GUIDELINES FOR PREFERRED PRACTISES DURING COVID-19 PANDEMIC

The pandemic caused by SARS-CoV-2 virus (COVID 19) has compelled hundreds of countries across the globe to impose nationwide lockdown and quarantine in an attempt to slowdown the spread of infection. The Government of India has declared a nationwide lockdown from March 25th 2020 to April 14th 2020; this was further extended to May 3rd

2020. It is likely that this may be further extended either nationally or region-wise depending on the number of new cases developing per day and the overall co-operation of the public in maintaining an effective lockdown. It is also possible that if the situation improves, the government may begin relaxation of the restrictions so that the public life may gradually and in a phased manner move towards normalcy. As and when the government and respective associations allow non-emergency work, we as medical professionals must aim for that delicate balance between promoting viral transmission and providing our services as plastic and aesthetic surgeons.

UNDERSTANDING COVID-19When to suspect:

All symptomatic people who have undertaken international travel in the last 14 days. All symptomatic contacts of confirmed cases All symptomatic health care personnel (HCP) Hospitalized patient with fever + cough +/- shortness of breath. Asymptomatic direct and high risk contact* of a confirmed case. (should be tested

between day 5-14 after the contact) In hotspots/ cluster and in large migration gatherings/ evacuees centers

*High risk contacts include those who live in the same household with a confirmed case and HCP who examined a confirmed case without PPE or with a breach in PPE.All such suspected patients should be avoided for any aesthetic procedure or surgery.ALL these patients should be referred to the nearby COVID testing centre.

Clinical Features: Patients may present with the following symptoms – fever, dry cough, fatigue, sputum production, shortness of breath, sore throat, loss of smell or taste sensation, headache, myalgia, arthralgia, chills, nausea or vomiting, nasal congestion, diarrhea, hemoptysis, conjunctival congestion or ARDS.

Laboratory DiagnosisCOVID-19 testing includes methods:

1. Real time reverse transcription polymerase chain reaction (rRT-PCR) - This detects the viral antigen from respiratory samples obtained by nasopharyngeal swab or coughed up sputum. Reports are generally available within 2 days.

2. Serology tests - these detect the presence of specific antibodies in the blood. Reliable point of care testing in not yet available.

Treatment optionsAs of now there is no proven vaccine or medicine or immunotherapy or gene therapy available for the treatment of COVID-19. There are several studies being conducted at various centers around the world to identify an effective treatment option.Until such a time that treatment or vaccine options are available, it is imperative that every attempt should be made to prevent the spread of virus and slowdown the viral transmission.

PREVENTIVE MEASURESCOVID-19 is caused by SARS-CoV-2 virus and is a highly infectious disease. The virus may be transmitted by following modes:

Droplet transmission - occurs when a person is within one meter of a patient. Fomite transmission - occurs when a person comes in contact with a surface

contaminated by the patient’s respiratory secretions (by cough, sneeze etc) Airborne transmission - occurs due smaller droplets in the air which may remain for

longer periods of time and over greater distances. This is particularly relevant in procedures that generate aerosols; eg. endotracheal intubation, bronchoscopy, open suctioning, nebulization treatment, manual ventilation before intubation, disconnecting from ventilator, tracheostomy, open circuit, nasogastric tube placement, and cardio-pulmonary resuscitation etc. The virus may also be released during laparoscopy with CO2; therefore, should be avoided unless urgent.

The following three measures if applied properly can effectively minimize transmission of the virus.

1. HAND HYGIENE: All HCP must perform hand hygiene using alcohol based hand rub (at least 20

seconds) or washing with soap and water (at least 40 seconds). This must be performed before and after using bathroom, before and after

preparing food, before and after eating food, after coughing, blowing nose or sneezing, after touching garbage, after touching mask or soiled PPE.

Whenever possible, foot operated sanitizers should be provided wards, rooms, elevators, screening areas and ICUs.

2. MASK ETIQUETTEIf masks are worn, then appropriate use and disposal is vital to reduce the risk of transmission of virus.

The mask must cover mouth and nose and tied securely to minimize gaps between face and mask.

While in use, avoid touching the mask. Remove the mask properly; do not touch the front but remove the ties from

behind. If a used mask is touched, then hand hygiene must follow. Replace a damp or moist mask with a new dry mask Do not reuse single use masks; dispose them properly. N95 respirators should fit the face snugly. Male HCP should remove facial

hair in the region of the base of these respirators (area where the mask sits on the face).

