Covid -19 Changing Medical Practices

COVID-19 changing medical practices

Foreword By: Dr. Jaideep Malhotra Dr. Narendra Malhotra Dr. Ragini Agarwal

Edited By: Dr. Jyoti Malik

Endorsed By:

Haryana Association of Obstetricians & Gynaecologists HarObGyn

COVID-19, CHANGING MEDICAL PRACTICES

covid-19, changing medical practices editor: dr Jyoti malik C Dr Jyoti Malik Dr. Jyoti Malik ROOTS IVF & Fertility Centre (a unit of JJ Institute of Medical Sciences Pvt. Ltd.) MIE, Opposite Metro Pillar No.-792, Bahadurgarh, Haryana-124507.

Ph: 7056100100, 7056108108 Mobile: 9811226648 Email: ms@jjmedicalinstitute.com, rootsivf@jjmedicalinstitute.com Website: http://rootsivf.com

First Edition: July 2020 Price: Free ISBN: 978-81-932743-8-5 Published by: Pugmarks Mediaa, 119, Swami Vivekanand Marg, Allahabad 211003 (UP), India Ph: 9956285988 Email: bhargavavicky@rocketmail.com Cover Design: Raj Bhagat Design: Team IVF India, www.theivfindia.com

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FOREWORD

Dr. Narender Malhotra

Dr. Jaideep Malhotra

It’s our great pleasure to write a foreword for this COVID update manual edited by Dr. Jyoti Malik.

The world today is facing an unpredicted medical crisis. In 2020, supposedly the most advanced year in the history of mankind, life has come to a halt due to a smallest microscopic virus called CORONA. This manual beautifully describes all the aspects of COVID 19, now renamed as SARS-COV-2.

This knowledge of this disease is changing every day and new evidence seems to crop up just when we think that we are wining our war.

Friends as of today 12th of June 2020 there is no drug, no treatment and no vaccine available. Plus, what we thought will work, does not work and surprisingly over 1700 papers have been published some of the reputed journals have fallen in disrepute for publishing papers not backed with data.

The only way out of this pandemic is: - SMS (Sanitize, Mask, Social Distancing)

dr. narendra malhotra

dr. Jaideep malhotra

M.D., F.I.C.O.G., F.I.C.M.C.H, F.R.C.O.G., F.I.C.S., F.M.A.S., A.F.I.A.P.

M.D., F.I.C.M.C.H., F.I.C.O.G., F.I.C.S., F.M.A.S., F.I.A.J.A.G.O., F.R.C.O.G., F.R.C.P.I.

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FOREWORD

Dr. Ragini Agrawal It is my proud privilege to write foreword for E-book on COVID edited by Dr Jyoti Malik.

Covid -19 has taken world for surprise and changed everything.

Medical crisis generated by this pandemic is unforeseen. Guidelines are ever changing.

Its effect is long lasting.

Many practices in medical world will be changed forever.

I congratulate Dr. Jyoti Malik for bringing out this book which is needed this time.

HARObGyn is proud to have dynamic secretary like Dr. Jyoti Malik. All members and medical fraternity will be benefitted with this short and crisp EBOOK. “BE SAFE, BE POSITIVE AND HUMAN KIND WILL COME OUT AS WINNER”

dr. ragini agrawal MS, FICOG, FICMCH Fellow clinical Gyne endoscopy UK Master course Cosmetic Gynaecology & Laser (Europe & American Academy of Aesthetic Medicine) President- HARObGyn Vice President- FOGSI 2020

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INDEx S. No.

topic

article By

page no.

1.

SARS COV2 Disease & Primary Prevention

Dr. Priya Varshney & Dr. Narendra Malhotra

6–9

2.

Pregnancy with COVID-19

Dr. Jyoti Malik

10 – 20

3.

Endoscopic Surgery during Covid-19 Pandemic Dr. Dinesh Kansal

21 – 26

4.

Safety Measures for Ultrasound Establishments Dr. Poonam Goyal in Covid Pandemic

27 – 31

5.

Managing your Business in Changing Scenario Dr. Ragini Agrawal of Ob Gyn Practice in Post Covid Era

32 – 33

6.

Covid & Respiratory System: A Hand in Hand Saga

Dr. Sushil Dhamija

34 – 38

7.

The way, we are opening surgical services especially coloproctology services in semi urban Haryana

Dr. Sanjay Singla

39 –50

8.

COVID 19 and Semen

Dr. Raman Tanwar

51 –52

9.

ICU Management of COVID 19 Patients

Dr. Naveen Malhotra

53 – 63

10.

General Consideration to Restart IVF Lab in COVID-19

Dr. Praveen Km Upadhyay 64 - 66

11.

Safety and prevention from COVID-19

Dr. Narendra Malhotra

67 - 70

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SARS Cov2 Disease & Primary Prevention dr. priya varshney (M.D.) Gynaecologist & Fertility Specialist, Cloud Nine Hospital, Gurugram

dr. narendra malhotra M.D., F.I.C.O.G., F.I.C.M.C.H, F.R.C.O.G., F.I.C.S., F.M.A.S., A.F.I.A.P. Managing DirectorGlobal Rainbow Healthcare, Agra Prof.- Dubrovnick International University Director- IAN Donald School (India) V.P. WAPM (world association of prenatal medicine) Member Education Committee IAPM Past President ISPAT (2017-2019), ISAR (2017) Past President FOGSI (2008) Founder Editor SAFOG Journal

epidemiology: The first case of Covid 19 has been reported from Wuhan, a city in Hubaei province of China. The epidemic in china peaked between late January and early February 2020 and new cases decreased substantially by early march.

SARS COV2 disease has worldwide spread, it involved all continents except Antarctica. Till date (10th may 2020) it has affected 213 countries. Most affected countries are USA, Spain, Italy, France, Germany, UK, Turkey, Iran, China. [1] World statistics: (as on 10th may) Total no of infected people- 3,917366 Total number of deaths -274361 indian statistics: First case was reported in India on 30th January 2020 at trissur, Kerala. Thereafter the disease is on rising trend with a fatality rate of 3.35%. The quoted infectivity rate in India is 1.7, which is lower than what has been observed in worst affected countries.

Total number of active cases- 41472 Total number of deaths-2109 Most affected states in India are Maharashtra (20,228), Gujarat (7796), Delhi (6542) & Tamil Nadu (6532). No confirmed case has been reported from Sikkim and Lakshadweep till date. [2]

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mode of transmission: There is various mode of transmission from person to person but exact mode is not known.

1. droplet transmission: This mode is presumed to be most common mode of spread. When a person with infection coughs, sneezes, talks, virus is released in the respiratory secretions and

can infect other person especially if it comes in close contact with mucous membrane. These droplets typically do not travel more than six feet (about two meters).

2. environmental transmission: This mode of transmission is unclear. Virus present in contaminated surfaces can infect others if susceptible individuals touch these infected surfaces and touch their face, mouth, nose after that. The persistence of virus in contaminated surface depends on surrounding temperature, humidity, size of inoculum. This mode of transmission works especially in setting where there is heavy viral contamination like household of infected person and health care facility.

3. air borne transmission: SARS CoV2 viral transmission can be possible by air borne infection i.e. by particle size, less than size of droplet that can remain in air over time and distance. This mode of transmission is controversial and has not been well documented in study.

4. others secretion: SARS CoV2 RNA virus is also documented in non-respiratory secretions like stool,

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ocular secretion, peritoneal secretions long after the virus has been cleared from respiratory secretions. [3] But potential risks of transmission from these sites is uncertain.

The detectable viral RNA in any secretions doesnâ&#x20AC;&#x2122;t always correlate with presence of infectious virus. In one study it has been shown that there may be threshold (<10^6) of viral RNA level below which infectivity is unlikely. [4] 5. transmission through animals: The source of origin of this virus thought initially is from an animal, but there has been no evidence that SARS- CoV-2 infection can be transmitted to humans through domestic animals. primary prevention: To prevent community transmission following precautions should be taken as primary prevention1. social distancing- Keep 6ft (2m) distance between each other. Stay at home as much as possible; avoid visiting crowded places and close contact with ill individuals.

2. hand washing- One should practice frequent hand washing, sanitizing hands with 60 percent alcohol, after every 20 minutes, especially after touching public surfaces.

3. respiratory hygiene- Cover the face and mouth while coughing or sneezing.

Avoid frequent touching of face esp. eyes, nose and mouth. Avoid using contact lenses.

4. Use of face masks- For people who does not have respiratory symptoms WHO does not recommend wearing a face mask. Recommendation on use of masks by healthy people of community vary from country to country.

WHO recommends face masks universally to: â&#x20AC;˘ health care professionals

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• symptomatic covid 19 patients • those who are taking care of covid19 positive patients.

5. isolation- Isolation of covid-19 positive symptomatic patients for the duration of illness. For asymptomatic contacts or those who has a close contact with positive cases, self-isolation is recommended. vaccines: Till now no vaccine has been developed which can provide protection against this Covid 19 infection. The first vaccine to undergo preliminary study in humans in the United states uses a messenger RNA platform to result in expression of the viral spike protein in order to induce an immune response. [8] post exposure prophylaxis: Clinical trials are being conducted everywhere to evaluate the safety and efficacy of post exposure drug prophylaxis against COVID19, but till now no effective postexposure prophylaxis has been recommended out of a clinical trial. [9] references: 1. https://www.who.int/docs/default-source/coronaviruse/situation-reports 2. www.mohfw.gov.in/index.html 3. Pubmed: Detection of SARS-CoV-2 in Different Types of Clinical Specimens.AUWang W, Xu Y, Gao R, Lu R, Han K, Wu G, Tan W SOJAMA. 2020; 4. PubMed: Virological assessment of hospitalized patients with COVID-2019.Wölfel R, Corman VM, Guggemos W, Seilmaier M, Zange S, Müller MA, Niemeyer D, Jones TC, Vollmar P, Rothe C, Hoelscher M, Bleicker T, Brünink S, Schneider J, Ehmann R, ZwirglmaierK,Drosten C, Wendtner C Nature. 2020; 5. World Health Organization. Novel Coronavirus (2019-nCoV) technical guidance.

6. Centers for Disease Control and Prevention. 2019 Novel coronavirus, Wuhan, China.

Information for Healthcare Professionals.

7. uptodate.com/contents/coronavirus-disease-2019-covid-19-epidemiology-virologyclinical-features-diagnosis-and-prevention 8. https://clinicaltrials.gov/ct2/show/NCT04283461 9. Pubmed Use of antiviral drugs to reduce COVID-19 transmission.,Lancet Glob Health.

2020;8(5):e639. Epub 2020 Mar 19.

latest statistics (as on 24/07/2020) The coronavirus COVID-19 is affecting 213 countries and territories around the world.

WorldWide: Total Coronavirus Cases: 15,654,649 Total Deaths: 636,479 Total Recovered: 9,535,641 india: Total Coronavirus Cases: 1,288,130 Total Deaths: 30,645 Total Recovered: 817,593 Total Active: 439,892 Critical: 8,944

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PREGNANCY IN COVID-19 PANDEMIC dr. Jyoti malik MBBS, DGO, DNB, MNAMS, MRCOG-1, FICS Infertility Specialist & Lap Surgeon ROOT IVF & JJ Institute of Medical Sciences, Bahadurgarh, Haryana.

Vice-Chairperson and Past Secretary: Haryana- ISAR

dr. hena Kausar MBBS, MS (Obs. & Gynae) Consultant (Obs. & Gynae.): JJ Institute of Medical Sciences, Bahadurgarh,Haryana

introduction: Novel coronavirus (SARS-COV-2) is a new mutant strain of coronavirus causing COVID-19, first identified in Wuhan, China. It was declared as pandemic by world health organization on 11th March 2020. Other coronavirus infections are Middle East Respiratory Syndrome (MERS-CoV), Severe Acute Respiratory Syndrome (SARS CoV) etc. This epidemic has spread to 215 countries around the world. [1] India declared its first recognized case on 29 January 2019. transmission: • Globally most cases of COVID-19 have evidence of human to human transmission. Virus can be readily isolated from respiratory secretions, faeces and fomites.

• With regard to vertical transmission (transmission from mother to baby antenatally or intrapartum), emerging evidence now suggests that vertical transmission is probable, although proportion of pregnancies affected and the significance to the neonate has yet to be determined. Two reports have published evidence of IgM for SARS-CoV-2 in neonatal serum at birth. [2,3] Since IgM does not cross the placenta this indicates neonatal immune response to in utero infection.

• A case series published by Chen et al, tested amniotic fluid, cord blood, neonatal throat swabs, genital fluid and breast milk samples from COVID-19 infected mothers and all samples tested negative for virus. [4,5,6,7] • At present there are no recorded COVID-19 positive cases from vaginal secretion infections.

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measures for pregnant women to prevent covid-19 infection: The greatest tool to prevent COVID-19 infection for pregnant patient and in the general population is social distancing. [8] Some important aspects from the advisory for pregnant women in India are: • Disinfection of surfaces to reduce fomites related spread.

• For women working outside the house, it is preferable to take work from home.

• Keeping a distance of at least one meter in various necessary interactions and activities.

• Avoid non-essential travel. If travel is undertaken, it is preferable to use a private vehicle. If public transport is used, distance should be maintained.

• Avoid gatherings and functions to celebrate the 7-month milestone, which is a common cultural practice.

• Minimize visitors from coming to meet the mother and newborn after delivery. precautions for healthcare workers: Healthcare workers are at high risk acquiring the COVID-19 infection while caring for patients. The three principles that healthcare workers should follow are social distancing, use of appropriate PPE correctly and chemoprophylaxis. The following measures may also be useful in addition to appropriate gear: • Maintain a distance of at least 1 meter from patients and from other healthcare workers. This is possible in clinic settings. However, this may not be feasible during examination of the patent, inpatient care and procedures.

• Remove non-essential items from the consulting or examination room to facilitate cleaning and disinfection and to reduce the risk of fomites related spread.

• Regular hand washing with soap and water or alcohol based rubs for at least 20 seconds.

• Patients should be offered surgical masks if they suffer from respiratory symptoms. effect of covid-19 on pregnancy: • Pregnant women do not appear to be more susceptible to infection with COVID19 than general population. Limited data are available at present but cases with concomitant medical disorders are to be taken care of as virus has tendency to be more virulent in immunocompromised or chronically ill patients.

• Majority of women will experience only mild or moderate cold/flu like symptoms.

Fever, cough and shortness of breath may be present.

• More severe symptoms like pneumonia and hypoxia are mainly seen in immunocompromised and in those with chronic illnesses such as diabetes, cancer and chronic lung and heart disease etc.

• Pregnant women with heart disease are at highest risk (congenital or acquired. [10] effect of covid-19 on the fetus: • Currently there is no data suggesting an increased risk of miscarriage or early pregnancy loss. There is no clear evidence of preterm birth or preterm rupture of membranes related to COVID-19 infection.

• There is no evidence suggesting this virus is teratogenic.

• COVID-19 infection is not an indication for Medical Termination of Pregnancy as of now.

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testing for covid-19 in pregnancy: Indications (Criteria): The currently recommended indications for testing for the general population (which also apply to pregnant women) as per the ICMR given on 09 April 2020 are as follows: [11] 1. All symptomatic individuals who have undertaken international travel in the last 14 days 2. All symptomatic contacts of laboratory confirmed cases 3. All symptomatic healthcare workers 4. All patients with severe Acute Respiratory illness (fever AND cough and/or shortness of breath. These are patients who have a severe illness which requires hospitalization.

5. Asymptomatic direct and high-risk contacts of a confirmed case should be tested once between day 5 and day 14 of coming in his/her contact.

6. All symptomatic ILI (fever, cough, sore throat, runny nose). ILI is an abbreviation for Influenza Like Illness a) Within 7 days of illness-RT-PCR b) After 7 days of illness- Antibody test (if negative, confirmed by RT-PCR) Recently pregnant women have been classified as a special category for testing and the current specific recommendations which have been added for them are: 7. Pregnant women residing in cluster/containment areas or in large migration gatherings/evacuees Centre from hotspot districts presenting in labour or likely to deliver in next 5 days should be tested even if asymptomatic. [12]The guidance further states that the testing should be carried out in the Centre where the woman is admitted for delivery and she should not be referred out for testing.

