EXPERT REVIEW- Dr Srinivas Samavedam.cdr - isccm

Introduction:

Oxygen therapy is a very common intervention among patients admitted to an Intensive Care Unit (

ICU). The COVID -19 pandemic has brought this aspect of ICU care into focus across the world. The

rationale for prescribing oxygen and the targets to be set for monitoring have been reviewed

thoroughly, being necessitated by the demand-supply mismatch brought on by the pandemic. This

review seeks to provide a guidance on the prescription, delivery, monitoring and weaning of oxygen

therapy.

Section1

General Recommendations

ISCCM recommends that

• all Covid-19 patients should preferably be treated in negative pressure rooms. [Best Practice

Statement (BPS)]

• a minimum of 12 air exchanges per hour should be maintained to dissipate aerosols. (BPS)

• Single-use oxygen delivery interface be used. (Strong Recommendation)

• Local protocols be laid down for transport and disinfection of equipments for institutions using

reusable equipment. (Strong Recommendation)

Section 1.1

Initiation of Oxygen Therapy:

Rationale: The optimal oxygen saturation (SpO2) in adults with COVID-19 is uncertain. However, a

target SpO2 of 92% to 96% seems logical considering that indirect evidence from experience in

patients without COVID-19 suggests that an SpO2 <92% or >96% may be harmful.1,2.

Indications: The ISCCM recommends the following Best Practices in deciding on oxygen therapy (

BPS)

* No oxygen at rest or ≤ 2l/min Oxygen on ambulation for > 1 minute to maintain SpO2≥ 93%:

- Absence of moderate and severe symptoms

- SCRB-60 score of 0-1

- Normal or mildly deranged lab values (lymphopenia is usually present)

- No or minimal radiological changes [Point Of Care Ultra Sound (POCUS), X Ray CT scan]

* Low ow nasal cannula at rest or 2-6 l/min of oxygen via facemask on ambulation to maintain SpO2≥

93%:

- Patients with moderate risk features like abdominal symptoms, syncope, seizures, confusion.

- SCRB-60 score of 2-3

- Liver enzymes more than twice the normal values, AKI I-II, CRP> 50

- Evidence of small patchy pneumonia or brosis and patchy or multifocal B-lines on (POCUS)

Oxygen Therapy Authors

1 2 3Dr Srinivas Samavedam , Dr Lalita Gouri Mitra , Dr Ketan Kargirwar ,

4 5 6Dr Pragyan Kumar Routray , Dr Jaicob Varghese , Dr Manoj Raju Prabhandakam

Reviewer : Dr Subhal Dixit

Submitted in September 2021

* High ow nasal oxygen (HFNC) upto 60 l/min or oxygen ow of 10-15 L/min via face mask

with a reservoir bag to maintain SpO2≥ 93%:

- Hypoxic agitation, respiratory failure, coma, cardiac arrest

- SCRB-60 score of4-5

- Elevated D dimers, respiratory/+ metabolic acidosis, AKI III, Type2 respiratory failure and

elevated lactate

- Multi-lobar pneumonia or pulmonary infarction, conuent B-lines on POCUS

Section 1.2

Mode of Oxygen Delivery:

• Rationale: Asymptomatic or mildly symptomatic Covid 19

o Consider for short term oxygen therapy with low ow nasal cannula if SpO2 ≤93% but stable

both at rest and on ambulation for 1 min for 6-12 hours in the emergency. A single breath

count test is a good tool to assess patients who are on room air.

o Patient is ineligible for short term oxygen therapy is SpO2 <93%, unstable and uctuating on

oxygen with respiratory acidosis and worsening hypercapnia (PCO2 rise of> 1 kPa).

• Moderate Covid 19

o Use reservoir bag with oxygen ow rate@15l/min or increase ow rate to 60 l/min in HFNC (+

awake proning) with worsening SCRB-60 scores, respiratory rate >22, qSOFA score >2 and

PaO2/FiO2 ratio >150. ROX index >4.88 predicts success.

o If ∆SCRB 60 or ∆ PaO2/FiO2 ratio>> ∆SBC consider primary oxygenation problem. HFNC

with awake proning is advisable.

o If ∆SBC >> ∆SCRB 60 or ∆ PaO2/FiO2 ratio, consider primary work of breathing problem or

tiring. Non-invasive positive pressure support is advisable.

• Severe Covid

o If PaO2/FiO2 ratio <150, consider invasive mechanical ventilation with lung protective

strategies and early proning.

