this opportunity to congratulate Dr Maitree Pandey and team for conducting such a well-
organized and wonderful meeting. All the topics presented were very interesting and novel.
The presentations were followed by an interesting quiz program. The academic feast was
attended by 173 delegates. The meeting ended with a vote of thanks proposed by Dr Maitree
Pandey.
The abstracts of topics presented are as follows:
• Anesthetic management in COVID-19 parturients scheduled for caesarean delivery –
A comparison with non covid parturients
Dr Ranju Singh, Dr Maitree Pandey, Dr Pooja Singh, Dr Mrinal Kamal,
Dr Eashwar Neelakandan*
COVID 19 pandemic is caused by SARS CoV-2. There is limited information regarding the
anaesthetic complications, maternal and neonatal outcomes. We conducted an observational
study from April to August 2020 after institutional ethical committee approval with the objective
to study the outcome in terms of length of stay, maternal and neonatal outcome. Study included
38 COVID positive parturients and 38 non COVID parturients. 57% of patients were
symptomatic in the COVID group with fever as most common symptom. COVID parturients had
significantly raised total leucocyte counts (11421.0±4003.5) with predominance of
lymphocytosis. Platelet count was significantly lower (p<0.05) in the COVID group but clinically
not significant (1.39±0.47). 35 patients in COVID group and 36 patients in non COVID group
received spinal anaesthesia and rest received general anaesthesia. No significant
hemodynamic disturbances were noted. The stay was significantly longer (5.6±3.8 days) in the
COVID group (p= 0.004). Among the COVID patients 3 needed oxygen post operatively and 1
needed ICU admission later expired. One neonate had NICU admission and one neonate had
positive RT PCR in the COVID group. So, we conclude that the length of stay was longer in the
COVID parturients and platelet count is a must before anaesthesia.
• Epidermolysis Bullosa - Tread carefully!!
Dr Neha Verma, Dr Raksha Kundal, Dr Ranju Signh, Dr Maitree Pandey
Epidermolysis bullosa is an inherited disease that leads to defective protein formation which
would normally help adhesion between epidermis and basement membrane and therefore even
after minor trauma bullae formation and ulcers are seen.
A 4-month-old male child with known case of epidermolysis bullosa with diaphragmatic
eventration was posted for thoracoscopic plication. He had generalized blisters and ulcers all
over the body. General anaesthesia with endotracheal intubation with gentle handling of patient
was done.
Proper airway assessment and management is to be done. Intravenous access and its fixation
can be challenging in such patients. Shearing forces are more harmful than compressive forces
therefore avoid any friction to the skin. Maintenance of skin integrity is a major concern in
anaesthetic management.
• A comparative study to assess the postoperative analgesic efficacy of proximal
versus distal approaches of ultrasound guided continuous adductor canal block
following total knee arthroplasty – a randomized controlled trial
Dr Vishal Arora, Dr Nitin Hayaran, Dr S.K. Sinha
Background: There is an ongoing debate regarding the ideal site for CACB following TKA. Our
study compared the analgesic efficacy of proximal vs distal sites of injection using descending
genicular artery (DGA) as a landmark.
Methods: Sixty adult patients planned for TKA were randomized to Group I (proximal to DGA)
and Group II (distal to DGA) as per injection sites for ACB. 0.2% ropivacaine was administered
as a 30 ml bolus followed by 8ml/hr infusion for 48 hours. VAS scores were recorded at 0, 2, 6,
12 & 24 hours along with site of pain, rescue opioid requirement & any complications.
Results: Mean VAS scores at 24 hours were similar for both groups (I: 2.10 ± 0.71 vs II: 2.27 ±
0.64, P=0.344). However, for the first 12 hours, Group I had significantly lower pain scores
(P=0.023, 0.001, 0.018, 0.009). Most subjects described diffuse pain except some group I
subjects localizing it posteriorly. Group I required significantly lower rescue analgesics. (IV
tramadol 31.40 ± 66.60 mg vs 79.47 ± 103.90 mg, P= 0.049).
Conclusions: CACB placed proximal or distal to descending genicular artery are effective in
managing the postoperative pain after TKA with proximal approach requiring lower rescue
opioids.
• Unusual complications of pregnancy -Food for thought Dr Sanjana Mohan, Dr Anil Kumar, Dr Pramod kohli
Unusual complications associated with pregnancy always pose a diagnostic dilemma. We had
a patient, who developed ascites and pancreatitis, rare complications associated with
preeclampsia, in the postpartum period. The pancreatitis associated with pregnancy can be a
direct complication or due to diuretics used in pulmonary oedema which can occur in
preeclampsia. Pancreatitis due to either reason responds well to conservative management.
The preeclampsia itself poses a high risk in pregnancy and the risk multiplied when it is
associated with other complications.
• Unusual complications associated with pregnancy: food for thought!!!
Dr. Mareena Thomas, Dr. Nishant Kumar, Dr. Maitree Pandey
Pregnant patients may present with the complications such as elevated blood pressure,
haemolytic anaemia, thrombocytopaenia, elevated liver enzymes, deranged renal function and
neurological symptoms either antepartum, intrapartum or postpartum. We report two patients,
who presented with above complications after the delivery of the foetus mimicking eclampsia
and HELLP syndrome. In such a scenario, the differential diagnosis of Thrombotic
thrombocytopenic purpura and haemolytic uremic syndrome should strongly be considered due
to the similarity in clinical manifestations. The major obstacles for the prompt diagnosis of TTP-
HUS are the unawareness regarding the diseases and the unavailability of definitive tests.