A pregnant woman who is presently asymptomatic should be tested for between 5 and 14 days of coming into direct contact and high risk contact of an individual who has been tested positive for the infection. test methods and facilities: The CDC recommends collection of nasopharyngeal swab specimen to test for COVID-19. [13] Detection of COVID-19 is done by reverse transcriptase polymerase chain reaction(RT-PCR) from a Centre authorized by Government of India and state governments. RT-PCR test is recommended by the ICMR. There are 10-30% chances of false negative results. In near future, testing may be done by Nucleic Acid Amplification Test (NAAT) or by serological testing. At population level to see the prevalence serological testing may be more feasible. After 3 weeks, the RT-PCR would be negative, but serology would give the diagnosis. other investigations: Other laboratory findings are leucopenia, lymphocytopenia, mild thrombocytopenia, mild elevation of liver enzymes and other acute infection markers. CT scan and other imaging modalities show patterns consistent with atypical pneumonia. Abdominal shield should be used if x-ray or CT scan is done in pregnant women after taking informed consent from patient and her relatives. notification of covid-19 cases: It shall be mandatory for all hospitals (Government and Private). Medical hospitals in Government health institutions and registered Private Medical Practitioners including AYUSH practitioners, to notify such person(s) with COVID-19 to

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concerned district surveillance unit.

Information of all such cases should be given to the state and national helpline number. Email can also be sent at ncov2019@gov.in.

Quarantine for pregnant women in the times of covid-19 pandemic: The term quarantine is separate restrict and the movement of well persons who are known to be exposed (directly or indirectly) or suspected to be exposed to a communicable disease to check if they become ill. Quarantine may be at home or in a facility designated by the states which includes hotels, hostels, hospitals or guesthouses. This is an effective measure against the spread of infection.

On the other hand, isolation refers to separation and restriction of movements of ill persons who have a contagious disease to prevent its transmission to others. It is typically done in hospitals or special facilities.

The criteria for quarantine are same for pregnant women and the general population. A contact in the context of COVID-19 is: • A person living in the same household as a COVID-19 case • A person having direct contact with a COVID-19 case or his/her infectious secretions without recommended personal protective equipment (PPE) or with a possible breach of PPE • A person who was in a closed environment or had face to face contact with a COVID-19 case at a distance of within 1 meter including air travel.

Instructions for contacts being home quarantined: the home quarantined person should follow these: • Stay in a well - ventilated single room preferably with an attached/separate toilet • If another family member needs to stay in the same room, it’s advisable to maintain a distance of at least 1 meter between the two.

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• Needs to stay away from the elderly people, pregnant women, children and persons with co-morbidities within the household.

• Restrict his/her movement within the house.

• Under no circumstances attend any social/religious gatherings e.g. wedding, condolences etc.

General health measures to be followed in quarantine include hand washing, avoiding to share fomites, wearing a surgical mask and changing it every 6-8 hours with correct disposal in 1% of hypochlorite solution. If symptoms appear during quarantine, the pregnant woman should contact a healthy facility telephonically and follow the given advice.

Family members of the pregnant woman quarantined at home should keep a distance at all times and to avoid direct contact with her and her fomites.

Disposable gloves should be used in case of soiled linen handling. Visitors should not be allowed and clothes should be washed separately.

The duration of home quarantine is about 14 days from the time of exposure to a confirmed case or earlier if test is done on a suspected case and it is negative. termination of pregnancy (mtp), sexual and reproductive healthcare in times of covid-19: Abortion care is an essential healthcare and the services therefore continue to be provided by both public and private providers. medical management and drugs used in the treatment of covid-19 infection in pregnancy: Supportive therapy includes rest, oxygen supplementation, fluid management and nutritional care as per need.

There are two approaches of COVID-19 infection treatment. The first approach is to use the combination of Hydroxychloroquine and Azithromycin. These drugs are readily available and also cost effective in India. The other approach is to use antiviral drugs, some of which are not available in our country. hydroxychloroquine is given in a dose of 600mg (200mg thrice in a day with meals) and Azithromycin (500mg once in a day) for 10 days has been shown to give virological cure on day 6 of treatment in 100% of treated patients in one study. [14] The study included 20 treated patients with upper and lower respiratory symptoms. In this study, pregnancy was an exclusive criteria. However, as such, both these drugs have been used in pregnancy and during breastfeeding without significant effects on the mother on fetus. Alternative dosage regimens for hydroxychloroquine are to give 400mg twice a day on day 1 and then 400mg once a day for the next four days. Chloroquine can also be used as an alternative. The dose is 500mg twice a day for 7 days. Some authorities recommend that Azithromycin should be added only where there is a clinical suspicion of superadded bacterial infection.[15] antiviral therapy Lopinavir- ritonavir was the first antiviral combination used for the treatment of COVID-19 infection. This may be considered as a possible line of for patients who have chronic disease, immunocompromised or uncontrolled diabetes. However, there was no difference in time to clinical improvement or mortality at 28 days in a

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randomized trial of 199 patients with severe COVID-19 given lopinavirritonavir(400/100mg) twice daily for 14 days in addition standard care versus those who received standard of care alone. [16] Other agents such as Remdesivir are being evaluated in a randomized trial. [15] In India, some health authorities have prescribed a regimen of Oseltamavir 75mg twice a day for 5 days in conjunction with hydroxychloroquine. [17]At present, data on this regimen is limited but it is simple, cost effective and the drug is available easily. vaccine At present, a number of organizations in the public and private have initiated towards the development of the vaccine. It is estimated that a vaccine would be available only after 6-12 months. [18] other drugs Many other drugs used that are used in the treatment of pregnant women with COVID-19 infection are discussed below.

• NSAIDS: These are used in pregnant women with COVID-19 infection for symptomatic relief of fever and myalgia. Paracetamol is the preferred mainly.

Ibuprofen and other NSAIDS should be avoided as it may potentiate ACE receptors.

• Antenatal Steriods (fetal maturity): Steroid are recommended to enhance fetal lung maturity in situations of likely preterm delivery between 24-34 weeks of gestation. There is no documented evidence for the use of steroids in COVID-19 infection.

• Antibiotics: Appropriate antibiotics which are safe in pregnancy are given when there is suspicion of secondary bacterial infection.

• Oxygen: If there is difficulty in breathing, oxygen supplementation by nasal prongs/mask is given at 4-6 litres per minute. general advice for antenatal women: Medical History• A detailed travel history within last 14 days particularly • History of any exposure to people with symptoms of COVID-19 • Symptoms of COVID-19 • Coming from a hot spot area • Any immunocompromised condition antenatal care• Women should be advised to attend antenatal clinic minimizing it according to discretion of the maternal care provider at 12,20,28 and 36 weeks of gestation age, unless they meet self-isolation criteria • For women with mild symptoms, appointments can be deferred until 7 days after start of symptoms, unless symptoms (aside from persistent cough) become severe.

Daily fetal movement count to be maintained.

• For women who are self – quarantined because someone in their household has possible symptoms of COVID-19 then their appointments should be deferred for 14 days.

• If a woman misses her routine appointment for more than 3 weeks should be

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contacted. (In rural areas ANMs/ASHAs can contact by telephone/routine household visits with PPE) • If woman needed to visit her health care Centre then she should take her own transport or call 108, informing about her status to the attending staff.

• Staff should take PPE (personal protective equipment) precautions as per local guidelines while handling suspected or confirmed COVID-19 cases.

• If a woman was previously negative for COVID-19, if she presents with symptoms again, COVID-19 should be suspected.

• Women should be escorted immediately to isolation room, suitable for majority of care during hospital visit or stay.

• For overnight stays, isolation rooms should ideally have ante-chamber for donning and removing PPE equipment and ensuite bathroom facilities.

• Antenatal ultrasonography to be recommended for fetal growth surveillance 14 days after resolution of acute illness.

• All routine investigations should be minimized.

• At the time of discharge from hospital following a period of care for confirmed COVID-19 infection. All women should be prescribed at least 10 days of prophylactic low molecular weight heparin (LMWH). [19] intrapartum care • A protocol should be in place in every maternity unit to receive pregnant women with suspected or confirmed labour with suspected or confirmed COVID 19 infection. For healthcare workers previous mentioned protocols to be followed.

The following aspects to be borne in mind while in planning for this triage process: 8 The woman should call in advance to alert the maternity unit about her arrival if possible. This will give sometime to the healthcare workers to prepare in triage and don the PPE. 8 The woman should use private transport or an ambulance whenever possible to reach the maternity unit.

8 She should be met with appropriately donned PPE at the reception.

8 Reception and triage in the same room as to be used for admission in labour and delivery. This room should be a room with negative pressure but it is not available everywhere.

8 Keep the room free from any unnecessary items like decorations, extra chairs etc. which could act as infected fomite later on.

8 Restricted number of attendants should be allowed with the patient. There should be restriction on the entry and exit of no-essential staff inside the room.

The attendant of the woman should be treated as infected and all precautions should be taken.

• Once settled in isolation room, a complete antenatal and fetal assessment should be conducted following assessment of the severity of COVID-19 symptoms including multidisciplinary team approach along with consultant obstetrician, medical specialist (infectious disease specialist if available), consultant anesthetist, nursing in charge, delivery preferably at tertiary care centre, proper maternal vitals charting (temperature, respiratory rate, and oxygen saturation) • Confirmation of onset of labor to be done as per standard care.

• Women with mild COVID-19 symptoms can be encouraged for self-isolation at home in the latent phase of labor • Aim to keep oxygen saturation >94% and titrate oxygen accordingly.

• Continuous electronic fetal monitoring is recommended in labor by using

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cardiotocograph (CTG).

• (In two Chinese case series, including a total of 18 pregnant women infected with COVID-19 and 19 babies (one set of twins), there were 8 reported cases of fetal compromise). Given this relatively high rate of fetal compromise, continuous electronic fetal monitoring in labor is currently recommended for all women with COVID-19.

• If woman has signs of sepsis, investigation and treatment to be done as per guidance on sepsis in pregnancy but active COVID-19 to be considered as a cause of sepsis and investigate according to guidance.

• If maternal stabilization is required before delivery, this is the priority, as it is in other maternity emergencies e.g severe pre-eclampsia.[8] • Neonatal team should be informed in advance for delivery of moderate-severe COVID-19 patients.

• Mode of birth should not be influenced by the presence of COVID-19 infection, unless the woman’s respiratory condition demands urgent delivery.

• There is no evidence that epidural or spinal anesthesia is contraindicated in coronavirus infection. Epidural analgesia should be recommended in labor to women with suspected/confirmed COVID-19 cases to minimize the need for general anesthesia if urgent delivery is needed and there is a risk that use of Entonox may increase aerosolisation and spread of virus.

• If woman’s symptoms deteorate then individual assessment regarding the risks and benefits of continuation of labor versus caesarean section to be done.

• An individualized decision to cut short second stage of labor to be made for instrumental delivery in a symptomatic woman who is exhausted or hypoxic.

• All procedures either normal vaginal/instrumental/caesarean delivery to be done wearing PPE. • Due to lack of evidence, delayed cord clamping is still recommended after birth, provided there are no other contraindications. management of patients with covid-19 admitted to critical care: • Hourly monitoring with both absolute values and trends • Titrating oxygen saturation >94%

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• A rise in respiratory rate, even if saturations are normal may indicate deterioration in respiratory function and should be managed by starting or increasing oxygen.

• Radiographic investigations should be done as per non pregnant patient e.g chest x-ray, CT scan of the chest maintaining standard protocol of abdominal shield and not delayed due to fetal concerns.

• Consider additional investigations to rule out differential diagnosis e.g ECG, CTPA, echocardiogram etc. All pyrexia not to be assumed of COVID-19 and full sepsis screening to be performed.

• Apply caution with IV fluid management with special attention to avoid fluid overload. postnatal management • All babies of women with suspected or confirmed cases of COVID-19 need to be tested for COVID-19.

• Babies born to COVID-19 positive mothers should undergo appropriate close monitoring and early involvement of neonatal care, if necessary.

• Babies who are born to COVID-19 positive mothers need neonatal follow-up and ongoing surveillance after discharge.

• As per current limited evidence it is advised that women and healthy infants, not otherwise requiring neonatal care, are kept together in the immediate postpartum period.

• Literature from China advised separate isolation of infected mother and her baby for 14 days.

• The decision for discontinuation of temporary separation of the mother from her baby should be made on case-by-case basis.

• If colocation (“rooming in”) of the newborn with the mother is done in accordance with mother wishes or if unavoidable due to facility limitations, consider using physical barriers like curtain between mother and new-born and keep the new-born 6 feet away from the ill mother.

Breastfeeding: • Some viral infections like cytomegalovirus and HIV are transmitted through breast milk. However, at present there is no evidence that COVID-19 is secreted in breast milk. The CDC states that “we do not know whether mothers with COVID-19 can transmit the virus via breast milk”. [20] • For mothers who intend to breastfeed should be encouraged to express their breast milk to establish and maintain milk supply.

• Hand washing before touching the baby, bottles or breast pumps.

• Follow recommendations for breast pump cleaning after each use.

• Expressed breast milk should be fed to the new-born by a healthy care-giver.

• If mother wishes to feed at the breast, she should wear a fluid resistant surgical facemask and practice hand hygiene before each feeding.

• If a mother is confirmed with COVID-19 infection or who is a symptomatic and wishes for expression of breast milk with a manual or electric breast pump, the mother should wash her hands before touching any pump and bottle and should follow recommendations for proper cleaning of the pump after each use. diet for the pregnant woman and covid-19 infection • Diet has been the subject of, many controversies in the wake of the COVID-19 pandemic. There is no particular diet recommended to treat or use as part of the

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treatment against COVID-19 infection in a pregnant woman or in general population. There is no evidence that consumption of meat, chicken or eggs causes higher risk acquiring COVID-19 infection.

• Certain population of pregnant women who are at risk may have some benefits from dietary modifications like diabetic, obese or have other metabolic abnormalities by lowering infection risk. Based on the limited evidence dietary advice is generic and would include high protein diet, vitamin and micronutrients.

These natural sources are called superfoods and include citrus fruits, ginger, garlic, turmeric, broccoli, oregano oil and spinach. Liver detoxification is essential to reduce toxin burden on our body. Most the above lack any robust evidence, but by taking these measures will not do any harm, so they should be judiciously used in consultation with treating doctor. hospital discharge: • Test should be negative for both mother and new-born and condition should be stable.

• At the time of discharge from hospital following a period of care for confirmed COVID-19, which includes the birth of her baby, all women should be prescribed at least 10 days of prophylactic LMWH. [9]. This should be prescribed regardless of the mode of birth. A longer course should be prescribed if indicated by existing guidance. [21] • The discharge card from the maternity unit should be adviced about COVID-19 infection in addition to the usual post–delivery instructions. It should emphasize social distancing the need for evaluation if symptoms of acute respiratory illness (SARI) is arising after delivery.

References: 1. WHO. Coronavirus disease 2019 (COVID-19) situation report 46. March 6, 2020. https://www.who.int/docs/default-source/coronavirus/situation reports/20200306sitrep-46-covid-19.pdf?sfvrsn=96b04adf_2 2. Dong L, Tian J, He S,et al. Possible vertical transmission of SARS-COV-2 From an infected mother to her newborn. JAMA 2020 doi:10.1001/jama.2020.4621 3. Zeng H, Xu C, Fan J, et al. Antibodies in Infants Born to Mothers with COVID-19 Pneumonia. JAMA 2020 doi:10.1001/jama2020.4861 4. Chen H, Guo J, Wang C et al, Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. Lancet2020;395:809-815 5. Chen Y, Peng H, Wang L et al. Infants born to mothers with a new coronavirus (COVID-19). Frontiers in Pediatrics 2020;8 (108) doi:103389/fped.2020.00104 6. Li N, Han L, Peng M, et al. Maternal and neonatal outcomes of pregnant women with COVID-19 pneumonia: a case control study. Pre –print doi: 10.1101/2020.03.10.20033605 7. Zhu H,Wang L, Fang C, et al. Clinical analysis of 10 neonates born to mothers with 2019-nCoV pneumonia. Trans Pediatr. 2020;9:51-60 8. [Online][Cited: April 18 ,2020.]https://www.mohfw.gov.in/social distancingAdvisorybyMOHFW.pdf.

9. The First Affiliated Hospital, Zhejiang University School of Medicine. Handbook of COVID-19 Prevention and Treatment. Wuhan : Jack Ma Foundation,2020. https://covid-19.alibabacloud.com/.

10. ICMR : Guidance for management of pregnant women in COVID-19 Pandemic(1.1)

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11. India Council for Medical Research Department of Health Research. Strategy for COVID-19 Testing in India Version 4.[Online]April 09,2020. [Cited: April 22, 2020].https://icmr.nic.in/sites/default/files/upload_documents/Strategy_for_COVID19_Test_v4_09042020.pdf 12. Ministry of Health and Family welfare Department of Health Research. Strategy for COVID-19 testing for pregnant women in India Version 1.[Online] April 20,2020 [Cited: April 22,2020] https://icmr.nic.in/sites/default/files/upload_documents/COVID19_testing_strategy-_for_pregnant_women.pdf.