Recommendations: The ISCCM makes the following recommendations for deciding on

mode of oxygen delivery

• Short term oxygen therapy with low ow nasal cannula if SpO2 ≤93% in mildly symptomatic

Covid 19. (BPS)

• Reservoir bag with oxygen ow rate up to a maximum of15l/min or up to 60 l/min in HFNC (+

awake proning) in moderate Covid 19 disease. (Recommendation)

• Invasive mechanical ventilation with lung protective strategies and early proning, if

PaO2/FiO2 ratio <150 (BPS)

Section 1.3

Targets:

Rationale: Different countries have different national guidelines for oxygen targets for

COVID-19 ARDS. In the UK the target SpO2 for the commencement of oxygen therapy is 91%

and 94% in Singapore. They have found that the case fatality rate in Singapore is 0.08% and in

the UK it is 13.4%. So, improving supplemental oxygen is likely to reduce mortality in COVID-19

pneumonia.

Surviving sepsis guideline for COVID-19 pneumonia suggests starting supplemental oxygen if

the SpO2 is less than 92% and recommended to start supplemental oxygen if the SpO2 is less

than 90%. They recommended to target SpO2 should not be more than 96%.

Currently, we should keep a balance between liberal oxygen therapy and conservative

oxygen therapy. We should avoid hyperoxia as well as hypoxia. Target SpO2 between 92%

and 96% is associated with good outcomes both in COVID-19 ARDS as well as in non-COVID

ARDS.

Recommendations: The ISCCM makes the following recommendation for targets of oxygen

therapy

• Start supplemental oxygen if the SpO2 is less than 92%. (Strong Recommendation)

• Target SpO2 not more than 96%. (Recommendation)

Section 1.4

Weaning :

Rationale: Oxygen therapy should be given with caution in patients admitted with Paraquat

poisoning, Acid inhalation and Previous Bleomycin use.

Patients with chronic carbon dioxide retention, oxygen administration may cause further

increases in carbon dioxide and respiratory acidosis. This may occur in patients with COPD,

neuromuscular disorder, morbid obesity or musculoskeletal disorders.

High concentration O2 (70%-100%) may damage the alveolar membrane when inhaled for

greater than 48 hours. This risk can increase after chemotherapy/Bleomycin administration.

Recommendations:

The ISCCM makes the following recommendations for weaning a patient from Oxygen

therapy

• In mild to moderate Covid 19 illness, start with weaning O2 off at rest and to decrease ow

rate by max 1l/min at a time. (BPS)

• Subsequently, once patient is able to walk for 30min without supplemental Oxygen with an

O2 Sat above 90%, patient can wean off Oxygen at night. (BPS)

• Weaning off at night should be done last and only if O2 Sat is stable above 92% during the

day at rest. (BPS)

• Avoid higher concentrations of oxygen for prolonged periods of time in patients of COPD,

neuromuscular disorder, morbid obesity or musculoskeletal disorders (Recommendation)

Section 1.5

Triage:

Rationale: Covid war rooms have been comparatively effectively diverting patients to

appropriate care and tempering confusion by triaging. The staff is made up of school

teachers primarily, supported by doctors and data entry operators, who gather each

patient’s vitals and information required to determine if home isolation is practical.

Patients are triaged based on the information received and ambulances are dispatched to

move high priority patients to hospitals in respective wards.

Patients should be evaluated by experts — those with mild symptoms should be directed to

less resourced screening centres to get advice for treatment, while those in a critical

condition should be immediately moved to a hospital.

A strong and widespread tele-consultation systems has helped in triaging.

Italy recommended prioritising treatment for younger patients who had higher chances of

survival.

Spain, rst reverse triaged existing patients from the ICU. Then it identied those requiring

advanced life support, and then sorted them into a priority list of those who need immediate

care.

A form of triage is now urgently required in all parts of the country, with centralised guidelines,

in order to address the critical oxygen shortage and optimize its use. This can help save

precious lives.