CME (18/09/2020)
A CME on 'Hypertensive disorders in pregnancy', was conducted by the eminent faculty of
LHMC and associated hospitals, on the 18th September from 4.30 pm. It was an outstanding
CME program. All the topics were very relevant and were well presented.
I would like to congratulate Dr Maitree Pandey and her team for organizing this excellent CME.
I am sure our viewers have definitely benefited from this academic feast. I applaud the faculty
for their efforts towards making this CME a great success.
The CME was attended by 190 delegates.
The abstracts of presentations are as follows:
• COVID 19 in Obstetric Patients
Dr Anshu Gupta, Professor, Dept of Anaesthesia, Lady Hardinge Medical college
and Associated Hospitals
Parturient are not more likely to contract COVID 19 infection but altered immune system and
response to viral infection more severe infection in 5% patients. However, majority of cases
have milder illness and good recovery. Problems are low lung reserve due to decreased FRC
with basal atelectasis, increased oxygen consumption, Immunosuppression, hypercoagulable
state and associated co-morbidities. Presentation is like acute respiratory illness with variable
severity from asymptomatic to severe picture of pneumonia, renal failure and multiorgan failure.
Fever is the most common presenting feature found in up to 65-85% patients. Test is done if
there is there is travel or contact history or patient is from containment zone or has symptoms.
RTPCR is gold standard. COVID-19 related precautions have to be taken at every step.
Screening at entry, teleconsultation, minimizing hospital visits to 12,20,28 and 32 weeks and
delaying appointment for 7 days if feasible in symptomatic patients. Home isolation in
asymptomatic patients and hospitalization with feto-maternal surveillance for symptomatic
patient if test is positive and Fetal ultrasonography and Doppler after 2 weeks in both situations.
Quick SOFA score is useful and ICU admission if > 1 parameter qualifies in SBP < 100 mmHg,
RR > 22/min, GCS < 15. Caesarean delivery is considered in septic shock and acute organ
failure and fetal distress. Regional anaesthesia is preferable with epidural labour analgesia and
GA if required. Curtailing second stage is can be considered. Tocolysis, beta agonists,
methylergometrine, delayed cord clamping and skin to skin bonding to be avoided. Oxytocin
should be used with care. Tranexamic acid & Prostaglandins deemed safe. Baby has to be
separated from mother and If rooming in >1-2-meter distance and barrier. Benefits of careful
breast feeding outweigh the risk. is debatable. COVID 19 is shown to have adverse maternal
and fetal outcome. Vertical transmission cannot be ruled out but is less probable. Treatment is
mainly supportive. Pharmacological treatment with Lopinavir/Ritonavir, hydroxychloroquine,
remdesivir, azithromycin and arbidol can be used in severe illness but long-term safety data is
still lacking SpO2 should be maintained 95% or more. High flow oxygen, prone position, BIPAP
and mechanical ventilation are used. ECMO used for intractable hypoxia. If sudden decrease
in oxygenation suspect pulmonary embolism.
• Role of early warning scores for prediction of outcome in obstetrics
Dr. Maitree Pandey, HOD and Director Professor, Department of Anaesthesia and
Critical Care, Lady Hardinge Medical college and Associated Hospitals
EARLY WARNING SYSTEMS (EWS)
Early warning system (EWS) scores are tools used by hospital care teams to recognize the
early signs of clinical deterioration in order to initiate early intervention and management. These
tools are used to assign numerical value to several physiologic parameters (SBP, HR, SpO2,
RR, level of consciousness and urine output) and composite scores are derived that are used
to identify patients at risk of deterioration. Introduction of the early warning systems in medical
practice was based on the observation that the clinical deterioration of patients was preceded
by deranged physiological values by up to 24 hours. EWS ensures timely and appropriate
management of deteriorating patients before they collapse.
The unique physiological adaptations of pregnancy may allow for a longer period of apparent
compensation, but if undetected can result in abrupt maternal deterioration. Implementation of
an early warning scoring system offers the advantage of early recognition of clinical signs of
impending maternal collapse and the initiation of appropriate intervention.