13. Centre for Disease Control, USA. Coronavirus laboratory testing guidelines[Online][Cited: April 19),2020.]https://www.cdc.gov/coronavirus/2019nCoV/lab/guidelines-clinicalspecimens-specimens.html.

14. Hydroxychloroquine and Azithromycin as a treatment of COVID-19: results of an open label non-randamised clinical trial. GautretP,LagierJC, Parola P et al. : Int J Antimicrob Agents,2020,Vol. Mar 20:105949.10.1016/j.ijantimicag.2020..105949.

15. Writing Group of the JohnsHopkins Universityand Johns Hopkins HospitalCOVID19 Treatment Guidance Working Group. JHMI Clinical Guidance for Available Pharmacological Therapies for CVID-19.[Online] [Cited:April19,2020]. https://www.hopkinsguides.com/hopkins/ub?cmd=repview&type=4791116&name=4_538747_PDF 16. A trial of Lopinavir-Ritonavir in adults hospitalized with severe COVID-19. Cao B,Wang Y, Wen D, Liu W et al. :n Engl J Med,2020, Vol. 2020 Mar 18.

10.1056/NEJMoa2001282.

17. Health Department, Government of Maharashtra. Treatment Protocols for COVID19.[Online]March 24,2020. [Cited: April 20, 2020]. https://arogya.maharashtra.gov.in/1175/Novel--Corona-Virus.

18. World Health Organisation. Draft Landscapeof COVID-19 candidate vaccines.[Online] WHO. March 20,2020. [Cited: March 28,2020.]https://www.who.int/blueprint/priority-diseases/key-action/novelcoronavirus-landscape-ncov.pdf?ua=1 19. The Royal College of Obstetrics and Gynaecology, COVID-19 Infection in Pregnancy; Version 8[online] April 17,2020. Accessed on April 19,2020.

20. Centre for Disease Control ,USA. Breastfeeding in Coronavirus Disease (COVID-19).

[Online] [Cited: April 19,2020.]https://www.cdc.gov/breastfeeding/breastfeedingspecial-circumstances/maternal-or-infant-illnesses/covid-19-and breastfeeding.html 21. Reducing the risk of Venous Thromboembolism during Pregnancy and the puerperium. In: Royal College of Obstetricians and Gynaecologists, ed. Green - top guidelines,2015

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Endoscopic Surgery During The Covid-19 Pandemic Background: COVID-19 pandemic disease is yet an enigma. SARS CoV 2 virus is essentially a respiratory virus. Although, its transmission through body fluids has not been proven, a possible transmission during endoscopic procedures cannot be ignored. In fact, majority of the actions taken during this pandemic have been made in the absence of hard data to support them. As a logical and necessary part of the country’s response to COVID-19 pandemic, elective surgery has been suspended throughout. In addition, the persistence of coronavirus circulating in the population and within hospitals poses a further challenge to patient safety, staff safety and efficient perioperative care processes. The challenge of providing safe pathways through the hospital system for patients at low or high risk of COVID-19 and of protecting staff and other patients from hospital acquired infection, will demand resources and time.

Urgency of surgical treatment: Most of the health systems all over are implementing plans to postpone elective and non-urgent procedures. This is part of the strategies to mitigate spread of the virus and to maximize health care resources. There will be a need to have clear prioritisation of surgical procedures. COVID-19 positive patients may be best served by delaying surgical procedures until their infection is resolved. However, in some instances, gynecologic surgical care may be deemed essential and unable to be delayed. Attention has been drawn to a potential increase in postoperative morbidity and mortality in patients who undergo major surgery during the incubation period of COVID-19 infection, as reported in China. The evidence is of low quality, with few and heterogeneous cases included in an observational study, and large disparities in the complexity and type of surgical intervention. emergency surgeries where laparoscopy may be offered are: • Ectopic pregnancy • Acute adnexal conditions like torsion • Oncosurgery if other treatment options are not suitable (e.g. early Cancer Cervix in young patient, early endometrial cancer).

• Severe AUB not responding to conservative therapy -

dr. dinesh Kansal President Delhi Gynae Endoscopic Society Director & HOD at BLK Super-Specialty Hospital, Delhi Laparoscopic & Robotic surgeon trained at Harvard, Boston

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Hysterectomy or TCRE. • Postmenopausal bleeding requiring endometrial sampling/biopsy (OPD sampling if possible).

• Surgeries to treat post-operative complications.

• Surgery cannot be deferred due to life- threatening conditions. safety strategies for surgery: All Standard Operating Procedures for surgical services, operating theatres and critical care should be in place and need careful review and adjustment in future as necessary. Surgeries in Covid crisis are planned depending on availability of these resources: Staff, Equipment and Systems. pre-operative evaluation: The COVID-19 status of every patient should be evaluated by pre-operative screening including history, physical exam and patient questionnaire regarding flu-related symptoms and exposures. When possible, COVID-19 testing should be undertaken for symptomatic and at-risk patients prior to surgery. As testing becomes more readily available, universal testing for COVID-19 may be recommended. Considerations should be made based on the prevalence of disease on a local level regarding the interpretations of test results due to the risk of false negative results early in the course of disease. Patients with unknown COVID-19 status may be considered positive until proven otherwise as there is considerable concern over the potentially severe impact of COVID-19 on patients who have undergone surgery.

Every member of the team should be either COVID-19 negative or should have recovered from symptomatic COVID-19 with negative reverse transcriptase– PCR tests or after specific immunity testing (IgM-negative and IgG-positive for SARSCoV-2). A surgeon should avoid operating at multiple centers and restrict himself/herself to a single center only to prevent cross-contamination between centers and avoid the need for isolating healthcare workers at multiple locations if someone tests positive. personal protective equipment (ppe) for operating room personnel: The risk of generating contaminated aerosols may potentially be lower with laparotomy.

However, to our knowledge, with the current few data, there is no evidence of an increased risk of COVID-19 transmission during gynaecological laparoscopic surgery when Personal Protective Equipment (PPE) is used.

Hence, it is recommended that anyone working in the operating room utilises full PPE, which includes shoe covers, impermeable gowns, N-95 masks, protective head covering, double gloves and eye protection. In addition, movement of personnel in and out of the operating room should be strictly limited, with efforts made to limit staff breaks mid-case when possible.

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Only personnel essential to the safe performance of the operation is allowed in order to avoid exposure and preserve PPE resources. aerosol generating procedures (agp): The risks entailed in performing laparoscopic surgery during this pandemic are twofold; namely general anesthesia and surgery itself; as both cause aerosol generation in surgical environment. anesthesia: Aerosol is produced during general anesthesia while suctioning, intubation and extubation. Premedications and analgesics must be provided so as to decrease cough reflex and avoid splash of secretions. The patient should be intubated by an experienced anesthetist to avoid multiple attempts, preferably using fiber-optic video laryngoscope and an aerosol box. nebulisation, supraglottic airway and high flow oxygen are to be avoided. Regarding hysteroscopic surgeries, oďŹ&#x192;ce hysteroscopy with sedation should suďŹ&#x192;ce in most of the cases. Otherwise regional anaesthesia ought to be given for the procedures where anasthesia becomes mandatory. surgical concerns: The data on risk of surgical plume exposure and transmission of COVID-19 are limited. The concerns are also unproven in relation to COVID-19 disease transmission. There are strategies for all surgical approaches that can help mitigate the risk of exposing operating room personnel due to pneumo-peritoneum surgical smoke. It is known that other blood borne viruses like HIV, Hepatitis B and Hepatitis C are found to be present in surgical plume. But, SARS-coV-2 virus is aerosolized in surgical smoke or not has not been proven; if yes, is it infectious? Its presence in extra-pulmonary tissue except bowel is rare and the concentration is 1 in 1000 or less. Potential concerns exist regarding aerosolization of viral particles by electrosurgical and ultrasonic device use at the time of surgery, which could then theoretically be transmitted to the operating room environment.

Additionally, with laparoscopy or robot-assisted laparoscopy, sudden release of trocar valves, leaking valves or washers, non-air-tight exchange of instruments or specimen extraction via abdominal or vaginal incisions may potentially expose the health care team to aerosolized viral particles. While it is important to acknowledge these concerns, at present, they remain theoretical in relation to risk of transmission of COVID-19 to operating room personnel. There is no available evidence from the COVID-19 pandemic, or from prior global influenza epidemics, to suggest definitively that respiratory viruses are transmitted through an abdominal route from patients to health care providers in the operating room. ot protocols: The number of people in OT should be minimised; a drawback of laparoscopy being the number of personnel for laparoscopy in the operating room are more than laparotomy. Only the anesthetist & required personnel need to be present during induction of anesthesia. The surgical team should enter OT after induction.

Full PPE to be used by everyone entering the OT and infection control practices should be followed, as determined by hospital and endoscopy society protocol.

Anesthesia medications, sutures and other items that may be needed during surgery should be kept in the OT in the beginning itself. This will minimize persons

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going in and out of OT during the procedure. surgical strategies to avoid potential risk to surgical team: The following are intra-op surgical protocols recommended for best practice by expert opinions, when laparoscopy or robot-assisted laparoscopy is performed.

• The use of a sterile Camera cover is mandatory.

• Surgeon should ensure that there is no leakage of CO2 from trocars (check seals in reusable trocars or use disposable trocars).

• Should use minimum possible intra-abdominal pressure which is just adequate for a safe and comfortable laparoscopy procedure.

• Smaller skin incisions are recommended to avoid leakage from port site. Open trocar entry should not be used as it has more gas leaks (prior Verses insufflation or Direct trocar entry are preferable).

• Energy devices- The surgical smoke generated from electrosurgical devices contains blood, tissue particles, carbon, bacterial and viral DNA/RNA. Employ electrosurgical and ultrasonic devices in a manner that minimizes production of plume, with low power setting and avoidance of long dessication times.

• In addition, a laparoscopic suction may be used to desufflate the abdominal cavity; so as to avoid venting pneumoperitoneum into the room. Avoid rapid desufflation or loss of pneumoperitoneum, particularly at times of instrument exchange or specimen extraction. Tissue extraction should be performed with minimal CO2 escape (desufflate with closed smoke evacuation/filtration system or laparoscopic suction prior to making extraction incision, vaginal colpotomy, etc.) and avoid explosive dispersion of body fluids when retrieving specimens and removing trocars.

• Port closure devices allow leakage of pneumo-peritoneum, hence should be avoided. Fascia should be closed after desufflation of abdomen.

• Minimize blood/stool/fluid droplet spray or splash laparoscopically or during vaginal manibulation. smoke evacuation techniques • A closed release of pneumoperitoneum through the suction is recommended over direct release through trocar valves or through vagina after colpotomy • A central suction is preferred. If this is not feasible, a bottle suction with intervening 1% hypochlorite fluid trap to filter gas/fumes should be used • When available, use of an automated closed smoke evacuation/filtration system with Ultra Low Particulate Air Filtration (ULPA) capability or High Efficiency Air Filters (HPPA) is recommended. These are active Filters with continuous smoke filtration e.g. those offered by Ethicon, Valleylab, Storz etc.

• Fluid in the suction should be disposed off as positive/contaminated fluid in the bottle. hysteroscopic procedures:

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The risk of COVID-19 transmission during hysteroscopy with bipolar electrosurgical devices and normal saline as the infusion medium is unknown, but theoretically low. Standard droplet precautions are recommended for PPE. Suction must be attached to the outlet so as to minimize spillage of uterine fluids. safety of surgical route: We have to adopt the best surgical route for optimizing patient care and outcome, at the same time minimising risk to the surgical team. Consider medical/ Nonsurgical management and surgery should be postponed if not emergency. If cannot be avoided, vaginal or open surgeries would have preference over laparoscopic surgeries. Vaginal approach is a good alternative whenever feasible.

Collaboration with Anesthesiology colleagues and discussion of performing vaginal and open procedures under regional anesthesia is appropriate to avoid the aerosol generating events of intubation and extubation. Rarely, in a proven Covid positive patient, emergency surgery may have to be performed. Laparotomy under regional anesthesia is the safest route.

COVID-19 has been found in feces presumably thorough transmission from the naso-pharynx with ingestion into the gastrointestinal tract (29% of cases) and in blood samples in approximately 1% of cases. Thus, operations involving the bowel may have different implications than in gynaecology. Gynaecological operations that carry a risk of bowel involvement, however small should be performed by laparotomy. In a patient that tests negative for COVID-19, should laparotomy be considered a safe surgical approach? Laparoscopic surgery is associated with reduced morbidity, shorter hospital stays and quicker return to daily activities; all of which will benefit the patient and make better use of hospital resources, particularly at the time of the current pandemic. During laparotomy, similar concerns exist in relation to aerosolisation of viral particles with use of hand-held electrosurgical devices. Scavenging the plume is less efficient due to plume release directly into the operating room environment in an uncontrolled fashion. Instead of energy, sutures may be used as often as possible for hemostasis and pedicles.

Cautery pencil with suction device is a good option. Considerations regarding choice of surgical route include patient comorbidities (such as but not limited to obesity, diabetes, cardiovascular disease) which could result in higher morbidity from laparotomy procedures. Additionally, prolonged hospitalization for recovery after laparotomy could expose patients to higher risk of nosocomial infection including COVID-19, and could place a higher burden on the health-care system. restarting elective surgeries: SARS-CoV-2 is likely to be with us for many months and perhaps years. It is essential that when the resumption of planned surgery takes place, the surgical care is delivered safely, efficiently and in a sustainable manner; taking into account the staffing, environment and equipment needed to operate. Standards of safety for patients and staff must not be compromised by a determination to increase productivity. It is pertinent that the planned activity matches a realistic assessment of the ability of the staff and resources to deliver this activity. Relaxation of surgical restrictions or other factors may lead to a second surge in viral infection. If this surge occurs, future planning must take this into account. Any increase in surgical activity may need to be reversed. It is clear that returning to more normal levels of surgical activity will be highly challenging. This is an unusual time with rapidly

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evolving circumstances, and we would expect recommendations to change. We encourage individual physicians to work closely with their hospital systems to ensure that patient’s needs are being met and that time-sensitive procedures are not rendered inaccessible.

References: Guidelines from following:

other references: 1 Zhu N, Zhang D, Wang W, Li X, Yang B, Song Y et al.; China Novel Coronavirus Investigating and Research Team. A novel coronavirus from patients with pneumonia in China 2019. N Engl J Med 2020; 382: 727– 733.

2 Spinelli A, Pellino G. COVID-19 pandemic: perspectives on an unfolding crisis. Br J Surg 2020; https://doi.org/10.1002/bjs.11627 [Epub ahead of print].

3 Lei S, Jiang F, Su W, Chen C, Chen J, Mei W et al. Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection.

EClinicalMedicine 2020; https://doi.org/10.1016/j.eclinm.2020.100331 [Epub ahead of print].

4 Soreide K, Hallet J, Matthews JB, Schnitzbauer AA, Line PD, Lai PBS et al. Immediate and long-term impact of the COVID-19 pandemic on delivery of surgical services. Br J Surg 2020; https://doi.org/10.1002/bjs.11670 [Epub ahead of print].

5 Mayol J, Dziakova J. Value of social media in advancing surgical research. Br J Surg 2017; 104: 1753– 1755.

6 CovidSurg Collaborative. Global guidance for surgical care during the COVID-19 pandemic.

Br J Surg 2020; https://doi.org/10.1002/bjs.11646 [Epub ahead of print].

7 Society of American Gastrointestinal and Endoscopic Surgeons. SAGES and EAES Recommendations Regarding Surgical Response to Covid-19 Crisis; 2020. https://www.sages.org/ recommendations-surgical-response- covid-19/ [accessed 15 April 2020].

8 Royal College of Surgeons. Clinical Guide to Surgical Prioritisation During the Coronavirus Pandemic; 2020. https://www.england.nhs.uk/ coronavirus/wp-content/uploads/ sites/52/2020/03/C0221-specialty- guide-surgical-prioritisation-v1.pdf [accessed 15 April 2020].

9 American College of Surgeons. COVID-19 and Surgery; 2020. https:// www.facs.org/covid19/clinical- guidance [accessed 15 April 2020].

10 Peak CM, Kahn R, Grad YH, Childs LM, Li R, Lipsitch M et al. Modeling the comparative impact of individual quarantine vs. active monitoring of contacts for the mitigation of COVID-19. MedRxiv 2020.