It is recommended to use a cleanable face shield over the mask. It is recommended that each mask be used for a maximum 8 hours duration at

a time.

SOP for extended use of N95 masks: Keep 4 N95 masks and 4 brown paper covers; label the covers from 1 to 4. Each mask is placed in its own paper cover. A spare N95 mask should always

be kept handy. On day 1, wear mask number 1 when you step out for duty or near the clinic/

hospital. After work, place the mask in the paper cover no.1 and let it dry for 4 days. Sunlight is not mandatory.

On day 2, use mask from paper cover no. 2 and repeat the same steps as with mask no. 1.

Do the same on day 3 and day 4. On day 5, use the mask no. 1 again. Repeat the exercise till all the masks have been used 5 times as recommended. At any stage, if a mask is used during an aerosol generating procedure, or gets

contaminated with blood, respiratory or other body fluids then it must be discarded.

These “personal use” N95 masks with their paper covers must be disposed in the yellow bag properly.

3. USE OF PPE (Personal protective equipment)PPE is protective gear used to safeguard oneself from being exposed to the infectious agent. It consists of – head cover, googles, face-shield, mask/ respirators, coverall/ gown, gloves and shoe covers. The appropriate use of PPE is imperative for effective protection and at the same time proper removal and disposal of PPE is important to reduce risk of transmission. Please empty bladder and bowel before wearing PPE.Steps for donning PPE:

Remove home clothes, watch, jewelry, electronics etc and wear surgical scrubs.

Wash hands with soap and water Wear shoe covers Wear first pair of gloves – sterile or unsterile Wear the coverall or gown (non-permeable) and secure it.

Wear the mask or N95 respirator – tie the lower strap behind the neck and then secure the upper strap such that the mask fits snugly to the face. You may use another 3 ply mask over the first one to protect the outer surface.

Wear the goggles or eye cover such that it sits on the upper end of mask Wear the head cover Wear the face shield Wear the second pair of gloves

Ask a companion to check if the PPE is fitting well and that the gown/ coverall is intact.

Steps for doffing PPE:Doffing should be done in a designated area only. Check if the PPE is torn or soiled before removing it. Used PPE must be disposed in a manner similar to any biomedical waste. Keep a large yellow bag to dispose the used PPE and a clean chair available.

Disinfect both hands with sanitizer Remove the shoe covers by touching outer surface only and perform hand

hygiene Remove outer gloves and perform hand hygiene Remove face shield/ head cover and perform hand hygiene Remove the gown/ coverall without touching the outer surface with a rolling

inside out technique and perform hand hygiene. Remove goggles and perform hand hygiene Remove inner gloves and perform hand hygiene Wear another pair of gloves Remove masks gently (so as not to produce aerosol) by holding straps only

and perform hand hygiene. All the parts of the gear are disposed of carefully. Clean the shoes with alcohol swab. Remove last pair of gloves and perform hand hygiene. Wear a snug fitting 3 ply mask

Due to limited supply of PPE kits, the Indian government recommends the use of PPE kits at dedicated COVID19 centers and for managing known COVID19 patients. Use of fluid resistant gown is recommended when performing an aerosol generating procedure and its use is optional in other scenarios.

MANAGING CLINIC / HOSPITALDoctors and HCP above 60 years or those with underlying medical conditions such as diabetes, chronic liver disease, chronic heart disease, chronic kidney disease, chronic lung disease like asthma, COPD, bronchiectasis, ILD etc, cancer, on chemotherapy or steroid treatment, seropositive status or pregnant. It is recommended that planned non-emergency procedures should be postponed till such a date that restrictions are lifted. The clinic should be kept open for a limited period on alternate days or daily basis depending on the patient load.Screening of patients should be done sequentially and systematically.

Telephonic triage Patients must be triaged based on the urgency of professional medical care. Patients must be screened for travel history, contact history and symptoms. Restrict the number of accompanying person to maximum 1. Restrict the entry of

children and elderly (>65 years). Patients should be given specific time for their appointment. Appointments should be staggered so as to avoid over-crowding. Patients must be instructed to reach the clinic on time, wear a mask and if possible

gloves at all times. Patients should be instructed to avoid wearing watch, jewelry and avoid carrying bags

or purses. They must be instructed to carry a pen with them (for signing form) and avoid touching their mobile repeatedly