TYPES OF EARLY WARNING SYSTEMS
➢ Single parameter systems
Define abnormal thresholds for a list of physiologic parameters
➢ Multiparameter systems
▪ Aggregate weighted scoring systems
▪ Score based on degree of physiologic derangement for each measured parameter
▪ More sensitive to detect early deterioration
▪ Multiple minor derangements may develop before a single parameter deviates
substantially from normal
MATERNAL EARLY WARNING SYSTEMS
➢ Modified Early Obstetric Warning Systems
➢ (MEOWS)
➢ Obstetric Early Warning Score (OEWS)
➢ Maternal Early Warning Criteria (MEWC)
➢ Maternal Early Warning Trigger (MEWT)
➢ Disease-Specific Obstetric scoring System
1) MODIFIED EARLY OBSTETRIC WARNING SYSTEMS (MEOWS)
➢ Bedside assessment tool designed to identify women at higher risk of severe maternal
complications
➢ Physiological parameters monitored - temperature, blood pressure, heart rate, oxygen
saturation, conscious level and pain
➢ Defines moderately and severely abnormal parameters
➢ Physician evaluation was suggested when patient demonstrated one severely abnormal
(red) or at least two moderately abnormal (yellow) parameters
2) MODIFIED EARLY OBSTETRIC WARNING SCORES (MEOWS)
➢ Introduced by NHS, UK as a modification of CEMACH recommended Modified Early
Obstetric Warning System
➢ Aggregate based scoring system
➢ Total score is considered clinically rather than the triggers
➢ Serial monitoring and scoring of clinical parameters done by the trained staff
➢ Review by physician and intervention is facilitated when the score is above a critical
threshold
3) OBSTETRIC EARLY WARNING SCORE
➢ The clinical OEWS had very good predictive ability to determine whether patients
survived their ICU admission
➢ Its complexity precluded routine use
➢ Was less accurate when applied to patients admitted for reasons not directly related to
pregnancy
4) MATERNAL EARLY WARNING CRITERIA (MEWC)
➢ Designed as a single parameter system
➢ Temperature and pain was deleted from the criteria and measure of oliguria was added
➢ They also expanded critical neurologic signs to include agitation, confusion and
unrelenting headache in the presence of HTN
5) MATERNAL EARLY WARNING TRIGGER (MEWT)
➢ MEWT included a list of vital sign thresholds, as well as altered mental status
➢ Implementation of MEWT resulted in significant reduction in CDC- defined severe
maternal morbidity
➢ In addition to including the triggers, the MEWT tool contained a flow diagram
➢ Functioned as pathway specific tool
➢ Guided evaluation and emergent management of
▪ hemorrhage
▪ sepsis
▪ cardiopulmonary dysfunction
▪ preeclampsia – hypertension
6) DISEASE SPECIFIC OBSTETRIC SCORING SYSTEM
a) Full Pre-eclampsia Integrated Estimate of Risk model
To predict which patients with preeclampsia would have adverse outcomes
b) Sepsis in Obstetrics Score (SOS): To identify obstetric patients at high risk of clinical
deterioration and subsequent admission to the ICU for severe sepsis
c) Shock Index (SI)
Detect and / or predict hypovolemia and early hemodynamic compromise
SI = HR / SBP
Ranges: < 0.7 – Normal
> 0.9 – Risk of deterioration
> 1.7 – Requires immediate intervention
Conclusion: Severe maternal morbidity and mortality are often preventable and obstetric early
warning systems that alert health care providers of potential impending critical illness must be
incorporated in our day to day care. An ideal scoring system which will be applicable to the
entire maternal population is lacking.
• Anaesthetic management of a PIH patient for LSCS
Dr Ranju Singh, Director Professor, LHMC
Pre-eclampsia is classified as severe when there is proteinuria with severe hypertension
(≥160/100 mm Hg). The hypertensive crisis should be treated, particularly the rising systolic BP
to improve maternal and foetal outcome. Treatment with first line agents should occur as soon
as possible within 30–60 minutes of confirmed severe hypertension to reduce the risk of
maternal stroke. Intravenous labetalol and hydralazine have long been considered first-line
medications. Immediate release oral nifedipine also may be considered as a first-line therapy,
particularly when intravenous access is not available. In the rare circumstance that intravenous
labetalol, hydralazine, or oral nifedipine fails to relieve acute-onset severe hypertension,
emergent consultation with an anaesthesiologist or critical care subspecialist to discuss
second-line intervention (nitroglycerine, nitroprusside) is recommended. Prophylactic
magnesium sulphate should be also be given as it reduces the risk of an eclamptic seizure by
around 58%. Regional anaesthesia is now recommended for women with severe pre-
eclampsia. There have been concerns with spinal anaesthesia (SA) in severe preeclampsia
due to the fear of causing significant hypotension. This fear appears unfounded because these
women have high levels of circulating catecholamines which may protect them against spinal
hypotension. In fact, SA is not contraindicated even after an eclamptic fit if the mother is
conscious and treatment for seizures and BP control has been commenced and urine output
and platelet count is adequate. Sometimes a regional block may be contraindicated, and GA
may have to be administered. The factors which make GA in pre-eclampsia particularly
hazardous include: increased risk of difficult airway and marked pressor response at
laryngoscopy. There is a significant risk of intracranial haemorrhage secondary to uncontrolled
severe hypertension at induction of GA which must be prevented. In the postpartum period,
monitoring should continue and anti-hypertensives and magnesium continued for 12-24 hours.
• Role of ultrasound in hypertensive disorders of pregnancy
Dr Anshu Gupta, Associate Professor. Department of Anesthesia and critical care,
LHMC
PIH is a multisystem disorder. It can progress to potentially severe disease. Clinical signs and
symptoms are late to develop, which may not be correlating with underlying pathology. Hence
it is desirable to know extent of severity by a real time and easily accessible modality like
ultrasound. Point-of-care ultrasound (POCUS) is a quick, noninvasive, bedside test used
increasingly in many ways by performing: • Measuring Optic Nerve Sheath Diameter to detect
increase in intracranial pressure. • USG to detect pulmonary interstitial syndrome & alveolar
edema. • Assessing fluid status for optimal management. • Assessment of Airway to detect
airway edema & difficult airway. Ultrasound is used to detect rise in intracranial pressure by
measuring optic nerve sheath diameter. Optic nerve sheath is a continuation of dura mater and
is surrounded by CSF. Optic nerve sheath diameter is measured 3mm posterior to the globe.It
is considered to be normal when in the range of 4.3- 4.8 mm and increased when ≥ 5- 5.5 mm.
Lung ultrasound helps in detecting interstitial edema, pulmonary edema and assesses
congestion in acute heart failure. Lung ultrasound shows A and B lines. Multiple Blines indicate
presence of extravascular lung water. It may due to interstitial lung edema or alveolar lung
edema. There are various scores to predict the severity of lung edema on the basis of number
of B lines like “B Line score” and “Echo Comet Score”. Early detection of interstitial fluid can
promote conservative fluid management and guide us in early initiation of diuretic therapy.