11 J. Mayol1 et al, Spain. Elective surgery after the pandemic: waves beyond the horizon.

Published online in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.11688 12 Alp E et al.Surgical smoke and infection control. J Hosp Infect.2006; 62:1-5.

13 Snyman L et al. A randomised trial comparing laparoscopy with laparotomy in the management of women with ruptured ectopic pregnancy. S Afr Med J 2017;107: 258-263.

14 Wang W, Xu Y, Gao R, Lu R, Han K, Wu G, Tan W. Detection of SARS-CoV-2 in Different Types of Clinical Specimens. JAMA 2020 Mar 11. doi: 10.1001/jama.2020.3786.

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Safety Measures for Ultrasound Establishments in Covid 19 Pandemic introduction: In this pandemic caused by Covid-19 many things are going to change forever. This virus has been and will go on a ruthlessly killing spree till we find a cure or a vaccine. This Covid era will be a landmark for human race.

As we all know USG is an unmatchable diagnostic tool and has tremendous role in patient work up.

In the current pandemic situation, a doctor can get infected from the patient and vice versa as social distancing is not possible. So we need to do certain adaptations in our work lifestyle.

Therefore, proper knowledge of PPE’s and other precaution methods to reduce the hazard of SARS-COV-2 infection is must for all clinicians.

SFM and ISUOG have issued guidelines for safe practice of ultrasound.

This chapter is mainly based on those guidelines. important Facts: • Respiratory droplets from coughing, sneezing, loud conversation and direct contact are responsible for the spread of virus. This happens when body fluids touch another person’s eyes, nose or mouth, or an incision, laceration, or abrasion.

• Evidence suggests that healthcare workers must use appropriate PPE, even if they remain further than 1 m away from a symptomatic patient.

• It is very much possible that carriers may be asymptomatic.

• Therefore, it would be correct to presume that every patient and attendant is a potential source of infection.

• Every institution/clinic should have a modified protocol to enhance protection in Covid era.

• Take help of concerned local government authorities in case of any issue and follow government guidelines. hazards to healthcare professionals during Usg exam: There are multiple factors that can increase transmission from the patient to the healthcare worker and vice versa, for example: • Small examination rooms • Absent or restricted natural ventilation • Keeping the door closed while doing scan • Closed vent and air conditioning without HEPA filtration • Insufficient distancing between patient and examiner • Long examination time, especially in obstetric scans.

dr. poonam goyal M.B.B.S., M.D., FICOG Panchsheel Hospital, Yamuna Vihar, Delhi

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• Trans-vaginal and invasive procedures • Coughing, sneezing, loud conversation, anxious deep breathing and sighing by the patient and attendant • Repeated handling of transducers, machine desktops, keyboards, touch screens, trackballs. modified indications for performing Usg: • First Antenatal Scan to confirm Intrauterine pregnancy / Ectopic pregnancy can be avoided if there are no symptoms.

• Dating can be done at 11-13 week scan.

• Patients with threatened abortion have to be scanned at priority, whatever be the gestation.

• Second trimester scan should be given priority over first trimester.

• Routine growth and Doppler scan can be done at 36 weeks with biophysical profile.

• Decision making growth and Doppler scans have to be done at the stipulated time only.

• Avoid transvaginal scans unless absolutely necessary.

• Avoid invasive ultrasound procedures unless absolutely necessary.

On the whole one should avoid too many pregnancy scans, minimize the number according to need, specially in non-high risk cases.

patient scheduling: • Discourage walk in patients • Advance appointments to be given and that too with proper gap which can vary according to your set up.

• Availability of waiting space should be modified according to social distancing norms.

• Attendants to be discouraged. patient evaluation at First point of contact: • Thermal screening • Hand Sanitization • Properly filled declaration • History of exposure • Symptomatic patients should be immediately referred to a Covid Centre. ppe requirements: N95 Mask, Face shield, Goggles, Gloves, Preferably foot cover, Disposable gown.

Another option is to put a transparent curtain between the sonographer and the patient.

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Picture Courtesy: Dr. Satish Arora equipment sanitation: The following steps should be followed.

• Excess ultrasound gel on the transducer should be wiped off with a soft cloth after each examination. Gel can harbor a lot of germs and its presence prevents adequate disinfection.

• Transducer surfaces and cords should be wiped with an equipment vendor approved low level disinfectant (LLD). Commonly approved agents include 70% Alcohol, Ammonia, 10% Bleach, Clorox, standard dilute Cidex, Protex wipes, SaniCloth, PI Spray, Oxivir wipes, Mikrobac, Microzid, Lonza, Klercide 70 and Descocept wipes.

• Equipment desktop, edges, keyboard, transducer resting stands and especially the side in close proximity to the patient should be wiped with an low level disinfectant.

• Commercial wipes should not be reused. These should be disposed off in appropriate bins. Cloths may be laundered with standard machine-washing.

• Transducer and cord covers are too overpriced for general use. Makeshift covers like laparoscopy camera covers are difficult to source. These are not encouraged and LLD is adequate.

• Ultrasound machines in COVID designated centers must be used with machine covers and covers for the transducer and cable. High level disinfectants (HLD) is recommended in areas if ultrasound has been done where AGPs were performed.

Details for COVID designated centers are beyond the scope of these guidelines.

• Use diluted accelerated hydrogen peroxide based disinfectants to wipe all surfaces. other precautions: • Sanitize the patient examination table after each patient with hypochlorite solution.

• Keep exhaust fan on all the time.

• Sanitize the OPD waiting area via fogger once every day.

• Staff to be in proper protective equipment according to their work.

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• Metallic surfaces, door handles, etc. should be repeatedly cleaned.

• Toilets should be cleaned with sanitizer containing 70% Alcohol.

• Document each and every sanitary procedure done with date and time. concluding comments: The basic principles in a situation of pandemic are: • Resources should be prioritized and optimized.

• The emphasis should be on avoiding unnecessary exposure of healthcare personnel to (potentially) infected patients and vice versa.

• The number of visits should be reduced to the essential minimum.

• It is wise to consider colleagues, staff and patients as asymptomatic carriers and follow PPE measures. self-declaration Form • Name & Address of Medical Organisation • Patient name: • Partner’s name: • Attendant’s name/s: • Current Address: • Permanent Address: • History of travel • Date of departure from home: • Date of return: • Places/countries visited: • Places of transit • Pilgrimages/Sporting Events/Public Events attended • Occupation: • Partner’s Occupation: • History of Contact with a Corona Positive/COVID19 Case: • Fever: yes/no • Tiredness: yes/no • Cough: yes/no • Headache: yes/no • Breathing Difficulty: yes/no patient declaration: I…………………, hereby declare that the above information declared by me is correct. I understand that any false declaration can put my health caregivers at serious risk for disease. I agree to follow all precautionary measures advised by the team of Dr. ……………… and his/her organisation.

I have come for a medically necessary ultrasound scan as evident from my prescription and am aware that there is a COVID19 pandemic. There is a risk of me getting this virus by visiting any place during this pandemic but that the risk of not doing an ultrasound scan is higher than the risk of contracting the coronavirus and getting COVID19.

I have been explained the content of this declaration in a language that I understand.

I hereby absolve Dr. ……………and all members of his/her team/clinic/institution of any punishable or legal liability arising out of my visit and hereby give consent for the same.

Signature of Patient

Signature of Attendant Witness: ______________________ Date: _________________________

Signature of Partner/Spouse/Companion

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Refrences: 1. SFM India Oriented Guidelines for Ultrasound Establishments During the COVID 19 Pandemic by Ashok Khurana, K. Aparna Sharma, [...], and T. L. N. Praveen : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7150531/ 2. Poon LC, Abramowicz JS, Dall’Asta A, Sande R, ter Haar G, Maršal K, Brezinka C, Miloro P, Basseal J, Westerway SC, Abu-Rustum RS, Lees C. ISUOG Safety Committee Position Statement: safe performance of obstetric and gynecological scans and equipment cleaning in the context of COVID-19. Ultrasound Obstet Gynecol. 2020 doi: 10.1002/uog.22027.[PubMed] [CrossRef] [Google Scholar] 3. Poon LC, Yang H, Lee JCS, et al. ISUOG Interim Guidance on 2019 novel coronavirus infection during pregnancy and puerperium: information for healthcare professionals [published online ahead of print, 2020 Mar 11] Ultrasound Obstet Gynecol. 2020 doi: 10.1002/uog.22013. [PubMed] [CrossRef] [Google Scholar] 4. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19). https://www.who.int.

5. Zhang Z, Liu S, Xiang M, Li S, Zhao D, Huang C, Chen S. Protecting healthcare personnel from 2019-nCoV infection risks: lessons and suggestions. Front Med. 2020 doi: 10.1007/s11684-020-0765-x. [PubMed] [CrossRef] [Google Scholar] 6. Yang H, Wang C, Poon LC. Novel coronavirus infection and pregnancy. Ultrasound Obstet Gynecol.

2020;55:435–437. doi: 10.1002/uog.22006. [PMC free article] [PubMed] [CrossRef] [Google Scholar] 7. Wong J, Goh QY, Tan Z, Lie SA, Tay YC, Ng SY, Soh CR. Preparing for a COVID-19 pandemic: a review of operating room outbreak response measures in a large tertiary hospital in Singapore. Can J Anaesth. 2020 doi: 10.1007/s12630-020-01620-9. [PMC free article] [PubMed] [CrossRef] [Google Scholar] 8. Royal College of Obstetricians and Gynaecologists. Coronavirus (COVID-19) infection and pregnancy. https://www.rcog.org.uk/globalassets/documents/guidelines/2020-03-26-covid19-pregnancyguidance.pdf.

9. Abu Rustum RE, Akolekar R, Sotiriadis RA, Salomon LJ, Da Silva Costa F, Wu Q, Frusca T, Bilardo CM, Prefumo F, Poon LC. ISUOG Consensus Statement on organization of routine and specialist obstetric ultrasound services in the context of COVD19. Ultrasound Obstet Gynecol. 2020 doi: 10.1002/uog.22029.

[PubMed] [CrossRef] [Google Scholar] 10. Revised SOGC COVID-19 Infectious Disease Committee Statement. 2020. https://sogc.org/en/content/featured-news/SOGC-Infectious-Disease-Committee-Statement-on-HealthCare-Workers-during-COVID19Pandemic.aspx.

11. La Marca A. COVID-19: lessons from the Italian reproductive medical experience. https://www.fertstertdialog.com.

12. Istituto Superiore di Sanità. Rapporto ISS COVID-19 n. 4/2020. Indicazioni ad interim per la prevenzione e il controllo dell’infezione da SARS-CoV2 in strutture residenziali sociosanitarie. https://www.epicentro.iss.it/coronavirus/pdf/rapporto-covid-19-4-2020.pdf.

13. Coronavirus disease 2019 (COVID-19) pandemic: increased transmission in the EU/EEA and the UK— seventh update 25 March 2020. https://www.ecdc.europa.eu.

14. European Centre for Disease Prevention and Control (ECDC), 2020. Infection prevention and control for the care of patients with 2019-nCoV in healthcare settings. 2020. https://www.ecdc.europa.eu/sites/default/files/documents/COVID-19-guidance-wearing-and-removingpersonal-protective-equipment-healthcare-settings-updated.pdf.

15. Centres for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19). Frequently asked questions about personal protective equipment. https://www.cdc.gov/coronavirus/2019ncov/hcp/respirator-use-faq.html.

16. Patel A, Jernigan DB. Initial public health response and interim clinical guidance for the 2019 novel coronavirus outbreak—United States, December 31, 2019-February 4, 2020 [published correction appears in MMWR Morb Mortal Wkly Rep. 2020 Feb 14;69(6):173] MMWR Morb Mortal Wkly Rep. 2020;69(5):140– 146. doi: 10.15585/mmwr.mm6905e1. [PMC free article] [PubMed] [CrossRef] [Google Scholar] 17. World Health Organisation (WHO), 2020. Novel Coronavirus (2019-nCoV). https://www.who.int/westernpacific/emergencies/novelcoronavirus.

18. Ong SWX, et al. Air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from a symptomtic patient. JAMA. 2020 19. COVID-19: Guidelines on disinfection of common public places including offices. https://www.mohfw.gov.in.

20. Cleaning and Disinfection for Community Facilities: Interim Recommendations for U.S. Community Facilities with Suspected/Confirmed Coronavirus Disease 2019 (COVID-19). https://www.cdc.gov/coronavirus/2019-ncov.

21. Australian Government Department of Health. Environmental cleaning and disinfection principles for COVID-19. https://www.health.gov.au.

22. Rational use of personal protective equipment for coronavirus disease (COVID-19): interim guidance. https://apps.who.int/iris/bitstream/handle/10665/331498/WHO-2019-nCoV-IPCPPE_use-2020.2-eng.pdf.

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Managing your Business

Changing Scenario of Ob Gyn Practice in Post Covid Era dr. ragini agrawal MS, FICOG , FICMCH Fellow clinical Gyne endoscopy UK Master course Cosmetic gynecology & Laser ( Europe & American Academy of Aesthetic Medicine) Clinical Director ObGyn & MAS, Head, Department of Cosmetic Gynecology & Pelvic reconstructive surgery: W- Pratiksha Hospital Gurgaon Sr. Consultant: AA Dermascience “Advance Clinic for Women Health” Gurgaon Vice President: FOGSI 2020 Founder President: HARObGyn (Haryana Association of Obstetricians & Gynecologists)

"When disaster strikes, it tears the curtain away from the festering problems that we have beneath them”.

Barrack Obama Covid-19 is going to stay and according to all sources it will continue well in 2021.

Social distancing and sanitization practices are going to be norm.

Medical practices are suffering from many ill treatment of society and accused of high costs and costly investigations. It is going to be more prominent in post covid era because of great economic recession.

A bigger section of medical practitioners are small time businessman which we do not talk about.

Obstetricians are most vulnerable group.

• Obstetric is unpredictable • Unbooked Emergency • Maternity homes are usually single hand run small establishments • Women are neglected in community • Dealing with two life and one patient • Delivery is least paying in all medicaims usually a fixed amount with medicines and a line u cannot charge extra from patient over and above • PPE quantity in one delivery is around 11-12 and more if you add aftercare • Providing protection accessories for self, staff and patients will put more economic • burden and as it is indirect cost no one is ready to understand effect of pandemic: This pandemic is going to affect practice in two ways Effect as health care provider – Direct and obvious Effect on Small scale business- Indirect and not focused What we have to understand that “Preserving Ourselves” along with protection from infection is very important.

Make it motto of your Practice Remember! These changes are not very short term and temporary. This pandemic will lead to great change in basic ways

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Healthcare Provider

of society permanently. Great crisis leads to changes in attitude of society and consumer behavior which in turn give birth to new ways of working and new policies.

As an owner of our establishment it is mandatory for us to think in terms of management. In our selfrun setup we are CEO, CFO, Manager, all in one. To maintain our survival, it is important to understand: • Changes in Consumer needs and behaviors • Saving Your Liquidity • Thin capital • No Flamboyance • Good Cost/ Bad Cost medical We have to practice imbibe this knowledge and accept that there will be a great change in policies towards • How we will work in post COVID era • Virtual offices • Increase in digital platforms activity • Maintaining and understanding of hygiene • Protection for all – self, staff and patient.

With changing scenario, we have to adopt following norms as our day today working protocol • Social Distancing • Staff Training &Safety measures • Hand Hygiene • Following corona safety norms There will be great changes in ways of practice.

Role of electronic media in our daily life will become very important. Embracing newer technologies will be an important tool in your success.

mantra to success: 1. Be proactive. Use this time to gather and motivate your team to review or create your business plan and set or evaluate your 2020 goals.

2. Communicate. open lines of communication with both your patients and staff are critical. Draft a concise statement that explains how your practice is handling questions and what your team can expect.

To Conclude Protection of your well-being is supreme never compromise your safety, not only as medical practitioner which is very obvious and what you understand but also as small scale businessman which usually we do not take in consideration specially effect of economy recession and increase cost of use of PPEs and electronic media.

1.Assess changing scenario 2.Acknowledge Socio economic shifts 3.Evaluate your lacunae 4.Move forward with a growth oriented insight

• Never forget we have to deal with humanity

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Covid and Respiratory System: A Hand in Hand Saga dr. sushil dhamija MBBS, DTCD, MD (Chest Medicine), AFIH, DHA, FIAMS Secretary: Indian Chest Society (Haryana- Chapter)

A new corona virus infection was identified in December 2019 as a cause of respiratory illness in Wuhan, Hubei Province of China.