Entry level triageWalk in patients must be avoided and only patients with prior appointments must be entertained. A clinic/ hospital staff must be stationed at the entrance to screen the appointment patients. There must be a barrier at the entrance so that only the patient and one accompanying person can enter. Patients are asked to leave their bags or purses outside / in their vehicle. The HCP at the entry must be wearing PPE – surgical cap, surgical scrub suit (gown), Double layer of 3-ply mask or N95 mask and gloves. He / she must screen patients based on following points:

Travel: international travel within 2 weeks Address: whether they are coming from hotspot or containment area Occupation: unprotected contact with COVID 19 patient or their contact. Contact with suspected or proven COVID 19 patient or their contacts. Cluster: attending any gathering or function with many people Symptoms: History of fever, cough, shortness of breath, loss of smell or taste

sensation, conjunctivitis etc. Fever: recording the body temperature using a non-contact thermometer. Anyone over

37oC must be advised to report at dedicated COVID 19 center.

Waiting Area After clearing the entry level screening, all patients and accompanying person must

perform hand hygiene and must be wearing a mask. A maximum of 2-3 patients should be allowed in the waiting area – depending on the

available area. Patients must maintain a minimum distance of 1 meter between each other and between hospital staff.

If the waiting room is already occupied, the other patients should be instructed to wait in their respective cars.

Patients and accompanying person must sign the declaration form using their own pen.

Format of this form: During the lockdown, in the wake of current Coronavirus situation, I / we have come to the doctor / clinic / hospital for treatment of my son / daughter / relative. I am aware that if I or any one of us is an asymptomatic carrier or are undiagnosed case of COVID-19, I may endanger the doctor and clinic / hospital staff. Therefore, it is my responsibility to take appropriate precautions and follow the protocols prescribed by the local government. I am also aware that I or anyone of us visiting the clinic / hospital may get an infection from the hospital / doctor / hospital staff and I will take every precaution to prevent this from happening. At the same time, I shall NOT at all hold the doctor / staff / clinic / hospital accountable if such an infection occurs to me, my patient or any accompanying patient. Furthermore, I acknowledge that all the information given by me is accurate and complete.

Whenever possible, the route for entry and exit must be separate, so that patients do not cross each other.

Hand sanitizers must be available in the waiting area. As far as possible, keep all doors open so that they do not touch door knobs. A non-AC, open door policy is recommended, keep doors and windows open to allow

cross ventilation. A detailed record of all HCP and visitors to the clinic / hospital must be maintained

along with their address and contact number. Medical record of follow-up patients must be kept ready and handy as per

appointments. For new patients, an App based registration and online payment should be used. Visual alerts reminding patients about hand, respiratory hygiene and mask etiquette

should be posted at the entrance and at strategic areas. Retain the names, address and contact details of all patients and accompanying

persons for atleast a month. This will help authorities trace people who may be exposed if one or more persons becomes COVID19 positive after visiting the clinic / hospital.

Consulting roomAn open door policy is recommended so that door knobs are not touched.

It is preferable that the doctor wears a surgical scrub suit and closed footwear. The doctor and nurse must be wearing PPE – head cover, N95 mask or two layers of 3

ply mask, face-shield or goggles and gloves. HCP coming in direct contact with patients must be encouraged to wear a surgical scrub suit. The use of a surgical gown is optional. This is however essential when performing injectables, peels, microneedling etc.

Discussion should be concise and kept to the minimum. Hand hygiene before and after examining each patient. All other times palms should

be kept together. Remove all unnecessary items from the consulting table and room. Keep the chairs for patient and accompanying person at a distance of 1 meter from the

table, so that they do not touch the table. All HCP should restrict the number of personal items that they bring to the clinic/

hospital. Food should be carried in a double layered carrier so that the outer layer can be easily disinfected.

Communicate with the staff – to educate and train them for use of PPE, hand hygiene mask etiquette, social distancing and respiratory hygiene. It is equally important to address their emotional needs as they too are likely to be stressed.

Do mock drills for correct donning and doffing of PPE. Prophylaxis: ICMR has advised oral Hydroxychloroquine 400mg BD for one day,

followed by 400mg once weekly for 7 weeks. However, this must be taken only after consulting a MD/DM physician.

At the end of the day:- Remove PPE, change into street clothes; then perform hand hygiene- Ring up home when you leave clinic/ hospital- No detour from hospital as far as possible- Someone at home keeps door open- Enter home and sanitize hands. - Keep items such as mobile, keys, pen etc in a separate box; to be sanitized - Sanitize hands again- Go to the bathroom without touching anything, take off all clothes including

inner wear and soak all clothes in a bucket of hot water and detergent soap. Clothes should be washed in washing machine (or by hand) with high temperature setting and should then be dried in direct sunlight.