Ultrasound also has an important role in airway assessment in PIH patients. It can be helpful in
many ways like prediction of difficult laryngoscopy and mask ventilation, airway edema
identification and estimation of endotracheal tube size. So, ultrasound is a quick, bedside non-
invasive modality which can be very helpful in assessing the severity of disease, thus helpful in
preventing complications.
• Hypertensive Disorder of Pregnancy Critical Care Issues
Dr Nitin Hayaran, Professor, Lady Hardinge Medical College
Quite often obstetric patients requiring critical care with moderately high mortality.
Hypertensive disorders of pregnancy account for the majority of them. Most common
indications for ICU admission are as follows: refractory hypertension, neurological dysfunction,
acute shortness of breath, HELLP syndrome and its associated complications. Organ
dysfunction stems from endothelial dysfunction and hypertensive crisis. Most of the patients
are admitted in the postpartum period but may have to admitted in antepartum period also.
Recurrent seizures, cerebral oedema, PRES are the most common neurological dysfunction
whereas strokes are the most cause of maternal mortality. Pulmonary oedema can be
cardiogenic or noncardiogenic in origin in patients with hypertensive disorder of pregnancy.
Disseminated intravascular coagulation, Acute Renal Failure and Hepatic dysfunction are the
most common anomalies associated with HELLP Syndrome. Neurological and cardiovascular
monitoring is required in the ICU. Early aggressive protocolised therapy is required for
appropriate management of complications associated with hypertensive disorders of
pregnancy.
Review Article
Cardiopulmonary Resuscitation (CPR) in confirmed or suspected COVID-19
victim: A global view
Smita Das1, Rakesh Garg2, Poonam Joshi1, Shashi Mawar1
1 College of Nursing, All India Institute of Medical Sciences, New Delhi 2 Department of Onco-Anesthesia and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, New Delhi.
Introduction
Sudden cardiac arrest (SCA) has always been a crucial public health issue as it is associated
with unacceptable high mortality rate. The sudden cardiac arrest accounts for 20% of the death
in the western countries. In India, every year approximately 4280 out of one lakh population die
from SCA. [1,2] The reasons for cardiac arrest are multifactorial which includes unattended
sudden cardiac arrest, late or inappropriate cardiopulmonary resuscitation (CPR) techniques
etc. Managing sudden cardiac arrest becomes even more challenging when it is combined with
coronavirus disease 2019 (COVID-19).[3]
Need for Revision
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing COVID-19 was
reported for first time from Wuhan, China in December 2019. This infection in less than 6
months has become pandemic and has spread to around 210 countries across the world.[4]
COVID-19 is extremely transmissible disease that spreads mostly through droplets of infected
person while sneezing or coughing. Approximately 12% to 19% of COVID-19 patients require
hospital admission and around 3% to 6% become critically ill and need intensive care
monitoring. Type 1 respiratory failure due to acute respiratory distress syndrome (ARDS),
myocardial injury, malignant rhythm abnormalities, and shock are common among critically ill
patient making them vulnerable to cardiac arrest.[5,6] Treatment of COVID-19 patients includes
use of drugs that prolong QT interval such as azithromycin and hydroxychloroquine which
predisposes them to cardiac arrest, though no robust evidence exists for the increased
occurrence during this pandemic. Preliminary studies have shown that COVID-19 may have an
increased incidence of cardiac arrest through some inflammatory response.[6] Providing CPR
is accompanied with various aerosol producing procedures such as chest compression, airway
management techniques and positive pressure ventilation via bag and mask.[7] These aerosol
generating procedures causes viral particles to stay suspended in the environment and can be
inhaled by person who are close by. CPR attempts keeps health care worker at risk of getting
infected because of close proximity and need for various aerosol generating interventions. This
may also be due to psychological stress due to COVID-19 as well leading to lapse in personnel
protection. Healthcare providers delivering CPR are therefore at increased threat of getting the
infection. This risk of getting the disease leads to increased fear among healthcare personnel
which may hamper with proper management of COVID-19 patient needing CPR. This will in
turn lead to poor patient outcomes.
Thus, it is important to aim at attaining the return of spontaneous circulation without
compromising the safety of the healthcare workers. The pre-COVID era guidelines available
don’t include various steps for healthcare protection along with effective CPR. Hence
modifications have been done in the techniques of performing CPR in order to make the
intervention safe for both victim and the caregiver. Table 1 shows the salient features of
resuscitation in COVID-19 patient and how it is different from resuscitation during pre-COVID-
19 era.
• PPE must be worn for COVID patient CPR.
• Cautious use of aerosol generating procedure during CPR
• High index of suspicion for cardiac arrest
• Appropriate preparation and training
• Self-surveillance and monitoring
Table 1. Comparison between Pre COVID-19 CPR guidelines and COVID-19 CPR
guidelines.
It is very well evident that there are no gold standard CPR guidelines as they are continuously
evolving. Various resuscitation councils across the world have created their own guidelines
suitable to the population they serve. The council makes guidelines that are suitable to their
own country keeping in mind varied infrastructural resources, financial limitations, geographical
diversity, and facilities available to majority of the population.
S.No. Pre COVID- 19 CPR guidelines COVID-19 CPR guidelines
1 Maximum 6 people required for managing
cardiac arrest.
Limited personnel in the room for managing cardiac arrest. 3-4 people including a runner outside the
room for providing necessary equipment
2 Gloves and triple layer surgical face mask
required. Mandatory PPE before resuscitation i.e., full COVID
suits, double gloves, goggles, N95 respiratory.
3 HEPA filters were not required. HEPA filters if using bag and mask for ventilation
4
Intubation was not given preference during resuscitation as it delays chest compression. Only required if bag and mask ventilations
were not effective
Immediate intubation using video laryngoscope. Bag and mask ventilation is not preferred due to
aerosolization.