This spread rapidly in the locality in this province of China and took the form of epidemic. Soon after cases were reported from other parts of world also with similar clinical features. After about a month of first report from China WHO on 30th January 2020 declared this as a Public Health Emergency of International Concern. Initially the virus was called SARS-Co-V2 but it was later named COVID 19 disease. It is supposed to be originated from Bats and then to Pengolins and to human thereafter, however still the hypothesis has not been fully accepted.

The virus involves both upper and lower respiratory system and has human to human spread. When an infected person sneezes, coughs or talks droplets of his respiratory secretions have a potential of spreading to the other person if there is a contact with mucus membrane of the second person. Virus can remain active on various surfaces and clothes and can spread through fomites. time to manifest respiratory symptoms: â&#x20AC;˘ Incubation Period it takes about 2-14 days for the symptoms to appear after infection.

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symptoms: Mild Disease: (approx. 80 % of cases) • Upper respiratory symptoms • Rhinorrhoea • Sore throat may be associated with streaking of blood • Low grade fever • Lethargy • Shortness of breath • May have nausea, vomiting or loose stools moderate / severe disease: (approx.15 % cases) • Tachypnoea (respiratory rate > 30/mt) • Oxygen saturation < 93% • PaO2/FiO2 <300 • Pneumonitis in x-Ray >50% developing 24-48 hours. critically severe cases: (5% cases) • Respiratory Failure • Septic Shock • Multi-Organ Dysfunction Syndrome (MODS) • Symptoms are usually mild in children.

• Adults may have severe symptoms and 2.3 to 5% cases may die. laboratory findings: cBc: • WBC are variable • 80% show lymphopenia and mild thrombocytopenia.

• Thrombocytopenia indicates poor prognosis. crp: • It is increased in COVID disease. If it is not raised, then it goes against this disease. serum procalcitonin: • Raised if disease is severe. rt-pcr: • RT-PCR sample is taken only by trained person with standard method from nasopharynx and oro-pharynx under strict air-borne precautions.

• Results are available after 2 days.

• Positive reports are reconfirmed by another sample.

• Negative reported can be resampled if suspicion is high. rapid – test Kit: • Tests antibodies IgG and IgM from blood/serum/plasma. chest X-ray: • Usually not specific, may show unilateral lobar, multi lobar or bilateral picture. ct thorax: • Early stage (0-4 days) Ground Glass Opacities GGOs which are sub pleural and mainly in lower lobes.

• Progressive Stage (5-8 days) GG with Crazy-paving shadows with consolidation multi-lobar.

• Peak Stage (9-13 days) dense consolidation with parenchymal bands.

• Absorption Stage (13 days onwards) Crazy paving disappear but GGOs remain.

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lung scan (lung Ultrasound): • Bedside Ultrasound can be done to avoid taking the patient for radiology.

Findings are irregular pleural lines, sub-pleural consolidation (starry sky pattern), areas of white lung with thick B-lines. pulmonary Function test: • Contraindicated due to aerosol generation.

Bronchoscopy: • Contraindicated due to aerosol generation. However, if bronchoscopy needs to be done in cases of emergency then one should follow protocols. treatment: • Presently many regeimen and drugs are under consideration.

• There is no treatment for COVID disease till date.

• Supportive treatment, proper categorization should be done to judiciously use the limited resources.

Where to manage the case: mild cases WithoUt co-morbidities: Home quarantine + Telemedicine supervision 1. Covid positive by RT-PCR upper respiratory symptoms, mild fever and respiratory symptoms.

2. Person with symptoms of fever, cough with either history of contact with a positive case or has visited a place with covid cases in last 14 days.

3. Any symptomatic health worker with cold, cough and fever who was treating COVID cases during last 14 days. mild cases With comorbidities: Keep the patient in Isolation ward / Isolation facility which follows strict isolation guidelines set by Govt.

Who are these cases: 1,2,3 with co-morbidities: 1. Covid positive by RT-PCR upper respiratory symptoms, mild fever and respiratory symptoms.

2. Person with symptoms of fever, cough with either history of contact with a positive case or has visited a place with covid cases in last 14 days 3. Any symptomatic health worker with cold, cough and fever who was treating COVID cases during last 14 days. criteria for admission to covid ward: • Respiratory rate > 30/mt • Oxygen saturation <93% • PaO2/ FiO2 < 300 • Lung shadows in x-Ray/ CT criteria for admission to covid-icU: 1. Covid positive by RT-PCR upper respiratory symptoms, mild fever and respiratory symptoms.

2. Person with symptoms of fever, cough with either history of contact with a positive case or has visited a place with covid cases in last 14 days 3. Any symptomatic health worker with cold, cough and fever who was treating COVID cases during last 14 days.

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With • Respiratory failure • Septic Shock • Multi Organ Failure treatment guidelines for covid disease: 1. Oxygen support (Keep saturation above 90%).

2. Conservative fluid management.

3. Start empirical antibiotics as per CAP guidelines along with antiviral Oseltamivir considering it may be H1N1 till RT-PCR report is available 4. Lopinavir/ Ritonavir Within 1-2 days of admission may be more effective.

5. Other Antivirals being tried *REMDESIVIR (compassionate use only) more studies yet to come.

Dose 200mg IV on day 1 followed by 100mg IV OD for 9 days *Lopinavir / Ritonavir 400mg/100mg (Recommended by WHO) Adult one tablet BD *Ribavarin Dose 2gram stat then 600mg 8 days *Oseltamir Given because many similar cases could be influenza Dose 150mg BD for 5 days *ACE inhibitor/ angiotensin receptor blockers are being studied for their action in reduction of cytokine storm *Interferons are being studied as whether it impairs the antiviral adaptive type 1 helper cells *Hydroxychloroquine acts by hampering pH dependant viral replication Dose 400mg BD on day 1 then 200 BD for 4 days *Tocilizumab (IL-6 Inhibitor) Dose 4-8 mg/kg max 400mg IV once is proposed to help overcome cytokine storm as per Italian and Chinese experience. *Vitamin –C: some studies have found it to be helpful and can be safely used but the data is not robust one. nB: keep in mind differential diagnosis Keep a watch on ventilator induced pneumonia, catheter related infections, secondary bacterial fungal or viral infections role of non-invasive ventilation: role of NIV is limited as the patient is very tachypneic and it is usually not successful. role of hFno: High Flow nasal oxygen is avoided due to high aerosol formation. If at all it is to be used, then use a helmet interface. The situation arises in “Do not intubate” status patients or “Do not Resucitate” status patients mechanical ventilation: • Preferably a separate cubicle to be used for intubation.

• An early controlled intubation is preferred rather than delaying till the patient is too restless and aggressive.

• Best sepsis is maintained to avoid superadded infection otherwise it will prolong the ICU stay.

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• Full PPE should be worn by all the staff in room.

• Quick Intubation strategy to be adopted.

• Early prophylactic antibiotics are added to minimize stay in ICU. • ARDS NET protocol to be followed with low tidal volume, low plateau pressure and high PEEP to prevent ventilator induced lung injury.

• Ventilator settings as tidal volume as 6ml/kg body weight, Pplat as <30mm H2O and SpO2 88-93% or PaO2 5580mm Hg. • Sedation and neuromuscular blockade initially help stabilize the patient.

• Prone position ventilation has been found to give better results.

• Conservative IV fluid management strategy to be adopted so as to keep the patient on mechanical ventilation for minimum time.

ECMO: may be considered in refractory patients. plasma therapy: Convalescent plasma therapy is being experimentally used with promising results but still more studies are needed.

Plasma is donated by cured patients of COVID19 who have EISA antibody titre higher than 1:1000 and a neutralizing antibody titre of 40. An amount of 400 ml of plasma is donated by donor and transfused to the patient immediately. heparin therapy: Still trials are going on with anticoagulation therapy in COVID and results are awaited When to discharge the patient • When patient is asymptomatic.

• Radiologically improved.

• Two consecutive RT-PCR samples at least 24 hours apart should be negative for COVID virus.

The work is going on at a fast pace. Many studies are going on in various countries.

Things are evolving fast. Let’s hope mist is clear soon and we are able to control the pandemic soon with right drugs at right time.

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The way, we are opening surgical services especially coloproctology services in semi urban Haryana experience from a small hospital and a small town Bhiwani: Though the Covid-19 was knocking doors since it reached Indian shores as early as last week of January. First Covid-19 positive case was reported from Kerla (India), on 31st January 2020.

Novel Corona virus or higher ups at WHO befooled us and delayed in declaring Covid19 a pandemic till 14th march 2020.

Indian government started screening on travellers from china and Hong-Kong from January 18 itself, but initially we didn’t screen travelers from other countries reporting Covid-19 cases.

Actually we became proactive on 22nd march with declaration of Janta curfew, lockdown by the people for the people announced by our worthy prime minister Mr. Modi. Two successive lockdowns flattened the peaks on graph but had no signs of down ward trend as such.

Initial few days were of horror and despair, everybody just shut their doors.

In my town a Covid-19 suspected patient was brought from civil hospital to a private nursing home in the initial week of lockdown i.e. within seven days of 25th of March 2020, doctor their expressed inability to handle such a case, out of fear and security issues. Later I learnt that patient was intubated at another private hospital and transferred to nearby medical college and hospital PGIMS Rohtak. at the same moment a decision was taken,’ to make local civil hospital as the main covid-19 designate hospital for our district by chief medical officer of district Bhiwani. no suspected covid-19 patient will be kept at any private health facility’, to keep them free of the disease.

It is because of that decision, we are thinking of opening emergency and semi emergent surgical services in private hospitals in our area.

As no authentic test to detect Covid-19 is available for public at large. Due to paucity of kits and centers to analyse these samples, PCR Ag detections sampling is being done strictly for people with flu like symptoms and who have history of: • Travelling outside country in last 2 months or say 14 days before air travel was banned for public.

• Close contacts of people who came from abroad if have any symptoms were quarantined for 14 days.

dr. sanjay singla MS. FIAGES FACRSI FALS (Colorectal) Faculty for ATLS Travel Fellow Heartlands Hospital, Birmingham Singla Hospital Bhiwani, Haryana

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• Close contacts of proven Covid-19 patients.

• In my town only Govt. hospital NAGRIK HOSPITAL is allowed to sample such people.

• Though Govt. of India authorized few private labs to conduct the test but it fell in to controversy on the issue of who will pay the charges, people or government.

• In my town still it’s not open for any private lab to conduct the test or even sample these patients.

• We opened routine OPD services for patients first telephonically and then slowly in physical attendance during the period of first lockdown itself.

• Initially we started with two hour OPD. with six patients per hour. Now within three weeks we are giving appointments to around 24 patients in four hrs. OPD time.

• We triage patients for suspected Covid-19 illness by • History of fever, respiratory symptoms, • Travel history to hot spots with in country and abroad, • Exposure to other Covid-19 patients, or tested positive for Covid-19 • We segregate these suspects and they are taken to isolation ward in separate designate location (in my town to NAGRIK hospital. They are examined by separate medical team designate for the purpose • Triage officer wears surgical mask and uses face shield (STUDDS) surgical gloves and washed surgical gown and shoe cover.

• Visual alerts have been pasted on prominent areas.

• All medical staff was given prophylactic hydroxy quinine for 7 weeks (we understand the risk involved in it). As a benefit of doubt it was given to all health care workers.

• Medical staff was time and again addressed by me to reinforce standard hygiene practices social distancing, hand wash, use of face masks and cough etiquettes.

• Waiting area design was changed so that people sit six feet apart. They sit facing walls instead of facing each other.

• All patients are given paper masks. Their hands sanitized and they wore gloves to protect themselves and gloves are removed and put in Bio waste bins before they leave our health care facility.

• OPD work is being kept to minimum to decrease crowding to prevent transmission.

• Unless unavoidable, relatives of the patients are not allowed inside doctor’s office.

• All communication is done on video calling using whats app.

• Patients of benign colo-proctology like haemorrhoids fissure fistula are being managed with medicines or office procedures like sclera therapy with due precaution. although some modifications have been done. To rule out any

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suspected growth in colorectum, Double contrast barium enema is done instead of screening colonoscopy.

• Even a young patient of pain abdomen who had melaena next day was resuscitated with conservative means and pack cells patient recovered completely for the time being. And is being investigated by radiological tests instead of endoscopy. In case his bleeding is not controlled then of course we had to do therapeutic endoscopy. During Covid-19 outbreak we should avoid aerosol producing procedures.

• All paper work has been decreased like. All prescriptions are being sent on whats app to the patient so that they don't bring back papers for follow up. this has another advantage patient can chat on whats app for small complaints and we also have electronic record of everything which can be easily retrieved also.

• Side product of this messaging is, we will have data that what %age has no access to smart phones in our society.

• Every time we get a chance to talk to staff or people in hospital we reinforce standard hygiene practices along with hand and respiratory hygiene practices.

• Guidelines from various hospitals from abroad are pouring in, as well Indian associations have also issued guidelines for surgeons to follow during pandemic.

Following are the guidelines jointly issued by three minimal access surgery associations in india as on 23rd april 2020. inter association sUrgical practice recommendations in covid 19 era (For minimal access sUrgeons in india) 23rd april 2020.

• In the current pandemic COVID 19 scenario, there is urgent need for guidelines for performing various surgical procedures. The utmost priority remains the safety of the patients and health care workers. Current recommendations are mostly based on expert opinion and knowledge of other pathogens with similar characteristics. These recommendations are time sensitive. These are bound to change as evidencebased data emerge. general recommendations: • We should provide timely surgical care to patients presenting with urgent and emergent surgical conditions while optimizing patient care resources (e.g. hospital and intensive care unit beds, personal protective equipment, ventilators) and preserving the health of caregivers.

• All elective surgical and endoscopic cases should be postponed at the current time.

• Non-operative management should be considered where ever possible (such as

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for early appendicitis and acute cholecystitis).

• All non-urgent in-person clinic/office visits should be cancelled or postponed, unless needed to triage active symptoms or manage wound care.

• All non-essential hospital or office staff should be allowed to stay home and telework.

• Multidisciplinary team (MDT) meetings should be sought after in any surgical decision and should be held virtually as possible. This team include the surgeon, intensivist, radiologist, infectious disease specialist and nurse managers. (Subject to availability and requirements).

• In case the treating hospital is not a COVID 19 designated center, patients with high risk and diagnosed cases should be referred to appropriate designated COVID 19 center. surgical consultation recommendation: • Avoid physical consultation for non-emergency cases.

• Use the telemedicine platform or provider’s help and consult your patients online for normal surgical problems and follow-up.

Please follow the regulations issued by the MOHFW. https://www.mohfw.gov.in/pdf/Telemedicine.pdf • Please follow the statutory policies of respiratory triaging in receiving surgical emergencies.

• The social distancing, restricting the attendants to not more than one, patient/attendant masking and hand hygiene measures should be adhered to.

• The entry and exit pathway should be according to statutory regulations.

• It is desirable, all preoperative patients be tested for COVID 19 status a day prior to surgery.

• In referral or transfer from other health care facility - Please discuss with the referring Physician in detail about the contact details, overseas travel history of the patient or family members and presence of respiratory symptoms.

Surgical Triage:

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definitions: • Emergency Life threatening conditions- these are those conditions in which immediate surgical intervention is required and there is not enough time available to do and get the results of COVID 19 testing. E.g. – life threatening Traumatic hemoperitoneum with hemodynamic instability, bowel gangrene.

• Emergency Procedures- These are those procedures that require immediate surgical intervention but provide a window of few hours to get COVID 19 testing. Interim non-surgical intervention could also be an option.

E.g.- Bowel obstruction, perforation of hollow viscus. Emergency procedures are undertaken in life threatening conditions and have no alternatives, Pic with uncontrolled diabetes requiring e.g. bowel perforation, gangrene and emergency surgery. unresolved obstruction, complicated appendicitis, complicated cholecystitis, obstructed / strangulated hernia which need immediate surgery.

• Semi emergent procedures- These includes condition where the procedure can be deferred for a few weeks or months but not more than 3 months due to worsening of symptoms or progression of stage of disease affecting final outcome.

E.g.- Major malignancies.

• Elective Procedures- These include those procedures which can be postponed by 3 months or more with mutual consent between patient and surgeon with no untoward effect on final outcome. E.g.- Uncomplicated groin hernia Pre-Operative Phase: • All patients in addition to surgical evaluation should be tested for COVID 19 RT PCR where possible.

• In emergency situations, patient should have a x-ray Chest. CT Chest is done if there is a need for CT abdomen.

• Non-surgical percutaneous interventions are prudent if it can defer surgery for the time being and minimize hospital stay and requirement for a longer institutionalized health care.