- Take a head bath; wash hair with shampoo and body with soap

Cleaning the facilityThe various disinfectants that may be used are as follows:

7% Lizol - Dilution:15 ml in 1liter water; Contact duration: 10 minutesFloor cleaning and toilet cleaning

Hand sanitizers (propanol/ ethyl alcohol/ isopropyl alcohol) –3-5 ml for hand sanitization; Contact duration: 20 seconds

1% Sodium hypochlorite – Dilution: 9 parts of water + 1 part of 10% sodium hypochlorite

Contact duration: 1-15 minutesFor cleaning all surfaces

10% Sodium hypochlorite – for large blood spill 0.1% Sodium hypochlorite – for disinfecting patient bed 1% Bacilocid solution – For cleaning all surfaces

Disinfectants must be applied to surfaces using a damp cloth instead of spraying.Recommendations:

High touch surfaces – (door knobs, handles, telephone, call bells, bed rails, chairs, arm rest, light switches, toilet walls etc) must be cleaned with freshly prepared 1% sodium hypochlorite or 1% Bacillocid solution, every 2 hourly.

Low touch surfaces – (walls, mirrors etc) must be cleaned once daily with 1% sodium hypochlorite solution; before work.

Floors, walls, blinds - must be cleaned with 1% sodium hypochlorite or soap water once daily, and with Lizol every 2 hours.

Fabrics (curtains, linen, quilts etc) – washed with hot water (70oC) with detergent for atleast 25-30 minutes.

Cleaning items made of cloth (mop heads, wiping cloth etc) must be discarded into biohazard bags after each use. Buckets used for cleaning must be disinfected with bleach solution or hot water, before use.

HCP must clean and disinfect their equipment such as pen, torch etc with alcohol based sanitizers.Cleaning staff must wash their hands with soap and water after removing their PPE.

Recommendations for PPE use by various hospital staff

Setting Activity Risk Recommended PPE CommentsEntry screening Screening Moderate Surgical scrub suit, cap, 3 ply

mask, face shield and glovesSocial

distancingWaiting area staff Registration,

SupervisionLow 3 ply mask, gloves Social

distancingSanitary staff Cleaning Moderate Disposable gown, cap, 3 ply

mask, face shield, gum boots and heavy duty gloves

Administrative staff

Admin support

Very low 3 ply mask Social distancing

HCP (Doctor, Nurse, wardboy,

etc)

Brief contact

High Surgical scrub suit, cap, N95 mask, face shield, Surgical

gown and gloves.Prolonged

contactHigh Surgical scrub suit, cap, N95

mask, face shield, plastic apron non-permeable

surgical gown/ coverall and gloves

Aerosol generating

Very high Surgical scrub suit, cap, N95 mask +3 ply mask, Face shield, non-permeable

coverall, gloves and shoe cover.

Operating roomThe Government of India has recommended that all non-emergency surgeries should be deferred till such a date that the situation improves and the government comes forth with new guidelines. Emergency surgeries can be performed but by taking all necessary care and precautions. This is with the intention to preserve resources in case of exponential increase in number of COVID19 patients.Even after the lockdown is lifted, it is evident that the virus will still be prevalent in the population. Therefore, health care personnel will continue to be at increased risk for infection unless precautions are taken. Consequently, the measures mentioned here must be continued even after the lockdown is gradually lifted, till such a time that threat of viral infection persists in the country. We must ease our way into elective surgeries and procedures even as the situation proceeds towards normalcy and Government guidelines are clearer.

BROAD REGIONAL GUIDELINES: Based on number of reported cases, regions are divided into 3 categories:RED zone (Hot spot) - doubling of cases in less than a week.

Only emergency health services allowed.ORANGE zone – doubling of cases in more than 7 days.

Red zone gets converted to orange if no new cases in 14 days. Judicious and cautious beginning of non-emergency health services.

GREEN zone – No new COVID19 case since last 28 days. Scrupulously start non-emergency health services.