5
Manual chest compression was given importance because putting patient on
external compression devices requires time delaying chest compression.
Use of external compression device preferred as it reduces direct contact with patient.
6 Paddles were commonly used as it was cost
effective Pads instead of paddles for defibrillation
7 Intravenous MgSO4 was not a very
commonly used drug earlier. Intravenous MgSO4 included in the list of drugs
needed for resuscitation
The American Heart Association along with other professional bodies has come up with
modified guidelines for CPR among COVID-19 patients with cardiac arrest (figure 1).[8]
Figure 1. AHA Advance Cardiac Life Support Algorithm
Circulation. 2020; 141e933-e943.O;10.1161/CIRCUATIONAHA.20.047463
The European Resuscitation Council published updated guidelines according to COVID 19
pandemic at the end of March 2020 which provides deeper knowledge for basic life support,
advance life support and provides general guidance doe education in CPR, ethical decision
making and first aid (figure 2).[9].
Figure 2. European Resuscitation Council Advance Life Support for COVID -19
Available from: https://www.erc.edu/covid-courses/advanced-life-support-in-adults
Indian Resuscitation Council (IRC) proposed updated guidelines are a continuum of
comprehensive cardiopulmonary life support (CCLS) guidelines by IRC with an emphasis on
the various challenges and concerns being faced during the resuscitative management of
COVID-19 patients with cardiopulmonary arrest (figure 3).[10]
Figure 3. Indian Resuscitation Council (IRC) Comprehensive Cardiopulmonary Life
Support (CCLS) for COVID -19
For managing cardiac arrest in COVID-19 also varies from country to country and probably
some difference in some of the salient features by different resuscitation councils (table 2).
However, it appears, the basic principle of self-protection remains paramount remains similar
across all the guidelines.
Table 2: Compare and contrast of available resuscitation guidelines by various
professional bodies.
Steps of resuscitation
AHA ERC IRC
Scene safety
PPE should be done before entering the scene to safe guard against infectious
airborne and droplet particles.
Steps should be taken to prevent cardiac arrest and unprotected CPR should be
avoided. Physiological track-and-
trigger systems can be used to help early detection of
critically ill patients. Do not perform CPR for
critically ill COVID 19 patients with MODS.
Preparation, Identification, and
Personal Protective Equipment (PPE) before
starting resuscitation Ensure the patient is
wearing surgical mask before resuscitation
begins.
Members of HCT Limit the number of staff to those required for patient
care
A gatekeeper assists in controlling the number of
person at place of CPR being done. Extra health care works can stay at safe distance and
if need arises can join the CPR team.
Maximum of three Persons allowed for CPR
in the room and the fourth person is a runner who remains outside the room or stands at 6 feet distance to help provide necessary equipment’s
during resuscitation.
Checking response
Assess for response by tapping on shoulders and
loudly saying “Are you Ok”?
Check response by shaking and shouting. DONOT place
your cheek near patient’s face to listen for breaths
Tap on the shoulders of the patient and speak
loudly. Maximum distance should be
maintained from patients face. Look for breathing,
if the patient is not on ventilator. Do not listen and feel for breathing.
Activating emergency
COVID code blue
Same as in previous guidelines
Shout for help if a victim is not responding and not
breathing. Someone can call COVID cardiac arrest call, and
activate them to bring a defibrillator.
If a patient is unresponsive and is not
breathing normally, then activate COVID code blue. Direct them to bring crash
cart with airway management
equipment’s, and defibrillator. and
defibrillator.
Checking pulse/ rhythm and
breath
Check for pulse. CPR should be started if no definitive
pulse is felt within 5-10 secs and no breathing or only
gasping
Same as in previous guidelines (No mention about
it)
Check carotid pulse or check for the rhythm if the patient is already attached to cardiac monitor. Assess for
oxygen saturation using pulse oximeter during
assessment
Initiating CPR Coordinated
chest compression and ventilation (30:2)
Start CPR with 30 compressions and 2 rescue
breaths using AMBU bag and mask device with HME filter and tight seal. Continuous
compression can be continued using face mask.
Use of mechanical chest compressor in place of
manual chest compression is preferred.
Continue with compression: ventilation ratio of 30:2. Ventilation with bag and
mask should be minimized and should be performed
using 2 persons technique. Person doing chest
compression can stop and squeeze the bag.
Till the extra help arrives, the first rescuer should
continue with the process of resuscitation. Use of
mechanical chest compression is
recommended in case of prolonged CPR.
Use two hand technique for ventilation
Early defibrillation
Use defibrillator as soon as it is available.
Applying defibrillator pads and delivering a shock is unlikely to cause aerosol-
generation and can be performed by healthcare
provider just wearing a fluid-resistant surgical mask,
gloves, eye protection, short-sleeved apron.
Resuscitation can start by providing two additional
shocks (if indicated) whilst the other healthcare workers
are donning airborne-precaution PPE.
Anterior-posterior pad placement for defibrillation in
the prone position is preferable.
Defibrillating the patient at the earliest using
disposable pads in an anterior lateral position.
Early intubation and use of viral
filters
Priority should be given to oxygenation and ventilation
strategies with lower aerosolization risk like use of
Early intubation recommended and ventilator
should be connected with filter when possible.
Early intubation using spill containment device and video-laryngoscope is of paramount importance
provided there is an
video laryngoscopy for intubation if available. Ventilator should be
connected with filter. Supraglottic airway with HME filter should be considered if intubation is delayed. Use of closed suctioning to minimize
disconnections and reduce aerosolization.