• Where possible, the role of alternate non-surgical approaches to GI cancer such as neoadjuvant therapy and radiation therapy are to be considered. A virtual multidisciplinary approach is advised. consent directives: • During COVID 19, an improvised consent form with additional information about COVID 19 and its associated risks have to be obtained.

• A model consent form is attached as an annexure. personal protection equipment: • The personnel in OT should don adequate Personal Protective Equipment. PPE GUIDELINES from the MOHFW are available at: https://www.mohfw.gov.in/pdf/GuidelinesonrationaluseofPersonalProtectiveEqui pment.pdf

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operating room directives: 1. Negative Pressure room is desirable where possible 2. Minimum no of personnel to be inside operating room 3. Limit the size of surgical team as much as possible 4. Avoid the operating room personnel stepping out of OT during the procedure 5. Minimum 1-hour time gap to be given between two procedures / surgeries.

6. Minimize duration of surgery a. No surgical or nursing training during this period b. Avoid multiple and complex procedures 7. Reusable accessories are cleaned and disinfected with appropriate solutions as soon as the procedure is over.

8. 1% Sodium Hypochlorite solution cleaning is recommended for OT Tables and trolleys as soon as the patient is shifted. phase 1 Patient enters the operating room • Checklist by OT staff with regards to Lap trolley, All Lap instruments, sutures, Staples phase 2 Anaesthesia team enters OR • Choice of Anaesthesia: Regional > GA • Safety precautions during GA/ET intubation • Stop Laminar AC/Negative Pressure OT Wait 15 mins phase 3 Surgical team enters OR • Protocols to minimize duration & extent of Surgery • Safe Pneumoperitoneum /Deflation policy • Safe smoke evacuation/filtration policy

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• Rational & minimal use of energy devices phase 4 Exit Strategy from OR • Operating Team • Patient after extubation • Anaesthetic team • OT nurse phase 5 Cleaning and disinfection of OR Wait 60 mins phase 6 OR ready for next procedure

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anesthesiologists directives: • The regulations for the anesthesiologists are issued by the Indian Society of Anesthesiologists. Salient outcomes are as follows: • Regional anesthesia is preferred.

• GA with ET intubation is high aerosol producing event.

• The surgical team is advised to enter OT minimum fifteen minutes after the patient has been anesthetized.

• Laminar flow / Air conditioners at the OT is to be started after induction of anesthesia.

• Stop laminar airflow / air conditioners twenty minutes before extubation.

• Post-surgery all anesthesia equipment to be cleaned with 1% sodium hypochlorite solution.

• Intra operative recommendations for Laparoscopic Surgery Pneumoperitoneum and Aerosol Protection: • Currently, the best practice for mitigating possible infectious transmission during open, laparoscopic and endoscopic intervention is to use a multi-faceted approach, which includes: 1. Proper room filtration and ventilation 2. Appropriate PPE 3. Smoke evacuation devices with a suction and filtration system • Once placed, ports should not be used to evacuate smoke or de-sufflation during the procedure without adequate precautions.

• If movement of the insufflating port is required, the port should be closed prior to disconnecting the tubing and the new port should be closed until the insufflator tubing is connected. The insufflator should be “on” before the new port valve is opened to prevent gas from back-flowing into the insufflator.

• During desufflation, all escaping CO2 gas and smoke should be captured with an ultra-filtration system and desufflation mode should be used on your insufflator if available.

• If the insufflator being used does not have a desufflation feature, be sure to close the valve on the working port that is being used for insufflation before the flow of CO2 on the insufflator is turned off. Without taking this precaution contaminated intra-abdominal CO2 can be pushed into the insufflator when the intraabdominal pressure is higher than the pressure within the insufflator.

• The patient should be flat and the least dependent port should be utilized for desufflation.

• Specimens should be removed once all the CO2 gas and smoke are evacuated.

• Surgical drains should be utilized only if absolutely necessary.

• Suture closure devices that allow for leakage of insufflation should be avoided.

• The fascia should be closed after desufflation.

• Hand-assisted surgery should be avoided as it can lead to significant leakage.

• Wound protection devices used for specimen retrieval should only be placed after desufflation.

• The leakage around cannulas need to be minimised.

• Suction devices are a potential source of infection. Use of appropriate filter is advised.

• For routine evacuation of smoke and fumes, a member of the operating team should be designated for this and he/she should use the side channel for controlled evacuation. Standardised smoke evacuation devices can be used.

• All pneumoperitoneum should be safely evacuated from the port attached to the

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filtration device before closure, trocar removal, specimen extraction or conversion to open. energy devices: • “Aerosolization” of viral and bacterial RNA/DNA may occur during the use of energy devices in general surgery - both open and laparoscopic - although there is limited evidence that viable infective particles are dispersed.

• The various energy sources lead to varying particle sizes with electrocautery and laser having the smallest, hottest particles and ultrasonic devices larger, cooler particles. During both open and laparoscopic surgery, the particle concentration tends to increase over time of use of energy sources.

• Use of energy devices is a potential risk.

• Minimal use and short burst usage are advised.

• Judicious use of energy devices and smoke evacuation is advised.

• Cold hemostasis is the choice method advised.

• The energy sources should be used at the lowest power setting and charring of tissues should be avoided to minimize the creation of smoke.

Flexible endoscopy: • Surgical colleagues perform various flexible endoscopic procedures. It is pertinent to follow safe endoscopy practice directives issued by the respective society.

• We should stop all elective endoscopy work. Flexible endoscopy and therapeutic procedures are indicated only for clearly defined emergency and urgent cases.

• All Staffs in the unit should wear N 95 mask and good quality PPE during any endoscopic procedure • Every emergency or urgent endoscopy patient should be presumed as Covid positive and managed accordingly taking all strict safety precautions.

• Comprehensive well written informed consent form comprising of all necessary details relevant to covid pandemic should be signed by the patient and relative prior to undergoing any endoscopic procedure • All emergency and urgent endoscopic procedures should preferably be done under GA with careful endotracheal intubation.

• Endoscopy requires high level disinfection while endoscopic accessories should be either disposable or need sterilization. conclusion: • Our surgical health care system should adapt to this rapidly changing health environment due to covid 19 pandemic. Next few months are going to be critical in mitigating the spread of infection. Surgical interventions are considered only for clearly defined emergency and urgent cases. We should understand our vital role in protecting our staffs while treating our surgical patients. We should ensure best surgical care by having clear management strategy and compassionate approach. prof. Bhupinder singh pathania President – AMASI dr. Kalpesh v Jani Secretary – AMASI drafted and reviewed by: Dr. Tamonas Chaudhuri – AMASI Prof. Pawanindralal – SELSI Dr. M Kanagavel – IAGES

dr. ramen g goel dr. virinder Kumar Bansal President – IAGES President – SELSI dr. s easwaramoorthy dr. amit srivatsava Secretary – IAGES Secretary – SELSI

Dr. S Easwaramoorthy – IAGES Dr. Kalpesh Jani – AMASI Dr. Krishna Asuri – SELSI

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DISCLAIMER: This document is not valid for Medico-legal purpose. references: 1. https://www.sages.org/notes-from-the-battlefield-april-6-2020/ 2. https://www.sages.org/notes-from-the-battlefield-march-30-2020/ 3. https://www.sages.org/wp-content/uploads/2020/04/Closing-the-Back-Door-SOP.pdf 4. https://www.sages.org/recommendations-surgical-response-covid-19/ 5. Rothan H, Siddappa B. The epidemiology and pathogenesis of coronavirus disease (COVID-19) Outbreak. Journal of Autoimmunity. https://doi.org/10.1016/j.jaut.2020.102433.

2020.

6. Zheng M, Boni L, Fingerhut A. Minimally invasive surgery and the novel coronavirus outbreak: lessons learned in China and Italy, Annals of Surgery. 2020.

7. https://www.sages.org/resources-smoke-gas-evacuation-during-open-laparoscopicendoscopicprocedures/ 8.https://journals.lww.com/annalsofsurgery/Documents/Are%20we%20harming%20cance r%20patients.pdf 9.https://www.isde.net/resources/Documents/Resources/ISDE_Position_Statement_COVID 19_2020.03.30.pdf 10. https://umbraco.surgeons.org/media/5162/guidelines-for-emergency-upper-gi-andbariatric-surgeryduring-the-covid-_v2_6-april.pdf 11. https://umbraco.surgeons.org/media/5136/optimal-surgical-approach-during-thecovid-19-pandemic_updated-version.pdf 12.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7117791/pdf/FVVinObGyn-12-3.pdf 13. https://www.facs.org/covid-19/clinical-guidance/review-committee 14. https://www.facs.org/covid-19/clinical-guidance/statement-maintaining 15. https://www.facs.org/covid-19/clinical-guidance/surgeon-protection#ppe-use 16. https://pbs.twimg.com/media/EUjMyWrWAAIt7bh.jpg 17. https://pbs.twimg.com/media/EUjMyWqWAAYxxhN.jpg

reFerence consent Form For sUrgerY dUring covid 19 pandemic • I/We__________________________ knowingly and willingly consent to have treatment / surgery / investigation completed during the COVID-19 pandemic.

• I/We have been informed that I am opting for treatment / surgery / investigation in the midst of community outbreak of COVID19 pandemic.

• I/We have been explained about the risks and side effects of COVID 19 infection and precautions being taken by the hospital to prevent transmission of infection in patients and staff.

• I/We understand and acknowledge that although all precautions as prescribed by the Government of India have been duly implemented by the hospital, as the disease is new and its kinetics, symptoms and treatment are still being studied, no assurances or guarantees can be offered regarding disease transmission to the patient or clinical outcome in case of disease transmission to the patient.

• I/We understand the implications and give our consent for the continuation of treatment / surgery / investigation.

•I have been tested for COVID 19 to found be negative and I have been told that I may become positive in the post -operative period, if I am in the carrier stage of the disease.

•I have not been tested and I agree to continue with the surgical procedure. If found positive later, I would not attribute the same to the surgical procedure conducted and the surgeon and doctor concerned.

•I have been explained that there is evidence that surgery in infected but

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asymptomatic patients is associated with a more severe disease manifestation in the post-operative period and an increased mortality.

Patient’s Name: _________________________Signature__________________Date_________Time ___________ Doctor’s Name: _________________________Signature__________________Date_________Time ___________ Witness’s Name: ________________________Signature__________________Date_________Time_ __________ Contact No. of witness___________________ Address_______________________________________________ Attendant’s Consent: If patient is unable to give consent, reason (Minor/unconscious/under sedation/ mental incapacity/ disoriented, other please specify) Attendant’s Name: ___________________________________ Relationship_______________________________ Signature of the Attendant: _____________________________ Date__________________ Time______________ Statement of Interpreter (where applicable): I have comprehensively explained the information above along with the discussion/explanations provided by the doctors, to the patient and /or his/her attendant and in a way which I believe he/she/they can understand and the patient and /or his/her attendant have informed me that they have understood the aforesaid information completely.

Interpreter's Name___________________________Signature___________________Contact No_____________ Date______________ Time_______________________

We have made it available in hindi language for our patients. there are one practical problem i.e. covid-19 tests.

• Still when we are writing this article, Covid 19 antigen detection PCR is not available easily in our area. Only Govt. hospital is authorised to take samples. And due to paucity of testing facility these have been reserved for suspected Covid 19 patients who present with flu like symptoms. So we are forced to do emergency surgery without Covid-19 testing, of course taking all possible precautions against the transmission of all blood born and air borne diseases • I have learnt that my colleagues are doing caesarian sections without such testing under spinal anaesthesia.

• We are all avoiding general anaesthesia where ever possible.

• There are reports that viable viral particles are present in stools of Covid-19 patients. How this will effect on the outcome of surgery in anorectal area, probably nobody knows at present. Whether these particles can further transmit disease is also not known at present. Whatever rudimentary information is available to medical world, is to take all precautions. and faecal matter should also be treated like blood as far as care and disposal of soiled clothes is concerned.

• We are preparing ourselves to start operating on semi urgent conditions, which if

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not treated urgently may progress to more complicated problems.

• We understand that tests to detect Covid-19 Ag may not be available soon for these patients in our Area. We have to take proper consent and prepare patient, relatives of the patient and of course medical team to take these challenges.

Annexure of consent form already attached with recommendations of surgical associations.

• We did a mock drill for such care in our OT. and operated today (seventh of May 2020) one case of perianal abccess with fistula in another abccess was increasing in size after conservative treatment. Another patient of chronic fissure in ano is also waiting for LIS. as her pain is not being taken care by medical treatment.

• We have treated acute appendicitis patients conservatively under strict precaution, most of the time patients have gone home after relief of pain completely.

• Obstructed hernia patients have been helped by reducing hernia in outpatient department and advised surgery when things unfold for better and safe care.

• All most all patients of cholecystitis could be managed by drugs, and same also proved use full for acute pancreatitis patients.

• Two patients of anorectal sepsis with gangrene reported late and required surgery to get rid of necrosed tissue and improve their metabolic disorder like toxaemia and uncontrolled diabetes mellitus in one of them.

• Two cases of bleeding and impending obstruction due to malignancy in sigmoid and rectal area were sent to gastroenterologist and Onco therapist colleagues for stenting, control of bleeding and chemo radio for time being.

• Need less to say, operation theatres with air handling units are being used where ever possible, but I understand that many of colleagues in town don't have access to such modular operation theatres.

Doctor is wearing face shield. Examination area.

• One patient of carcinoma breast never turned up for treatment, not even for needle biopsy after her cytopathology report.

• We are slowly opening for surgical care of our patients with utmost care, precaution and transparency to our patients.

• Teaching classes: we organized five webinars related to minimal invasive surgery in coloproctology during this Covid-19 era. I also contributed as a faculty and panelist for a national webinar on pilonidal sinus by ACRSI.

We have uploaded an awareness video for public to stop the transmission of deadly virus, on YouTube: https://youtu.be/vWPrNA1qxHw With good wishes to all front line warriors and prayers to almighty to save human race from this deadly illness.

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COVID 19 and Semen What you need to know as a fertility expert: With the pandemic of COVID-19 spreading its wings further every day seems to be a day of new discoveries with regards to the effect of COVID-19 on various parameters. The virus has been identified in many body secretions including the urine, faeces and the blood. [1] The percentage of patients with the presence of viral RNA in urine and blood appears to be fairly low and thus the next pertinent question is the effect of COVID-19 on semen and conception, especially for couples hoping to find fertility blossom. The presence of the novel coronavirus in semen is also pertinent because men seem to be getting infected more often than women with COVID-19. [2] 2019-nCoV RNA in semen samples collected from 12 patients [3] in their recovery phase, as well as in testicular samples from one patient who died of COVID-19 during the acute phase were studied in late 2019. Song et al found that 2019-nCov does not directly infect the testis and the male reproductive tract. They mentioned that it is highly unlikely that the 2019-nCov can be sexually transmitted by men. Further to support this fact were individual case reports. [4] Despite the earlier claims of absence of the virus in semen there have been many theoretical factors that created a disbelief such as the Testicular tissue expression of a certain degree of ACE2 receptors. ACE2 expression patterns in different tissues suggest the possibility of different extra-respiratory viral transmission routes through several body fluids, also including the seminal fluid. According to earlier studies on corona viral infection Testicular damage and germ cell destruction was clearly observed. [5] ACE2 is highly expressed in Leydig cells and cells of the seminiferous tubules in the human testis. Thus, the binding of the virus to these ACE2-positive cells could not only cause severe alteration of testicular tissue but also provide a site for viral infection. In view of these earlier findings, the majority of publications in this regard have tated that further studies are needed before it can be declared that the novel coronavirus is not present in the semen. Finally a study in May suggested the presence of the novel COVID 19 in the semen of patients with infection.In this study including 38 participants who provided a semen specimen, 23 participants (60.5%) had achieved clinical recovery and 15 participants (39.5%) were at the acute stage of infection. Results of semen testing found that 6 patients (15.8%) had results positive for SARS-CoV-2, including 4 of 15 patients (26.7%) who were at the acute stage of infection and 2 of 23 patients (8.7%) who were recovering. [6] Probably the low sample size in earlier studies was the reason for

dr. raman tanwar MBBS, MS, FMAS, MCH-Urology Fellowship in Andrology and Men’s health Chief Urologist & CEO at Urocentre (a chain of urology & andrology centres) Panelist: National Guidelines on Male Infertility and Male Sexual Dysfunction Secretary General: Men’s Health Society of India

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not being able to find the traces of the virus in the semen samples. Postponing diagnostic semen analysis and sperm banking in men with seminal issues as per the latest guidelines has also created a tension in this already tense environment. Men who don't have cancer are finding it a tough time to manage fertility due to lack of offerings for sperm retrieval and preservation. Many patients such as those with inflammatory and systemic auto-immune diseases who are about to start treatment with gonadotoxic drugs and those with severely impaired semen parameters need liberalization of guidelines to proceed in the path of achieving fertility. [7] Apart from these more specific concerns the effects of a febrile situation that can arise in symptomatic coronavirus patients also has a lasting impact on patients.