Suggested COVID19 testing protocol for planned surgery (For orange and green zone)

Admitted in isolation for 24 hours

PCR testing during stay & at time of discharge (Exit) PCR testing every 7 days

Patient for

Patient for planned surgery

P PCR testing Antibody testing

P PCR negative Antibody positive

P PCR negative Antibody negativeP PCR positive

Antibody negative

P POSTPONE SURGERY

P CARRY OUT SURGERY OUT OUT SURG

P CARRY OUT SURGERY OUT OUT SURG

All surgeries must be deferred (unless there is risk of loss of limb, limb function, eyes, vision, brain function or life) on a known COVID 19 patients for atleast 2 weeks. If it has to be performed, then it must be performed in a hospital approved for COVID19 treatment. Similarly, all surgeries (except when there is risk of loss of limb, limb function, eyes, vision, brain function or life) must be deferred for 2 weeks on an asymptomatic suspected COVID19 patient. Proper testing for confirming the infection status should be done. Surgery can be performed after 2 weeks if the test is negative and patient has effectively quarantined oneself for that duration. For unsuspected, asymptomatic and healthy patients, apart from routine pre-surgery investigations, rRT-PCR test must be done. A routine X-Ray chest is mandatory, along with a thorough evaluation by a physician to rule out airway pathologies. One must bear in mind that a study from China has suggested high morbidity (40%) and mortality (20%) after elective surgery, if patient gets COVID19 infection post-operatively.

1. Operation room An operating room with separate air handling unit (AHU) is preferable. AHU must

allow increased fresh air exchanges (25 cycles/ hour) and if possible the HEPA should be retrofitted with dynamic UV and ultrafilters. Similarly, one must reduce turbulence in the OR eg. minimize opening and closing of doors and moving machines.

If the OR has been closed for more than 72 hours, then fumigation as per standard protocol and negative microbiological cultures are mandatory before restarting operations. All surgical instruments and equipment must be cleaned and disinfected / sterilized.

Empty the OR of all unnecessary materials. If possible, negative pressure inside the OR. The positive pressure ventilation in the

OR must be stopped 30 minutes before surgery, throughout the surgery and for atleast 30 minutes after the patient has been shifted out and OR has been cleaned and disinfected.

All equipment should be dedicated i.e. used only in that OR. Disposable pen must be provided. A separate negative pressure anteroom with separate access must be used for donning

and doffing of PPE. Doffing of PPE must be done either in such an anteroom or in the OR before the exit door.

Use of diathermy should be minimized; smoke evacuation must be used. Keep the following ready in the OR

- large yellow bag for disposable waste- double yellow bag for used linen - separate bin for reusable instruments (until they are cleaned and

disinfected/ sterilized)

2. Patient Patient must be informed about the various safety measures adopted at the clinic/

hospital. Patients must be reminded about social distancing, hand hygiene and respiratory

hygiene. Patient must be informed that the planned surgery may be cancelled if – he/ she

develops symptoms of COVID19, there is suspicion of exposure, screening test comes positive or the government instructs all hospitals to stop all planned work.

Patient must be explained the financial implications of doing any procedure; additional cost of PPE etc.

The clinic / hospital must contact the patient more frequently both before and after the procedure to confirm overall wellbeing of patient.

A thorough Pre-anaesthesia check-up (PAC) must be ensured. Apart from routine inform consent, patient must sign the declaration form. 3. OR staff Avoid surgeries during non-routine hours; so that experienced staff is available. Minimum number of staff in the OR. Surgical, nursing and support staff must be well trained about precautions and proper

use of PPE. Whenever possible, all personnel in the OT must don proper PPE; as anaesthesia and surgery may involve aerosol generating steps.

The support staff must be dedicated to the OR throughout the procedure. The quickest possible surgical procedure must be selected. Patient should be brought to OR through a clear path and wearing a 3 ply mask. No non-essential items should be brought into the OR eg. bags, purses, mobile

phones, pens, watch, food etc. must be left outside the OR

4. Anaesthesia Detailed pre-anaesthesia checkup (PAC) must be done. Avoid GA unless mandatory. However, any patient with active cough, GA is

preferred. Regional, Local or topical anaesthesia is preferred. For GA, all breathing circuits must be fitted with an appropriate, high efficiency

hydrophobic HME filter. An extra filter is placed on the expiratory limb of the breathing circuit at the machine end. Pre-oxygenate patient with 100% oxygen for 5 minutes (not high flow).

Intubation should be done using Rapid Sequence Intubation; preferably using Video laryngoscope. Adequate neuromuscular blockade to avoid bucking of patient. Inflate the tracheal tube cuff immediately before starting ventilation.

Avoid manual ventilation Suctioning should be minimized and a closed suction unit should be used. Prophylactic use of anti-emetic is preferred. After surgery, the breathing circuit and canister of soda lime must be discarded.