FiO2 should be increased to 1.0 and 10 breaths a minute
should be set in the ventilator.
If delayed intubation considers bag-mask device with filter and tight seal or supraglottic airway device. se viral filter (HME or HEPA
filter) to filter exhaled breaths in between the self-inflating
bag and airway (mask, supraglottic airway, tracheal
tube)
experienced anesthetist to do so. Before insertion
of the tracheal tube it should be clamped and
released only after cuff is inflated and tube is connected to the
ventilator with HME filter. The ventilatory
parameters should be tuned by increasing
airway pressure limit in volume control
ventilation or by increasing FiO2 to 100%
in pressure control ventilation.
If patient is already on ventilator continue previous ventilatory settings with 100%
oxygen. Closed suctioning system is recommended. Bag and mask ventilation and use supraglottic devices with
a viral filter is recommended if there is
delay in intubation.
Resuscitation in prone position
Those patient in prone position with advance
airway, it may be reasonable to avoid turning patient to supine. Chest compression can be provided with the heel of the hand position
over T7/10 vertebral bodies.
Position the heel of the hand in between the scapulae
(shoulder blades) for chest compression at a depth 5-6
cm and rate of 2 compressions per second). Aim for diastolic pressure more than 25mmHg for
effectiveness of the compression only if the
patient has arterial line. If ineffective compressions or
interventions necessitates the patient in supine, e.g. for
ventilation problems, then turn the patient to supine
position.
Turn the patients in prone position to supine before
initiating CPR.
Drugs Same as in previous
guidelines Same as in previous
guidelines
Recommends the use of MgSO4(1-2 g) slow IV as
part of management protocol, if patient gives
Future prospect
In case of COVID-19 pandemic there are various unknown factors and how this virus will
behave is not known fully. So, the current guidelines developed to manage cardiac arrest in
COVID-19 patient is still budding subjected to changing knowledge and experience regarding
this infectious disease. These guidelines shall change based on the mutable nature of COVID-
19 from time to time.
history of taking HCQ and Azithromycin.
Effective communication
and team dynamics
Clear communication regarding COVID-19 status of
patient should be given to the health care providers who are joining the team during CPR or its transfer.
A team debrief after resuscitation is helpful.
Role of rescuers may be established as
appropriate and conduct of drills for COVID code
blue members
Post- resuscitation care
Same as in previous guidelines (5H, 5T)
Same as in previous guidelines (5H, 5T)
Same as in previous (HIT THE TARGET)
Discontinuation of CPR
The relevance of CPR such as comorbidities, age and
severity of illness should be taken into consideration. The likelihood of success must be balanced against the risk to
rescuers and patients.
Once all the reversible causes has been assessed and
optimized without return of spontaneous circulation, CPR
may be discontinued.
Discontinue CPR, if the end tidal carbon dioxide
(EtCO2) more than 10 mmHg is not achieved and there is absence of any organized rhythm
after 20 min of resuscitation.
Disinfection of equipment
Not mentioned in guidelines Not mentioned in the
guidelines. As per institutional policy
Disposal of clinical waste
Not mentioned Not mentioned As per institutional policy
Doffing PPE Not mentioned
The PPE should be safely removed ‘doffing’ in a
dedicated place to avoid risk of self-contamination.
Safe removal (‘doffing’) of PPE to prevent self-
contamination under supervision of another
buddy should be ensued
Conclusion
COVID-19 requires modification of existing CPR guidelines due to its infectivity. These modified
guidelines incorporate appropriate steps for use of PPE for protection of self-contamination
during attempts of CPR. Appropriate training is needed during this time of pandemic in order
to save lives and prevent transmission of infection.
References:
1. Wong CX, Brown A, Lau DH, et al. Epidemiology of sudden cardiac death: global and
regional perspectives. Heart Lung Circ 2019;28:6–14.
2. Choudhury DOP. Less than 2% cardiac arrest patients in India receive CPR [Internet].
Health news, Medibulletin. Available from: https://medibulletin.com/moolchand-study-
shows-less-than-2-cardiac-arrest-patients-receive-cpr/[cited 10 July 2020]
3. COVID-19 | The Medical Journal of Australia [Internet]. Mja.com.au. 2020 [. Available
from: https://www.mja.com.au/journal/covid-19. [cited 10 July 2020]
4. Zhu N, Zhang D, Wang W, Xingwang L, Yang B, Song J, et al. A novel coronavirus from
patients with pneumonia in China, 2019. N Eng J Med 2020; 382:727-33.
5. Bhatraju PK, Ghassemieh BJ, Nichols M, Kim R, Jerome KR, Nalla AK, Greninger AL,
Pipavath S, Wurfel MM, Evans L, et al. COVID-19 in critically ill patients in the Seattle
region: case series. New Eng J Med 2020;382:2012–2012.
6. Cardiac arrest in patients with COVID-19: Reducing resuscitation risks [Internet].
Lippincottsolutions.lww.com. Available from:
http://lippincottsolutions.lww.com/blog.entry.html/2020/04/20/cardiac_arrest_inpa-
JucB.html. [cited 10 July 2020]
7. World Health Organization. Modes of transmission of virus causing COVID-19:
Implications for IPC precaution recommendations: Scientific brief. Available at
https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-
causing-covid-19-implications-for-ipc-precaution-recommendations. [cited 10 July 2020]
8. CPR guidelines. Available from:
https://www.ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.120.047463. [cited 10
July 2020]
9. Erc.edu. 2020. Available from:
https://erc.edu/sites/5714e77d5e615861f00f7d18/content_entry5ea884fa4c84867335e4d1
ff/5ea885f34c84867335e4d20e/files/ERC_covid19_pages.pdf?1588257310. [cited 10 July
2020]
Singh B, Garg R, SSC Chakra Rao, Syed M Ahmed, JV Divatia, TV Ramakrishnan, et al.