Sperm concentration, morphology and motility in a semen sample are adversely affected by a febrile episode during the post meiotic period of spermatogenesis (spermiogenesis). Sperm concentration is also adversely affected by fever during the period of meiosis again causing a negative impact on fertility. [8] The overall effect of the novel coronavirus on male fertility may not be very consequential but the risk of transmission to partner and the possible effects on the fetus are so threatening that fertility is taking a major blow due to this pandemic. Fertility experts need to make a careful decision when advising couples and it will be good for them to know the interaction of this virus with semen and seminal parameters. references: 1. Ling Y, Xu S-B, Lin Y-X, et al. Persistence and clearance of viral RNA in 2019 novel coronavirus disease rehabilitation patients. Chin Med J (Engl) 2020 doi: 10.1097/CM9.0000000000000774 2. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, Liu L, Shan H, Lei CL, Hui DSC, Du B, Li LJ, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med 2020. doi: 10.1056/NEJMoa2002032 3. Song C, Wang Y, Li W, et al. Absence of 2019 Novel Coronavirus in Semen and Testes of COVID-19 Patients [published online ahead of print, 2020 Apr 16]. Biol Reprod .

2020;ioaa050. doi:10.1093/biolre/ioaa050 4. Paoli D, Pallotti F, Colangelo S, et al. Study of SARS-CoV-2 in semen and urine samples of a volunteer with positive naso-pharyngeal swab [published online ahead of print, 2020 Apr 23]. J Endocrinol Invest . 2020;1‐4. doi:10.1007/s40618-020-01261-1 5. Xu J., Qi Lihua, Chi Xiaochun, Yang Jingjing, Wei Xiaohong, Gong Encong, Peh Suatcheng, Gu Jiang. Orchitis: A complication of severe acute respiratory syndrome (SARS) Biol. Reprod. 2006;74:410–416.

6. Li D, Jin M, Bao P, Zhao W, Zhang S. Clinical Characteristics and Results of Semen Tests Among Men With Coronavirus Disease 2019. JAMA Netw Open .

2020;3(5):e208292. Published 2020 May 1. doi:10.1001/jamanetworkopen.2020.8292 7. Esteves SC, Lombardo F, Garrido N, et al. SARS-CoV-2 pandemic and repercussions for male infertility patients: a proposal for the individualized provision of andrological services [published online ahead of print, 2020 May 1]. Andrology .

2020;10.1111/andr.12809. doi:10.1111/andr.12809 8. Carlsen E, Andersson AM, Petersen JH, Skakkebaek NE. History of febrile illness and variation in semen quality. Hum Reprod . 2003;18(10):2089‐2092. doi:10.1093/humrep/deg412

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ICU Management of COVID 19 Patients dr. naveen malhotra Professor Anaesthesiology & In Charge Pain Management Centre: Pt BDS PGIMS, Rohtak, Haryana.

introduction: Corona virus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome corona virus 2 (SARS-CoV-2), a newly emergent corona virus, that was first recognized in Wuhan, China in December 2019. Since then it has spread to more than 200 countries. It has strained the economy and health care system of many developed countries. India is persistently recording higher number of cases. It is important to have a high index of suspicion for COVID and to follow infection control practices in intensive care units, hospitals and daily routine. [1-4] clinical Features: The median duration from exposure to symptom is 5-6 days, but may be up to 14 days. The signs and symptoms of COVID-19 present at the onset of illness are nonspecific, but eventually most patients of COVID-19 will present with fever, cough, fatigue, anorexia, shortness of breath, sputum production and myalgias.

COVID-19 is associated with mental and neurological manifestations, including delirium or encephalopathy, agitation, stroke, meningo-encephalitis, impaired sense of smell or taste, anxiety, depression and sleep problems. [5] Atypical presentations have also been found, and older adults and persons with medical comorbidities may have delayed presentation of fever and respiratory symptoms. Other symptoms like headache, confusion, rhinorrhea, sore throat and haemoptysis have also been reported. Patients of COVID-19 may experience gastrointestinal symptoms such as diarrhoea and

dr. sukhminder Jit singh Bajwa Professor & Head (Deptt of Anaesthesiology & Critical Care): Gian Sagar Medical College & Hospital, Banur, Patiala, Punjab dr. sudhir Kumar Bisherwal Assistant Professor Anaesthesiology: Pt BDS PGIMS, Rohtak, Haryana. dr. parveen malhotra Sr. Professor Medical gastroenterology: Pt BDS PGIMS, Rohtak, Haryana.

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vomiting, which may precede development of fever and lower respiratory tract signs and symptoms. Anosmia or ageusia preceding the onset of respiratory symptoms has been anecdotally reported, but more information is needed to understand its role in identifying COVID-19. [6-9] In severe cases, COVID-19 can be complicated by the acute respiratory distress syndrome (ARDS), sepsis and septic shock, thromboembolism, and/or multi organ failure including acute kidney injury and cardiac injury. Older age, smoking and underlying non-communicable diseases (NCDs), such as hypertension, cardiac disease, chronic lung disease and cancer, have been reported as risk factors for severe disease and death. 6-9 Around 80-85% of patients show mild symptomatic disease, 10-15% of patients have moderate disease and 3-5% of patients develop critical disease. In these severe and critical patients, overall fatality rate is 2-3%. Majority of deaths occur in â&#x2030;Ľ60 years of age and/or have had pre-existing co-morbid conditions such as hypertension, cardiovascular disease and diabetes. [4] Presentation in children is usually milder than adults and deaths have been very rare. [10, 11] Exact cause of this milder disease is yet to be identified, nonetheless they need to be protected because even without showing symptoms, children may harbour large amount of virus and be a potential source to infect others. [12] There is currently no known diďŹ&#x20AC;erence between the clinical manifestations of COVID-19 in pregnant women and non-pregnant adults of reproductive age. investigations: Nasopharyngeal swabs are taken for sampling. WHO suggests using upper respiratory tract (URT) samples in suspicious cases, and lower respiratory tract (LRT) samples whenever readily available. LRT samples can be taken by expectorated sputum, endotracheal aspirate or broncho-alveolar lavage. Sampling the nostrils or tonsils is not to be done. If a single sample comes negative in a suspected case with severe illness or pneumonia, it does not exclude the diagnosis, and sending additional URT and LRT samples are recommended.

Sampling of LRT can generate aerosols and utmost airborne precaution must be taken while taking these specimens. Bronchoscopy should generally be avoided to limit exposure of health care workers to corona virus. [13] Reverse transcription polymerase chain reaction (RT-PCR) is quantitative polymerase chain reaction technique, which identifies the nucleic acid of the virus.

RT-PCR test is currently the back bone of diagnosing and confirming the coronavirus disease. Sensitivity of this test in critically ill is currently unknown. The guidelines are to use one time RT-PCR based pooled sampling for surveillance purposes. If any of the pooled samples tests positive, individual samples would be tested from the aliquoted samples preserved in the laboratory. [14] The humoral response to SARS-CoV-2 can help in diagnosing COVID-19. IgM and IgG antibodies can be detected after fifth day of onset of symptoms. It can even help in detecting subclinical cases. [15] CT scan, if available, can help in identifying and isolating patients of covid-19. The sensitivity of chest CT scan has been shown to be up to 97% in identifying COVID. However, shifting the patient for radiology may lead to contamination of the corridors with corona virus aerosols and pose a substantial risk to health care workers. [16] Haematology and biochemical laboratory testing and electrocardiogram should be performed at admission and as clinically indicated to monitor for complications,

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such as acute liver injury, acute kidney injury, acute cardiac injury, disseminated intravascular coagulation (DIC) and/or shock.

The biochemical tests and organ function tests are repeated as per critical care unit protocol. Blood gas analysis, liver function tests, renal function tests and haemogram are investigations routinely done in ICU to monitor for severity of infection. It has been consistently found that these patients usually have decreased lymphocyte counts, CD4 and CD8 cells along with increased CPR, ESR, and a normal PCT. IL-6 and d-dimer have been shown to be positively linked to severity of the COVID-19. [17] Depending on local epidemiology and clinical symptoms, test for other potential etiologies (e.g. malaria, dengue fever, typhoid fever) are conducted.

Samples whenever sent to labs must be properly marked and preferably sent in boxes marked for COVID patients. These samples should be handled carefully to minimise risk of infection to health care workers. It is important to avoid person to person contacts during collection of paper reports. Reports can be sent by electronic hospital management systems where ever available. At other places, whats-app groups can be made so that reports can be uploaded and are seen by treating physicians. icU management: Currently no specific therapy is available for novel coronavirus disease and current guidelines and recommendations are based on data available from other viral infections and their management, and other general supportive management of critically ill. Distance of at least two meters between each patient bed is advised to avoid droplet infection. The characteristic feature of COVID-19 is development of acute respiratory distress syndrome (ARDS). [18,19] oxygen therapy: Immediate administration of supplemental oxygen therapy should be done in any patient with emergency signs and in patients without emergency signs and SpO2

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< 90% to maintain saturation of ≥90%. Adults with emergency signs (obstructed or absent breathing, severe respiratory distress, central cyanosis, shock, coma and/or convulsions) should receive emergency airway management and oxygen therapy during resuscitation to target SpO2 ≥ 94%. Once the patient is stable, the target is > 90% SpO2 in non-pregnant adults and ≥ 92–95% in pregnant women. [18] Face masks or nasal prongs are used in patients with low oxygen requirement. In others, face mask with reservoir bag, high flow nasal oxygenation (HFNO), or noninvasive ventilation (NIV)-continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP) may be used to maintain appropriate oxygen saturation. Adult HFNO systems can deliver 60 L/min of gas flow and FiO2 up to 1.0. HFNC and NIV have a potential to generate aerosols, however reports are inconclusive to definitely confirm or refute this. These devices have potential to delay intubation in mild ARDS, however studies in COVID is lacking. Thus, NIV and HFNC can be used in patients with mild ARDS until further data are available, with close monitoring, airborne precautions, and preferably used in patients in single room. There is insufficient evidence to classify nebulizer therapy as an aerosolgenerating procedure that is associated with transmission of COVID-19. [13,19] invasive ventilation: Tracheal intubation of patients with COVID-19 also poses a risk of viral transmission to health-care workers, and intubation drills are advised to better prepare and reduce the risk of virus transmission. The most skilled operator available should perform the procedure with full personal protective equipment (PPE) and the adequate preparation for difficult airway. The number of assistants should be limited to reduce exposure. Generation of aerosols with bag-mask ventilation is a concern and should be minimised by prolonged pre-oxygenation; a viral filter may be used between the exhalation valve and the mask. Rapid sequence induction with muscle relaxants will reduce risk caused by bag ventilation and reduce the time to intubation. End-tidal carbon dioxide detection and observation of chest rise should be used to confirm correct endotracheal tube

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placement. The use of closed suctioning systems post-intubation are advised to reduce aerosolization. [20] Ventilator induced lung injury should be avoided and hence, lung protective ventilation strategy is advised with use of low tidal volume (4–8 mL/kg predicted body weight) and lower inspiratory pressures (plateau pressure < 30 cmH2O).

Permissive hypercapnia is permitted. The use of deep sedation may be required to control respiratory drive and achieve tidal volume targets. In patients with moderate or severe ARDS, a trial of higher positive end-expiratory pressure (PEEP) instead of lower PEEP is suggested and requires consideration of benefits versus risks.

In patients with moderate-severe ARDS (PaO2/FiO2 < 150), neuromuscular blockade by continuous infusion should not be routinely used. Avoid disconnecting the patient from the ventilator, which results in loss of PEEP, atelectasis and increased risk of infection of health care workers. Use in-line catheters for airway suctioning and clamping endotracheal tube when disconnection is required (for example, transfer to a transport ventilator). In patients with excessive secretions, or difficulty clearing secretions, consider application of airway clearance techniques. [19-21] In adult patients with severe ARDS (PaO2/FiO2 < 150) prone ventilation for 12–16 hours per day is recommended. Prone position has shown an improvement in mortality in severe ARDS, and hence should be used early. [21] There is little evidence on prone positioning in pregnant women with ARDS; this could be considered in early pregnancy. Pregnant women in the third trimester may benefit from being placed in the lateral decubitus position. However, data on prone position outcome in COVID patients is yet to come.

Veno-venous extracorporeal membrane oxygenation (ECMO) is reserved for the most severe of ARDS patients in centres wherever available. However, it is resource intensive and the decision to provide it should be balanced against the requirement to provide care for more patients in pandemic. [22] intravenous Fluids: Reported prevalence of shock in patients of COVID-19 is variable and depends on the severity of illness, and other co-infections. Use of dynamic parameters over static parameters is suggested to access volume responsiveness and administer fluids. A conservative approach for intravenous fluids is advised over liberal approach in patients presenting with ARDS patients without tissue hypoperfusion and fluid responsiveness. [19] Patients with severe corona virus disease have a high rate of cardiac injury and early detection with troponins and brain natriuretic peptide to predict clinical severity, and early use of vasopressors and/or inotropes is advised. [23,24] septic shock: Recognize septic shock in adults when infection is suspected or confirmed and vasopressors are needed to maintain mean arterial pressure (MAP) ≥ 65 mmHg and lactate is ≥ 2 mmol/L, in the absence of hypovolaemia. Antimicrobial therapy, and initiation of fluid bolus (250–500 mL crystalloid fluid as rapid bolus in first 15– 30 minutes) and vasopressors (norepinephrine is considered first-line treatment in adult patients; epinephrine or vasopressin can be added to achieve the MAP target. Because of the risk of tachyarrhythmia, reserve dopamine for selected patients with low risk of tachyarrhythmia or those with bradycardia) for hypotension has to be done. If signs of poor perfusion and cardiac dysfunction

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persist despite achieving MAP target with fluids and vasopressors, consider an inotrope such as dobutamine. [18] antibiotics: Empirical antibiotics are advised as the testing for COVID takes time and the pneumonia is difficult to differentiate from community acquired pneumonia. [30] The use of empiric antimicrobials to treat all likely pathogens, based on clinical judgment, patient host factors and local epidemiology should be done as soon as possible (within one hour of initial assessment if possible), ideally with blood cultures obtained first. Antimicrobial therapy should be assessed daily for deescalation. [18] corticosteroids: Routine corticosteroids should be avoided unless they are indicated for exacerbation of asthma or COPD, septic shock or ARDS, and risk/benefit analysis needs to be conducted for individual Corticosteroids can be used only for patients in whom adequate fluids and vasopressor therapy do not restore haemodynamic stability. If corticosteroids are prescribed, monitor and treat hyperglycaemia, hypernatraemia and hypokalaemia. Monitor for recurrence of inflammation and signs of adrenal insufficiency after stopping corticosteroids, which may have to be tapered.

Cytokine syndrome has been suggested to be present in subgroup of COVID patients. Patients may be screened to identify those who could benefit from immunosuppression and corticosteroids. [25-26] coagulation dysfunction: Coagulation dysfunction has been reported in patients infected with novel SARSCoV-2 virus, with increased d-dimers, fibrin degradation products and fibrinogen.

Low molecular weight heparin (LMWH) is advised in patients without any contraindication to reduce the risk of pulmonary embolism. LMWH (enoxaparin) have also been shown to reduce the severity of cytokine syndrome and has been proposed as potential treatment. For those with contraindications of using MWH, use mechanical prophylaxis (intermittent pneumatic compression devices). [27-29] antiviral drugs for coronavirus treatment: The past and current researches have suggested role of antiviral drugs for treatment of Corona viruses. The antiviral group includes anti HIV drugs, drugs used for treating hepatitis C. HIV protease inhibitor, lopinavir is being studied along with ritonavir for the treatment of MERS and SARS corona viruses.

Lopinavir/ritonavir in combination with ribavirin showed reduced fatality rate and milder disease course during an open clinical trial in patients in the 2003 SARS outbreak.