Steps to follow in ER-

o SpO2 on arrival <92% or >92%

o SpO2 every 4-6 hours <92% or >92%

o Respiratory rate <12 or >20 /min

o Temperature <35◦ or >38.5 ◦

o Heart rate <45 or >120 beats/min

o Single breath count or breathlessness tool (Maximal counting number <10 or counting time

<7� seconds identied patients with a room‐air pulse oximetry <95% with sensitivity of 91%

and 83%, respectively. Maximal counting number <7 or counting time <5�seconds identied

patients with a room‐air pulse oximetry <90% with sensitivity of 87% and 82%, respectively)

o Six-minute walk test (If the SpO2 drops below 93% or if there is an absolute drop of more

than 3% to 5%, patient is at risk and consider hospital admission)

o Prognosticator in ER/ HDU SpO2/FiO2

o Clinical risk stratication ER/ HDU SCRB-60

o Prognosticator in ICU PaO2/FiO2 (<150 or >150)

o Clinical risk stratication ICU SCRUB-60/ APACHE II

APACHE-II: Acute Physiology and Chronic Health Evaluation II, ER: Emergency department,

FiO2: Fraction of inspired oxygen, SCRB-60: Proposed severity score, SpO2: Peripheral

capillary oxygen saturation)

A) RED CATEGORY

If patients meet one or more of the following criteria, transfer to a secondary care setting.

1. Severe breathlessness (1 or more of these)

o Patient so breathless that they are unable to speak a few words or complete a sentence

o Patient’s breathing in the last hour has deteriorated signicantly from baseline(breathing

faster or harder)

o Patient is breathless at rest –new symptom (not associated with any known underlying

condition and not normal for patient)

o Sudden onset of breathlessness (usually after 7 days of mild symptoms)

2. Shockor peripheral shutdown (1 or more of these)

o New confusion or reduced level of consciousness (unable to rouse patient, drowsy); can

use AVPU (Alert, Verbal, Pain, Unresponsive) to assess

o Extremities –cold and clammy to touch

o Pallor –skin colour is mottled, ashen, blue,or very pale

o Reduced urine output –little or no urine in last 24 hours

3. Functional impairment

o Inability to self-care

o Unable to perform activities of daily living

4. Recent hospital admission with COVID OR conrmed diagnosis of COVID (recent

evidence pointing to deterioration and severe disease)

5. Other serious clinical concern

B) AMBER CATEGORY

If patients meet one or more of the following criteria, they can be reviewed in a Primary Care

setting. Please explore the following criteria with the patient.

o Recent hospital admission with similar problem

o Breathing worsened in the last 24 hours

o Breathing has never been this bad before

o Breathlessness on exertion –new symptom (not associated with any known underlying

condition and not normal for patient)

o Medications ineffective in treating condition (e.g. inhalers not working for asthma or

COPD)

o Clinical concern about comorbidities

Recommendations: The ISCCM makes the following recommendations for triage of patients

requiring oxygen

• Centralized system of triaging of patients to optimize oxygen usage. (BPS)

• ICU admission and discharge policy to optimize bed utilization. (BPS)

REFERENCES:

Barrot L, Asfar P, Mauny F, et al. Liberal or conservative oxygen therapy for acute respiratory

d i s t re s s syndrome. N Eng l J Med. 2020 ;382(11) :999 -1008 . Ava i lab le a t :

https://www.ncbi.nlm.nih.gov/pubmed/32160661.

Chu DK, Kim LH, Young PJ, et al. Mortality and morbidity in acutely ill adults treated with

liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis.

Lancet. 2018;391(10131):1693-1705. Available at:

https://www.ncbi.nlm.nih.gov/pubmed/29726345.

Yatin Mehta, Dhruva Chaudhry, OC Abraham, et al POSITION STATEMENT Critical Care for

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

Medicine. Indian Journal of Critical Care Medicine (2020): 10.5005/jp-journals-10071-23395

Sinha S, Sardesai I, Galwankar SC, B. Nanayakkara PW, Narasimhan DR, Grover J, et al.

Optimizing respiratory care in coronavirus disease-2019: A comprehensive, protocolized,

evidence-based, algorithmic approach. Int J Crit Illn Inj Sci 2020;10:56-63.

Carter C, Osborn M, Agagah G, Aedy H, Notter J. COVID-19 disease: invasive ventilation.

Clinics in Integrated Care. 2020;1:100004. doi:10.1016/j.intcar.2020.100004

Srinivasan S, Panigrahy AK. COVID-19 ARDS: Can Systemic Oxygenation Utilization Guide

Oxygen Therapy? Indian J Crit Care Med 2021;25(2):115–116.

Herreros B, Gella P, Real de Asua D. J Med Ethics 2020;46:455–458.

NIH breathlessness tool kit and triage tool kit 2020.