Indian Resuscitation Council (IRC) suggested guidelines for Comprehensive
Cardiopulmonary Life Support (CCLS) for suspected or confirmed coronavirus disease
(COVID-19) patient. Indian J Anaesth 2020 May Supplement 2;64:S91-6.
Ethics in Covid Times (Part-3)
The Unprecedented Challenges
Dr Arun K Mehra
The Covid pandemic has thrown up many fresh challenges. Though pandemics are as old as
history, many of the new challenges are unheard of in the day present world, and some may
be unknown in all of human history.
These new challenges are varied, across all spheres of human activity. We will enumerate the
most important ones related to healthcare. None of the questions raised below have easy
answers, and some have no answers at all. Let us also remember that each nation, each region,
each city, each locality has its own unique set of circumstances, and hence there can be no
“one size fits all” kind of approach.
• How do we care for the most vulnerable? After all, we are collectively as safe as the
most vulnerable.
• Insurance, hospital bills and economic viability – how feasible is it for the private sector
to provide concessional healthcare, without being forced to shut down? If there is price
capping, should the government give financial support?
• How do we tackle out-of-pocket payment of health bills, which land many Indians in
poverty?
• Testing – which tests are most useful, and hence more justified?
• Should the government provide free PPE kits for all healthcare workers? Especially
because there is a real risk of profiteering? Can we compromise on their quality?
• How do we meet the principle of distributive justice? Is rationing of healthcare justified?
Who gets treatment? Who is denied? How can we say that one life is more important
than the other? Should it be first-come-first-served?
• How are ventilators rationed? How are drugs rationed? Who gets the vaccine first,
whenever it becomes available?
• Should healthcare workers get priority of treatment, as they need to return to work to
look after patients?
• Who decides who gets treatment? Is the doctor left on his own? Will he suffer mental
trauma and moral injury as a result?
• Society expects doctors to be a role model. How far is this possible in a state of fear?
• How do we deal with a breakdown of the doctor-patient relationship? How do we deal
with violence on healthcare workers?
• How do we address the psychological issues of healthcare workers, especially post-
traumatic stress disorder? Should there be guidelines?
• How do we look after the mental, emotional and psychological problems of a population
in lockdown, especially with the risk of domestic violence? How do we look after their
healthcare needs in general?
• Besides physical and mental health, there are community health issues. How are they
best dealt with in a pandemic?
• How do we keep other priority areas going, like trauma, dialysis, cardiac units,
transplants, cancer surgery?
• What do we do about other major killers like tuberculosis?
• Is it justifiable to convert a portion of all hospitals into Covid units? Won’t that spread it
further? Should there be exclusive Covid hospitals?
• Isolation of the elderly is a serious challenge for them, in terms of solitude and its
resulting loneliness. How do we provide them psychological support?
• Can a doctor refuse to treat if no proper protection, like PPE, is provided? Though
coming into any profession means accepting the risks involved, is there a limit to the
risks doctors can be expected to take? Like firemen are not required to go into a
collapsing building?
• If someone gets sick on duty, what are their rights? Should there be a special insurance
for healthcare workers?
• What measures should be taken to protect the family members of doctors from getting
infected?
• How do you deal with stigmatization of healthcare workers?
• Should elder and sick doctors be exempt? Can retirees be called back for active service?
• Can medical students be called for duty? They are not yet fully trained, nor qualified. Or
can they serve in auxiliary work, like completing papers? Does the public have a right to
know they are being looked after / treated by trainees?
• Can online teaching be a substitute for bedside teaching?
• Can individual clinics be forced to open if they do not have sufficient protective means?
• With work from home becoming a norm, tele-consultation in medical practice is picking
up – what are the legal, moral and ethical issues? What are the consent issues involved?
We will discuss these issues individually in the subsequent months.
The only possible guiding principle can be: the maximum good of the maximum number.
Dr Arun K Mehra is a Senior Consultant at Bhagwati Hospital. Besides Anaesthesiology, he has also
done an MBA in Healthcare Administration from the Faculty of Management Studies (FMS) Delhi
University, a Diploma in Creative Writing from the Indira Gandhi National Open University (IGNOU), and
Certificate in Bio-Ethics and Human Rights from UNESCO. His special interest is the sociology of
medicine. He also has vast experience as a writer, blogger, and editor.
Experiences during Covid Pandemic…………
Dr Rohan Khandelwal, postgraduate student 2nd year, VMMC &
Safdarjung Hospital
" Living with four senses "
Negative. I hadn’t been well for a couple of days.
Malaise, irritability, occasional cough and sore throat.
But aren’t these the ambiguous symptoms we all have had since we heard
about the corona virus? I kept telling myself, being a resident doctor who
has seen these symptoms and covid patients too up close, I am over
diagnosing myself. But truth be told, I did have a history of being exposed
to a positive patient a couple of days ago. So, maybe I should get tested.
Negative. What a relief! I dismissed my earlier feelings and continued with
ebbs and flows of life.
Until one afternoon, a couple of days after, I couldn’t smell the
strongest of smells! That too on the same day as WHO named “anosmia” as
one of the features of covid. I was particularly feeling weak that day. Just
to be sure, I checked my temperature. 100.4. I was immediately relieved of
my ongoing COVID ICU duty, where I regularly saw patients struggling but
also tried to calm myself down by the thought of the ones we treated and
discharged, stronger than they came in. Amongst the fears I had for myself,
another one adding to my troubles was having met my parents not too
long ago. Being strong for myself was hardly difficult but the thought of
my family made me weak.