5. Aerosol generating proceduresExtra care must be taken when performing any aerosol generating procedure. It is critical to reduce the aerosolizing procedures such as:

High flow nasal cannula (>6 liters/min) Nebulizers Awake fiber-optic intubation CPAP, BiPAP Nasogastric tube placement Inhalational anaesthesia Non-invasive ventilation Bag masking Use of T-piece or open ventilation Open suction Laparoscopy – due to expelled CO2; therefore must be avoided as far as possible.

6. Recovery Smooth extubation must be ensured. Patient should be monitored in the OR after recovery from anaesthesia. Must be

transferred to isolation room directly from OR. The transport staff must also use proper PPE. Maintain a detailed roster of staff (nurses, technicians, wardboys, other helps, cleaners

etc) duty in the hospital. Preferably one staff should be assigned to one patient only. This way if any patients turns positive at a later stage, tracing of contacts is easier.

7. Cleaning protocol The OR housekeeping must wear proper PPE Used PPE is discarded in yellow bag. All disposable waste must be collected in yellow bag and goes to BHW. Monitors can be decontaminated by 2-3% hydrogen peroxide spray. Linen is sprayed with 1% sodium hypochlorite and put in separate double yellow bag

and then goes to laundry. All surfaces are sprayed with 1% sodium hypochlorite and left for 30 minutes. Floors are mopped with 1% sodium hypochlorite Bacillocid spray is done and ideally left for one hour. No two patients should be handled together and there should be a gap of atleast 30

minutes between two surgeries.

8. If a patient or staff is detected to be COVID19 positive at a later stage Center should be fumigated and all surfaces should be cleaned with 1% sodium

hypochlorite Center should be closed for 24 hours All HCP who were not in contact with the positive patient (or staff) may continue

duty subsequently. All HCP with proper PPE who came in contact with the positive patient (or staff)

need not be tested or quarantined unless they develop symptoms. All HCP without proper PPE who came in contact with the positive patient (or staff)

should be considered as close contact and quarantined. - No symptom by 7th day – then resume duty- Develop symptoms, then test on 7th day – if positive, transfer to COVID19

center. Other patients who came in contact with the positive patient or staff should be tested. Anyone who test positive for COVID19 should be transferred to a dedicated

COVID19 hospital.

Broad guidelines for precautions to be taken during OPD and surgery services have been enlisted here. We hope that these are readily adopted by all plastic and cosmetic surgeons and become preferred practices in times to come. Some of these guidelines may have to be modified as the Government of India comes forth with newer directives and protocols based on more data available regarding transmission, epidemiology and treatment. Using these preferred practices will help us provide clinical services to our patients and at the same time keep us safe in these difficult times. Triage system, social distancing, hand hygiene, proper use of masks and PPE and judicious testing for COVID19 should be the mantra which will enable us to fulfill our professional duties without becoming a hotspot for virus transmission. References:

1. Information on the official website of Ministry of Health and Family Welfare, Government of India (www. mohfw.gov.in) –

Revised guidelines on Clinical management of COVID19. Advisory for hospitals and medical education

2. Information from the official website of WHO (www.who.int) – COVID19 advice for the public. Guidance for health workers

3. Information from the official website of ASPS (American Society of Plastic Surgeons) (www.plasticsurgery.org) – Consideration for the resumption of elective surgery and visits

4. Information from the official website of ISAPS (International Society of Aesthetic and Plastic Surgeons) (www.isaps.org) – Managing global aesthetic practices during the COVID19 pandemic.

5. COVID19 preparedness document – published by AIMMS, New Delhi, India. 21st April 2020.

6. Sengupta S, Honavar SG, Sachdev MS, Sharma N, Kumar A, Ram J, et al. All India Ophthalmological Society - Indian Journal of Ophthalmology consensus statement on preferred practices during the COVID-19 pandemic. Indian J Ophthalmol 2020; 68: 711-24.

7. Malhotra N, Joshi M, Datta R, Bajwa SJ, Mehdiratta L. Indian Society of Anaesthesiologists (ISA National) Advisory and Position Statement regarding COVID-19. Indian J Anaesth 2020; 64: 259-63.

8. Updated Indian Association of Surgical Oncology COVID19 guidelines – 16th April 2020.

9. M.A. Al-Muharraqi. Testing recommendations for COVID19 in patients planned for surgery – continuing the service and suppressing the pandemic. Br. J. Oral Maxillofac. Surg. 2020; April 13.

10. S. Lei, F. Jiang et al. Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID19 infection. EClinical Medicine.(I don’t have the complete reference detail for this article)