SECTION 2:

HUMIDIFICATION AND MONITORING:

2.1 HUMIDIFICATION:

Rationale: Humidication is an integral part of oxygen therapy and needs to be tailored as

per the mode of oxygen delivery and the ow of oxygen

Humidication is not necessary in low ow oxygen like nasal cannula or face mask. It is also

not mandatory for short term use of high ow oxygen like Non rebreather masks for less than

24 hours.

The Bubble Humidiers where humidication is delivered by bubbling oxygen through sterile

water before it reaches the patient should not be used as they do not have clinical benet

but are potential risk for aerosol generation and secondary infections.1

In patients requiring Mechanical Ventilation using the type of Humidication is a clinical

decision. But during Covid 19 ventilation all patients should be placed on Heat and Moist

Exchanger (HME) at the onset to limit infection risk posed by aerosol generation.

Further down the course of illness if there is an increase in quantity or thickness of secretions,

the decision can be made to switch to a heated humidity system when clinically indicated.

The decision to change to heated humidity should be taken by clinician taking into account

the benets of the added humidity with the increased risk of aerosolization should the

ventilator circuit become accidentally or incorrectly disconnected.2

HME with an electrostatic bacterial Filter (HMEF) should be considered to reduce exhaled

pathogens. Out of 2 types of bacterial lter, a pleated hydrophobic lter is more suitable

than an electrostatic lter in a humidied ventilator system to nullify the effect of condensate

on increasing resistance.3 HME should be placed between the exhalation port and ET Tube.

HMEF should not be used in copious and thick secretions or low tidal volumes which are

commonly found in severe Covid 19 pneumonia and this category of patients rather may

need to receive heated humidication.

Aerosol precautions should be taken while changing the HME or ventilator circuit to

decrease the exposure. While changing the HME or dual-limb heated ventilator circuit, the

ventilator should be placed on “stand-by” or “off “mode. If disconnection is required the ET

Tube should be temporarily clamped between disconnection and reconnection.2

HMEF may be changed at intervals as short as 12 hours or as long as every three to ve days,

depending on the patient-ventilator system and secretions. In settings where inexperienced

operator fail to identify moisture build up and signs of failing Filter, it is better to proactively

change the HMEF every 24 hours.2

It is strongly recommended to use high-efciency particulate air (HEPA) lter at the

expiratory port of the ventilator as an alternative to an HMEF for pathogen ltration in a

humidied ventilator system.4

Recommendations:

The ISCCM recommends that

•Bubble Humidiers may be avoided during management of acute phase of COVID illness (

BPS)

•HME humidiers are preferred to minimise aerosolization (Recommendation)

•Aerosol limiting precautions should be taken during change of lters and humidiers (Strong

Recommendation)

2.2 MONITORING

Pulse oximetry

Rationale: In all hospitalized patients saturation measurement by pulse oximetry should be

done. In ward patients it should be done as prescribed or at least every 6 hourly or more

frequently if there is clinical deterioration in form of increase in dyspnoea, cough and altered

mentation. In patients admitted to ICU continuous pulse oximetry is recommended.

Blood Gas Analysis

Rationale: Arterial blood gases (ABGs) are recommended in:

1. Unexpected hypoxemia (oxygen saturation, <94% or requiring supplemental oxygen to

maintain this)

2. Critically ill patients

3. Increasing oxygen requirement, decreasing saturation or increasing dyspnoea in a

previously stable patient.

4. Patients at risk of type 2 respiratory failure or other symptoms suggestive of hypercapnia.

5. Patients who are at risk of metabolic acidosis (e.g. diabetes and renal failure)

6. Unreliable oximetry signal due to poor peripheral circulation.

PaO2 / FiO2

Rationale: PaO2/FiO2 ratio is a measure of hypoxemia in respiratory failure widely known in

clinical practice due to its ease of use. It is an apt assessment of respiratory failure due to lung

parenchymal damage with subsequent shunt effect. The Berlin denition proposed 3

mutually exclusive categories of ARDS based on degree of hypoxemia: mild (200 mm Hg <

PaO2/FIO2 ≤ 300 mm Hg), moderate (100 mm Hg < PaO2/FIO2 ≤ 200 mm Hg), and severe

(PaO2/FIO2 ≤ 100 mm Hg) with PEEP/ CPAP > 5 mm Hg.