My report was taking longer than usual. Building up anxiety along
with my now deteriorating health. Then came that phone call. Asking me
politely was my very concerned senior, to isolate myself. Cautiously
narrating the protocol and treatment for corona, which of course I knew
and not very long ago was advising to patients myself. Fortunately, having
made appropriate prior arrangements, I could opt for home isolation and
still be away from where my family was putting up. But never had the
reality and practicality of it struck me like this.
Yet, I mustered some strength and decided to fight it the best I could.
Carefully choosing my words, I informed my parents, hiding my own fears,
asking them to isolate, get tested and be on a lookout for symptoms. That
night, I received numerous calls, and honestly only those got me through
the night. Keeping my mind off of what was actually happening. Making
me feel less lonely in this. Eventually, sleep found me. But morning was no
better. I woke up with headache, fever and an impending sense of doom.
I think I almost felt as bad mentally as I did physically. But I had decided
to not let a virus defeat me. In that moment, I knew, I will be okay. I went
on to arrange the essentials, keeping myself distracted. But in fleeting
moments of reality, the visuals of sick patients would cloud my mind. Even
though as a doctor I was aware that my present state could only be
classified as mildly symptomatic and that I had nothing to worry, the
slightest drop in saturation, or slightest increase in temperature would
ruffle the patient in me.
Every day I would try take whiff of smell, only to be disappointed. The
days seemed longer and being alone was as hard to deal with. But I was
fortunate enough to have in my life people so brave, who decided to fight
the disease and the stigma associated with it, better than I could. Never
was I left alone to think what I was having for my next meal. My very brave
neighbour, a doctor herself, became my guardian, putting out groceries for
me. My house help, calling me up every day, asking me what I wanted to
eat, leaving it at my doorstep silently.
My friends, thinking ahead of my needs. They had decided I was to be
left alone only physically and not in spirit. Just the thought of someone
outside my door would spread like warmth, keeping me sane. And just like
that, one morning, I felt as if some weight had been lifted off my chest, I
could breathe better and my general health had improved. I no longer felt
low and I was feeling so comfortable.
Realising it had now been almost 14 days since I received that call. It
was time for another test! The anticipation of test didn't let me sleep that
day. Negative! With a new sense of appreciation for my old life, normalcy
and people around me, I am glad to put this incidence behind me.
ART GALLERY
Dr Nishant Mishra Senior Resident
VMMC & Safdarjung Hospital
ART GALLERY
CITY IN CHAOS - Talent, Passion, Poverty, Anger & Depression
Dr Girish V
PG Student, 3rd Year
VMMC & Safdarjung Hospital
ART GALLERY
Medley of colours dancing in the rain
Dr Alka Chandra
Head of Department Anaesthesia & Critical Care,
Hindurao Hospital and NDMC medical college
ART GALLERY
Dr Renuka Choudhary PG Student 1st Year
VMMC & Safdarjung Hospital
POETRY/ कविता
आनन्द
जब डर को जीत जाएँ हम,
स्याही रात को भूल जाएँ हम....
सुबह का इंतजार करें हम,
हर पल को जी भर जजयें हम....
छोटी- छोटी खुजियो ंको भी
सहेजने लगे हम ,
आनेवाले मुसीबतो ं के
भँवर का ना जिन्तन करे हम ....
अभी जो पल हम जी रहे हैं
-इसी में खुजियाँ बाँटे हम,
- इसी में जकसी के आँसू
पोछकर िेहरे पर मुसु्कराहट लायें हम ....
सुनहरे यादो ंको बार - बार दोहराये हम,
कङवी यादो को भूल जाये हम....
अच्छाइयो ंके बीज वोएँ हम,
हमेिा मुसु्कराएँ और लोगो ं के होठो ंपर भी मुसु्कराहट लाएँ हम....
तो जनजित ही आनंद से सराबोर हो जाएँ हम।
मनोज
Written by: - Dr Manoj Kumar
Anaesthesiologist
ESI Hospital, Okhla
How correct were you?
ANSWERS TO AUGUST CROSSWORD
Answers: 1. Bjorn Ibsen; 2. Anion gap; 3. Post pyloric; 4. HFNC; 5. I PASS; 6. Hypophosphatemia; 7. Barium;
8. Rehabilitation; 9. Vancomycin; 10. Pseudomonas
Let’s see you solve………….
(By Dr Amandeep Jaswal, VMMC & Safdarjung Hospital)
VIRTUAL CONFERENCE
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We would like to express our gratitude and thanks to Wolters Kluwer India Pvt Ltd
team for their efforts and support in designing and developing ISA Delhi Branch News
Bulletin. We are highly appreciative of all suggestions and efforts put by them which
will have undoubtedly helped us in making complex infographics, data and web media
visualised in a beautiful way.
Mr. Rajesh Kumar Singh – VP Wolters Kluwer Health,
Ms. Shalini Kulshreshtha – Sr. product Manager,
Ms. Mitali Singh – Project Coordinator and
Mr. Gyanendra Swamy – Graphic Designer
Thanks
ISA Team
UPCOMING EVENTS
59th Annual Conference ISA Delhi State Chapter from 2nd to 4th October 2020
16th Oct. Friday 5 - 7.30 pm World Anaesthesia Day celebrations by all ISA Delhi
members
30th Oct. Friday, 5-7 pm clinical mtg by ESIC group of Hospitals