Several drugs approved for the treatment of hepatitis C viral infection have been identified as potential candidates against COVID-19 caused by the SARS-CoV-2 coronavirus. The four hepatitis C drugs simeprevir, paritaprevir, grazoprevir and velpatasvir have a high affinity to bind SARS-CoV-2 very strongly and may therefore be able to prevent infection. The SARS-CoV-2 and the hepatitis C virus are the so-called single-stranded RNA viruses. Other oral directly acting antiviral drugs in this group which are freely available in India, in addition to Velpatasvir are Sofosbuvir & Daclastavir, Ledipasavir. All of them have daily once dosage and are

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having minimal side effects in very few percentage of patients like dyspepsia, vomiting, diarrhea, itching, myalgias and insomnia. Ribavarin and Pegylated Interferon 2B have already proven their worth in treatment of Chronic hepatitis C and has raised hopes for treatment of corona viruses also. Remdisvir has given good results in initial trials and efforts for making it available in India are being done. [31] adverse effects of medications: Careful consideration should be given to the numerous, clinically significant sideeffects of medications that may be used in the context of COVID-19, as well as drug-drug interactions between medications, both of which may affect COVID-19 symptomatology. Chloroquine and hydroxychloroquine +/- azithromycin: each can cause QT prolongation and taken together can increase the risk of cardiotoxicity; Lopinavir/ritonavir: the most common adverse effects are gastrointestinal; Remdesivir: elevation of hepatic enzymes, GI complications, rash, renal impairment and hypotension; Umifenovir: diarrhoea, nausea; Favipiravir: QT interval prolongation; Interferon-β-1a: pyrexia, rhabdomyolysis and Tocilizumab: URT infections, nasopharyngitis, headache, hypertension, increased alanine aminotransferase (ALT), injection site reactions. [32] haemodialysis: Some patients might also require haemodialysis and it is advisable to have a dedicated machine for such patients. Strict infection control must be followed during the dialysis. It is advisable not to mix suspected and confirmed patients in dialysis room. [33] psychological care: Patients should be routinely assessed for mobility, functional, swallow, cognitive impairments and mental health concerns, and, based on that assessment, determine discharge readiness, and rehabilitation and follow-up requirements. Attendants or

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relative of such patients should be informed about the risk of contaminating themselves in going inside the COVID care units to meet the patients. There should be video conferencing sessions of patients and relatives conducted at least twice a day. Limited members of family should be allowed to go inside and meet the patient in person, after wearing proper personal protective kits. cardio-pulmonary resuscitation: WHO mentions cardiopulmonary resuscitation as potential aerosol generating procedure. “Protected Code Blue” should be followed, with emphasis on use of N 95/N 99 masks and full complement of PPEs during resuscitation due to high risk of airborne transmission. There should be disposable resuscitation packages instead of trolley. All the team members should wear PPEs and then enter the isolation bringing the defibrillator and packages along with. Every action for the patient benefit must be balanced against the risk posed by aerosol generation.

[20,33,34] dead Body disposal: It should be done according to the guidelines issued by Ministry of Health and Family Welfare, Government of India. The health worker attending to the dead body should be trained in infection control. He must perform hand hygiene and ensure proper use of PPE (water resistant apron, goggles, N95 mask, gloves. Any wounds on body (resulting from removal of catheter, drains, tubes, or otherwise) should be dressed with impermeable material after disinfecting with 1% hypochlorite. Body should be placed in a leak proof plastic bag and its outer surface should be disinfected with 1% hypochlorite.34 Family members may be allowed to see the body while removing from isolation area, however strict infection control measures must be used. The body, secured in a body bag, exterior of which is decontaminated poses no additional risk to the staff transporting the dead body to mortuary of funeral/burial area. [35] staffing the covid icU:

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Appropriate number of staff is required to work in shifts in COVID ICU. Six-hour shift is practically workable while working in ICU wearing Personal Protective Equipment (PPE). In between the shifts, the staff working in COVID OT who does not want to go home will have to be given suitable accommodation by the hospital. Those going home will have to tailor the approach according to the risk profiles of the family members (immuno-compromised children, elderly parents, two physician homes). This will include living in separate dwellings or partitioning their homes. This can cause tremendous work stress both clinical and psychological. The staff will have to be psychologically counselled and kept motivated. Institutional policies for quarantine of the staff working in COVID ICU have to be made. In majority of institutes, staff works for one week and is then quarantined for one week. Any health care worker who develops flu like symptoms should immediately inform authorities. Do mock drills for correct donning and doffing of PPE including cover all gown, N 95/FFP3 face mask, eye shields/face shields/visor and gloves. [36] conclusion: The percentage of COVID patients requiring intensive care is in single digit as of now. Majority of patients do well with oxygen therapy and prone positioning, but mechanical ventilation is instituted as and when indicated. The standard operating procedure (SOP) of managing a critically ill COVID patient in intensive care unit should be clearly defined to improve the clinical outcome. Infection control policies should be strictly implemented and followed by all health care workers. references: 1.https://www.worldometers.info/coronavirus/?utm_campaign=homeAdvegas1?%22 %20%5Cl%22countries as on 17 May’2020.

2. https://covid19.who.int/explorer 3. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-asthey-happen 4. Surveillances V. The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19)—China, 2020. China CDC Weekly. 2020;2(8):113-22.

5. Centers for Disease Control and Prevention. Interim clinical guidance for management of patients with confirmed corona virus disease (COVID-19). URL disponible en https://www. cdc. gov/coronavirus/2019-ncov/hcp/clinical-guidancemanagement-patients. html# Sepsis. 2020 Mar 20.

6. Jin X, Lian JS, Hu JH, Gao J, Zheng L, Zhang YM, et al. Epidemiological, clinical and virological characteristics of 74 cases of corona virus-infected disease 2019 (COVID-19) with gastrointestinal symptoms. Gut 2020;69:1002-9.

7. D’Amico F, Baumgart DC, Danese S, Peyrin-Biroulet L. Diarrhoea during COVID-19 infection: pathogenesis, epidemiology, prevention and management. Clin Gastroenterol Hepat 2020;4;8-10 8. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical characteristics of corona virus disease 2019 in China. New Engl J Med 2020;382:1708-20.

9. Giacomelli A, Pezzati L, Conti F, Bernacchia D, Siano M, Oreni L, et al. Self-reported olfactory and taste disorders in patients with severe acute respiratory corona virus 2 infection: a cross-sectional study. Clin Inf Dis 2020;3:26-30.

10. Qiu H, Wu J, Hong L, Luo Y, Song Q, Chen D. Clinical and epidemiological features of 36 children with corona virus disease 2019 (COVID-19) in Zhejiang, China: an observational cohort study. The Lancet Infect Dis2020;25:35-40.

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11. Ludvigsson JF. Systematic review of COVID‐19 in children shows milder cases and a better prognosis than adults. Acta Paediatrica. 2020;109:1088-95.

12. Brodin P. Why is COVID‐19 so mild in children?Acta Paediatrica. 2020;109:1082-3.

13. WHO/2019-nCoV/clinical/2020.4; Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected Interim guidance 13 March 2020.

14.https://www.mohfw.gov.in/pdf/GuidelineforrtPCRbasedpooledsamplingFinal.pdfd ated14May’2020.

15.https://www.mohfw.gov.in/pdf/ProtocolRapidAntibodytest.pdf;17April’2020.

16. Ai T, Yang Z, Hou H, Zhan C, Chen C, Lv W, et al. Correlation of chest CT and RT-PCR testing in corona virus disease 2019 (COVID-19) in China: a report of 1014 cases.

Radiology 2020; 26:2006-42.

17. Gao Y, Li T, Han M, Li X, Wu D, Xu Y, et al. Diagnostic utility of clinical laboratory data determinations for patients with the severe COVID‐19. J Med Virology 2020;17:310.

18. Alhazzani W, Møller MH, Arabi YM, Loeb M, Gong MN, Fan E, et al. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Corona virus Disease 2019 (COVID-19). Inten Care Med 2020;28:1-34.

19. Phua J, Weng L, Ling L, Egi M, Lim CM, Divatia JV, et al. Intensive care management of corona virus disease 2019 (COVID-19): challenges and recommendations. The Lancet Resp Med 2020;6:4-10.

20. Malhotra N, Joshi M, Datta R, Bajwa SJ, Mehdiratta L. Indian Society of Anaesthesiologists (ISA National) Advisory and Position Statement regarding COVID19. Indian J Anaesth 2020;64:259-63 21. Ayzac L, Girard R, Baboi L, Beuret P, Rabilloud M, Richard JC, et al. Ventilatorassociated pneumonia in ARDS patients: the impact of prone positioning. A secondary analysis of the PROSEVA trial. Inten care Med 2016;42:871-8.

22. Ramanathan K, Antognini D, Combes A, Paden M, Zakhary B, Ogino M, et al.

Planning and provision of ECMO services for severe ARDS during the COVID-19 pandemic and other outbreaks of emerging infectious diseases. The Lancet Resp Med2020;20: 3-15.

23. He XW, Lai JS, Cheng J, Wang MW, Liu YJ, Xiao ZC, et al. Impact of complicated myocardial injury on the clinical outcome of severe or critically ill COVID-19 patients.

Zhonghuaxinxue guan bingzazhi. 2020;48:E011-19.

24. Lippi G, Lavie CJ, Sanchis-Gomar F. Cardiac troponin I in patients with corona virus disease 2019 (COVID-19): Evidence from a meta-analysis. Progress Cardiovasc Dis2020;10: 15-35.

25. Moore JB, June CH. Cytokine release syndrome in severe COVID-19. Science 2020;368:473-4.

26. Mehta P, McAuley DF, Brown M, Sanchez E, Tattersall RS, Manson JJ. COVID-19: consider cytokine storm syndromes and immunosuppression. The Lancet.

2020;395:1033-4.

27. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical characteristics of corona virus disease 2019 in China. New Engl J Med 2020;382:1708-20.

28. Han H, Yang L, Liu R, Liu F, Wu KL, Li J, et al. Prominent huangges in blood coagulation of patients with SARS-CoV-2 infection. Clin Chem Lan]b Med 2020;Mar 16;1(ahead-of-print).

29. Shi C, Wang C, Wang H, Yang C, Cai F, Zeng F, et al. The potential of low molecular weight heparin to mitigate cytokine storm in severe COVID-19 patients: a retrospective clinical study. Med Rxiv.2020 Jan 1.

30. Zhao D, Yao F, Wang L, Zheng L, Gao Y, Ye J, et al. A comparative study on the

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clinical features of COVID-19 pneumonia to other pneumonias. Clin Inf Dis2020;Mar 12.

31. https://www.sciencedirect.com/science/article/pii/S0024320520302253 32. Gao J, Tian Z, Yang X. Breakthrough: Chloroquine phosphate has shown apparent efficacy in treatment of COVID-19 associated pneumonia in clinical studies. Bioscience trends 2020.

33. Basile C, Combe C, Pizzarelli F, Covic A, Davenport A, Kanbay M, et al.

Recommendations for the prevention, mitigation and containment of the emerging SARS-CoV-2 (COVID-19) pandemic in haemodialysis centres. Nephrol Dialysis Transplant2020;35:737-41.

34. Bajwa SJ, Sarna R, Bawa C, Mehdiratta L. Peri-operative and critical care concerns in coronavirus pandemic. Indian J Anaesth 2020;64;267-74.

35.https://www.mohfw.gov.in/pdf/1584423700568_COVID19GuidelinesonDeadbody management.pdf; 15March’2020.

36. Malhotra N, Bajwa SJ, Joshi M, Mehdiratta L, Trikha A. COVID Operation Theatre Advisory and Position Statement of Indian Society of Anaesthesiologists (ISA National).

Indian J Anaesth 2020;64:355 62.

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Considerations to Restart IVF Lab in COVID-19 dr. praveen Kumar Upadhyay M.Sc. (Biotechnology), PHD Sr. Embryologist

the covid-19 pandemic presents unprecedented challenges to healthcare services worldwide. the Fertility and reproductive healthcare providers, alongside every other medical specialties, are striving to protect their patients, colleagues, and the general public while retaining continuity and excellence of care within their clinics during these difficult times. prevention and safety: As many as 80% of COVID-19 patients are asymptomatic shedders of SARS-CoV-2, so preventing the introduction of COVID-19 into the lab is a priority. IVF laboratory staff is mandatory to follow a rigorous protocol for hand hygiene by regular washing with soap and water before entering the laboratory, after encountering patients, and after removal of gloves. Members using contact lenses must replace them with prescription glasses. All staff members must undergo daily screening of temperature using a non-touch infrared thermometer and use a proper set of personal protective equipment (PPE) including disposable laboratory coats, gloves, cap, eye protectors, shoe covers, and face mask, during working hours, and wear a face mask everywhere outside the facility as SARS-CoV-2 is airborne.

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sterilization and disinfectants: COVID-19 remains on surfaces from hours to days, which mandates the daily intensive disinfection of the lab and equipment. Hydrogen peroxide (H2O2; 6%), a safe disinfectant for gametes and embryos, is recommended when fighting SARSCoV-2. Although 70% ethanol is effective against SARS-CoV-2, it can adversely affect embryo development. Sodium hypochlorite (0.1%) also showed effectiveness against SARS-CoV2, although its safety in IVF setting has been questioned. In this exceptional time, the effectiveness of ethanol and sodium hypochlorite can outweigh their possible risk when used cautiously and in certain circumstances such as an infected member or when preparing for shutdown. supplies, stock and equipment: As a shortage of supplies could occur, it seems logical, then, for IVF facilities to establish a collaboration policy to ensure enough stocks of supplies including PPE that can be transferred to any center if needed. There must also be practical plans ready to be enacted should equipment maintenance The cryopreserved biological materials must be safely maintained throughout the duration of the pandemic, and so it is critical to ensure the availability of sufficient amounts of liquid nitrogen (LN2).

Cross contamination in Liquid Nitrogen: While there is no clear evidence in relation to SARS-CoV-2 transmission via nitrogen vapor or LN2, we cannot entirely rule out this possibility. As SARS-CoV-2 is airborne, it could be introduced into the LN2 itself during its production and transportation to IVF laboratories, or through exposure to infected persons during the cryopreservation process or long-term storage. This again mandates the use of a full set of PPE by staff. It appears logical to specify certain tanks for the pandemic period to easily track any future genetic or epigenetic effects.

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air Quality: IVF laboratories are equipped with a heating, ventilation, and air conditioning (HVAC) system to maintain clean air flow under positive pressure, which can prompt COVID-19 transmission. Thus, although strange, it appears safer to switch off HVAC systems along with all other direct or indirect air flow including the workstations during the working hours to minimize the risk of COVID-19.

Operating theatres, intensive care units, and hospitals for COVID-19 patients use negative pressure as standard to reduce the viral load (19). Whether the negative pressure can be applied safely in the IVF setting for higher protection to personnel remains an open question. recommendation: Patients must provide complete data about their general state of health for the past two weeks and continue to do so until cycle completion, and they must be counseled about the risk of cancelation anytime.

Set of blood examinations should be done every two weeks for all staff, and must be under surveillance and continuous revision. Laboratory staff aged 55 years or older, pregnant women, and those with chronic diseases are advised to stay home.

Most COVID-19 patients are asymptomatic shedders of the virus, which suggests that maintaining negative pressure would be prudent in the operating theatre at least. For the IVF lab, as no data exists on whether negative pressure is embryo safe, switching on the HVAC system is only recommended when there are no team members in place. We also recommend stopping all direct and indirect air flow including the workstations.

As high relative humidity discourages the spread of viruses, we recommend maintaining it at the highest level accepted for IVF laboratories. Using humidified incubators across this period is in line with the main concept of “higher humidity is safer”. We recommend each lab to specify certain incubators (where possible) to be used across the pandemic.

Sterilization must include all laboratory surfaces and equipment, and all disposables and media bottles must be wiped with disinfectant. Sterilization must be done with higher precision for doorknobs, cameras, monitors, benchtops, and chairs, and light switches.

While no data is available for gamete contamination, sperm preparation protocols must follow those used for hiv-positive patients. multiple washing for the oocytes and embryos is also advisable to dilute any possible contaminants. although it might sound logical to use a single culture protocol by placing each embryo in one droplet, there is no evidence to recommend this and so the decision is left to each facility or practice. the risk of cross contamination with previously cryopreserved samples, although theoretical, cannot be ruled out. also, it is unknown if there will be any genetic and epigenetic effects associated with this crisis. therefore, it is advisable to specify certain tanks for cryopreservation across the pandemic.

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dr. narendra malhotra M.D., F.I.C.O.G., F.I.C.M.C.H, F.R.C.O.G., F.I.C.S., F.M.A.S., A.F.I.A.P. Managing DirectorGlobal Rainbow Healthcare, Agra Prof.- Dubrovnick International University Director- IAN Donald School (India) V.P. WAPM (world association of prenatal medicine) Member Education Committee IAPM Past President ISPAT (2017-2019), ISAR (2017) Past President FOGSI (2008) Founder Editor SAFOG Journal

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