SpO2 / FiO2

Rationale: There are several studies suggesting role of SpO2/ Fio2 in detecting early ARDS in

Covid 19 to facilitate early adjustment of treatment and overall survival. The advantages

include continuous measurement and non-invasive nature.

The SpO2/FIO2 less than or equal to 315 (with a requirement of Spo2 ≤ 97%) for the hypoxia

cut-off, directly corresponds to a PAO2/FIO2 ratio of 300.

The SpO2/FiO2 identied patients at high risk of HFNC failure when this index is <4.88 at

12hours. This threshold was conrmed also in COVID-19 patients who show, however an

unusually high rate of intubation.

Recommendations:

The ISCCM recommends that

• Pulse oximetry be used for monitoring all hospitalised patients (Strong Recommendation)

• ABG assessment be used for high-risk patients (Strong Recommendation)

• PaO2 / FiO2 be used to assess severity of ARDS (Strong Recommendation)

• SpO2 / FiO2 be used only in the absence of ABG assessment (BPS)

REFERENCES:

1. B R O Driscoll et al. BTS guideline for oxygen use in adults in healthcare and emergency

settings. Thorax 2017;72: i1–i90.doi:10.1136/thoraxjnl-2016-209729.

2. NH Regional Ventilator Humidication Guideline for Novel Coronavirus (COVID-19): NH

Respiratory Working Group Final May 5, 2020.

3. Wilkes AR. Heat and moisture exchangers and breathing system lters: their use in

anaesthesia and intensive care. Part 2–Practical use, including problems, and their use with

paediatric patients. Anaesthesia 2011; 66:40–51.

4. Hui-Ling Lin MSc et al. Managing humidity support in intubated ventilated patients with

Corona virus disease 2019 (COVID-19): Infection Control & Hospital Epidemiology (2020),1–2.

https://doi.org/10.1017/ice.2020.418.

5. World Health Organization: Open Who Clinical Care Severe Acute Respiratory Infection:

Module 9 Mechanical Ventilation. 2020. Retrieved March 26, 2020.

6. Clinical management protocol for covid 19 (in adults). Govt of India. Ministry of health

and family welfare. Version 6: 24.05.21

7. Emergency oxygen therapy: from guideline to implementation Breathe | June 2013

|Volume 9|No 42.

8. Acute Respiratory Distress Syndrome. The Berlin Denition. The ARDS Denition Task Force:

JAMA. 2012;307(23):2526-2533. doi:10.1001/jama.2012.5669.

9. Elisabeth D. Riviello Hospital Incidence and Outcomes of the Acute Respiratory Distress

Syndrome Using the Kigali Modication of the Berlin Denition

10. CLINICAL MANAGEMENT PROTOCOL: COVID-19 Government of India Ministry of Health

and Family Welfare Directorate General of Health Services (EMR Division) Version 4 27.06.207

11. Zucman N, Mullaert J, Roux D, Roca O, Ricard JD. Prediction of outcome of nasal high

ow use during COVID-19 -related acute hypoxemic respiratory failure. Intens Care Med.

2020 Oct;46(10):1924

SECTION 3: PRESCRIPTION AND LOGISTICS

3.1 PRESCRIPTION:

Rationale: Oxygen is a therapeutic agent. The administration of oxygen has to be governed

by the same principles that govern all other prescriptions for patients. This will help in

conserving a resource which has witnessed scarcity in both the waves of the pandemic. The

prescription should include

a) O2 ow rate

b) FiO2

c)Target SpO2 & PaO2

d) O2 delivery device settings

Oxygen therapy should be deescalated based on clinical improvement which has to be

monitored very frequently. The monitoring frequency has to be part of the prescription along

with the interface to be used. Due care should be taken to ensure that the interface is a

good t and leakages are minimised. Devices that can deliver metered doses of oxygen

should be used.

Recommendations:

The ISCCM recommends that

• Only high-quality medical grade oxygen be used for therapeutic purposes (Strong

Recommendation)

• Standard prescription format be followed for administration of oxygen (BPS)

• Adequate t of right size mask in patients receiving non – invasive ventilation be ensured to

avoid leakage (BPS)

• A standard prescription template be followed for all patients receiving oxygen (BPS)

3.2 LOGISTICS

3.2.1 Preparing for increased demand:

Rationale:

• Even production capacity of Oxygen in the various states of India along with

uninterrupted movement of medical oxygen is to be ensured to cope up to the increased

demand

• A sustained and continuously updated mapping exercise of the sources of supplies with

the demand of medical oxygen to the critically affected States depending on expected

active case load should be undertaken at different levels

• Establish minimum disruptions in existing oxygen supply chains. if the normal supply chain is

disrupted to any hospital for any reason. The emergency stocks should be created without

undue delay and replenishment of the emergency stocks will also need to be monitored on

a real time basis

• Production of liquid medical oxygen in steel plants and by private manufacturers should

be ramped up with restrictions on use of oxygen for industrial use .

• Commissioning of PSA plants: Pressure Swing Absorption to generate oxygen at a local

level. PSA plants should be established in hospitals to enable self-sufciency in generation of

oxygen

• Availability of cylinders to meet the surge in oxygen demand.

Recommendations

The ISCCM recommends that

• A concerted administrative decision should be taken by the Executive to ensure optimum

generation and rational distribution of Oxygen to the hospitals (BPS)

3.2.1 Minimising Wastage:

An Oxygen Central Command needs to be constituted in every health care facility to

• Do their own daily oxygen audits in ICUs / Wards

• Keep a close watch on patients on oxygen therapy and observe its consumption regularly.

• Prioritize oxygen supply to the critical areas

• Monitor storage capacity and ensure at least 50% stock availability

• Anticipate shortage and timely information to be passed to district and state level

authorities

Usage of Equipment should be optimised to minimise wastage. Several steps may need to

be followed to achieve this objective including

• Using non- breathing bag with optimally tting mask.

• Ensuring adequate t of right size mask in patients receiving non – invasive ventilation to

avoid leakage .

• Encouraging to keep patient’s mouth closed during HFNC use

• Use of triple layer mask over HFNC can reduce oxygen usage

• Ensuring right size of endotracheal tube with optimal cuff pressure so as to minimize

leakage

• Using closed suction device thus preventing de- recruitment during open suctioning

• Switching to stand by mode when disconnecting the ventilator NIV from patient as in

during feeding . Instead oxygen can be supplemented with nasal prongs/ cannula while

feeding .

• Installing devices that can deliver metered doses of oxygen .

• Selecting the most appropriate equipment and set recommended oxygen ow so as to

maintain oxygenation goals

Recommendation: The ISCCM recommends that a formal team be constituted in all health

care facilities to monitor oxygen therapy and optimise the utilisation (BPS)

REFERENCES:

Covid-19 and oxygen: Selecting Supply Options in LMICs that Balance Immediate Needs

with Long-Term Cost-Effectiveness, Lisa Smith, Tim Baker, Gabriel Demombynes, and

Prashant Yadav ,center for global development, May 2020

GASPING FOR AIR ,The deadly shortages in medical oxygen for COVID-19 patients MSF

Brieng Paper May 2021

Oxygen sources and distribution for COVID -19 treatment centres ,Interim guidance 4th April

2020 – WHO

Advisory regarding rational use of oxygen during COVID pandemic, Health and family

welfare department government of Kerala

Priority for optimum use of oxygen, THE Hindu MAY 14, 2021

In The Supreme Court Of India Civil Original Jurisdiction Suo Motu Writ Petition (Civil) No.3 Of

2021 ,In Re: Distribution Of Essential Supplies And Services During Pandemic.

Authors

1. Dr Srinivas Samavedam, Head, Critical Care and Medical Director, Virinchi Hospital,

Hyderabad - [email protected]

2. Dr Lalita Gouri Mitra, Professor and Ofcer in Charge – Department of Anaesthesia, Critical

Care and Pain, Homi Bhabha Cancer Hospital and Research Centre, Medicity, Mullanpur

and Homi Bhabha Cancer Hospital, Sangrur

[email protected]

3. Dr Ketan Kargirwar, Consultant, Critical Care Medicine, Sir HN Reliance Foundation

Hospital and Research Centre, Mumbai - [email protected]

4. Dr Pragyan Kumar Routray, Consultant and HOD, Critical Care, Care Hospital,

Bhubaneswar.- [email protected]

5. Dr Jaicob Varghese, Senior Consultant and Head, Department of Critical Care, Rajagiri

Hospital, Kochi - [email protected]

Dr Manoj Raju Prabhandakam, Registrar, Critical Care, Virinchi Hospital, Hyderabad -

[email protected]

Reviewer Dr Subhal DixitDirector,Critical CareSanjeevan & MJM HospitalPuneEMAIL: [email protected]