Updated management protocol covid 19-aiims rishikesh_version 4.0

@Dr. P. K. Panda (Nodal officer, Covid-19 Task Force, AIIMS Rishikesh) 1
Clinical Management
Protocol of Covid-19
AIIMS, Rishikesh
Objectives
1. Flow of patients
2. Suspect criteria
3. Admission criteria
4. Testing criteria and Quarantine policy
5. Treatment of suspect critically ill patients
6. Treatment of confirmed patients as per
institute trial
7. Dept/Disease specific SOP
1

Screening @
Parking area in
front of trauma
centre
PROVISIONAL SCREENING FOR COVID-19 SUSPECT
1. Screening questions to be asked again with a printed form:
• Have u suffered from any of the following symptoms (fever,
cough, cold, throat pain, breathlessness, chest pain, loss of
smell/taste, diarrhea, abdominal pain, or bleeding
tendency) in past 14 days
• Have you visited any foreign country or Indian place/region
where positive cases being detected in past 28 days
• Do you want to be screened or have any concern for Corona
2. Again Making patient line as per above questions and deciding whether
patient will go to Covid-19 centre or other area
3. Availing Hand hygiene and at least 1m physical distancing of patient and
attendants
4. HCWs to wear surgical mask, gloves and others as required
ENTRY at SCREENING OPD
COVID- 19 SUSPECT
ENTRY TO COVID-19 EMERGENCY
STABLE PATIENT COMING
BETWEEN 5 PM TO 8 AM
CRITICALLY ILL PATIENT
STABLE PATIENT COMING
BETWEEN 8AM TO 5PM

IF YES
WHEN TO SUSPECT COVID-19 ?
1. A patient with severe acute respiratory illness (fever and at least one sign/symptom of
respiratory disease (e.g., cough, shortness of breath) OR Chest pain OR Acute loss of smell/taste
OR Acute Diarrhea OR Abdominal pain OR bleeding tendency OR Afebrile states* associated
with any respiratory illness, AND a history of travel to or residence in a country/area or territory
reporting local transmission (see WHO/NCDC designated areas) of COVID-19 disease during the
14 days prior to symptom onset
2. A patient with above symptom category AND having been in contact with a confirmed
or probable COVID19 case in the last 14 days prior to onset of symptoms
3. A patient requiring hospitalization with any of the above symptoms
* Afebrile state: Chronic lung/liver/kidney disease, neurological, hematological disorder, Pregnancy, old
age (>60), morbid obesity, malignancy, diabetes, persons of NSAIDs/corticosteroids and other
immunosuppressive, or HIV-AIDS. Maintain high index of suspicion in these patients
DOES NOT REQUIRES ADMISSION
1. Mild symptom category
2. Can be monitored properly at home
*Advised for Covid-19 testing, Home
Isolation (till reports negative and 72hrs of
clinical recovery and 10days of symptom
onset), and basic medical management.
REQUIRES ADMISSION @Isolation ward
1. Any Severe symptom category
2. Any symptom category AND chronic
Lung/heart/liver/kidney/neurological/blood
disease/Immunological diseases, morbid obesity,
malignancy, uncontrolled hypertension/diabetes,
HIVAIDS, on long term
immunosuppressant/NASAIDs, Pregnancy, Age >60
years
3. Breathlessness, chest pain, drowsiness, fall in blood
pressure, hemoptysis, cyanosis, hypoxia
4. Mild symptoms but staying alone/monitoring not
possible – Admitted in Facility based
isolation/quarantine center
*Any Confirmed case will be admitted as per Nodal
officer discussion along with state IDSP

LABORATORY
TESTING
1. All above suspects
2. All health care workers with any of the above symptoms
3. Asymptomatic close and high-risk contacts of a confirmed case should be
tested once between day 5 and day 14 of coming in his/her contact
4. All who are advised home quarantine (once at day1 and another at day13)
5. All surgery/procedure cases if clinician prescribes
6. All symptomatic Influenza Like Illness cases from a hotspot/migration gathering
a. Within 7 days of illness – rRT-PCR
b. After 7 days of illness – Antibody test (If negative, confirmed by rRT-PCR)
Close and high-risk contact include those who live in the same household with a
confirmed case for a duration of more than 15 mins within a distance of 2 mts and
healthcare workers who examined a confirmed case without adequate protection as
per WHO recommendations.
All those tested but not hospitalised should be home isolated/quarantined with
strict compliance as per guideline.
Sample collection:
Collection location: designated place beside screening OPD or in isolation rooms or in Emergency
Collection time: 8am to 5 pm (for OPD patients) or 24hrs in isolation rooms
Preferred sample: Throat and nasal swab in viral transport media (VTM) and transported on ice
Alternate: Nasopharyngeal swab, BAL or endotracheal aspirate which has to be mixed with the viral
transport medium and transported on ice
General guidelines:
1. Trained health care professionals to wear appropriate PPE with latex free purple nitrile gloves while
collecting the sample from the patient
2. Maintain proper infection control when collecting specimens
3. Restricted entry to visitors or attendants during sample collection
4. Complete the requisition form for each specimen submitted
5. 30min gap between two sample collections if in an isolation room
6. Proper disposal of all waste generated
7. Maintaining register of all patients who are tested, report delivery to right place, person and in
right time, and regular update to non-admitted patients for 14days of follow-up of symptoms onset
Lower respiratory tract
• Bronchoalveolar lavage, tracheal aspirate, sputum
• Collect 2-3 mL into a sterile, leak-proof, screw-cap sputum collection cup or sterile dry container

Functions of Covid-19 Screening OPD
1. Make the patients sit in 1meter distance area from each other according to token no
2. Ensure/Provide surgical mask (if not available, N95) to the patient when entering OPD area and allow
attendant with a mask if patient can’t take care him/her-self
3. Registration of patient details including contact no and address
4. Doctors will see patients and decide regarding need for testing and admission
5. Patients requiring testing only to be routed to sample collection center in open designed area with home
isolation/quarantine advice and basic treatments
6. Contact Isolation ward for availability of bed if admission required
7. Ensure the patient is shifted to isolation ward in mask/surgical Gown/head cover in wheel chair/trolly and
accompanied by HCW en-rooted till emergency entry
8. If no admission required, guide properly home isolation/quarantine with IDSP team follow-up
9. Maintain a soft copy of all patients’ management on daily basis, better will be in excel
Functions of Covid-19 Emergency Area
At security check in
1. Ensure/Provide surgical mask to the patient
2. Attendants will not be allowed inside
3. Attendants to be instructed to stay nearby for sos availability and maintaining 1m distancing
4. Patients admitted from screening OPD will be enrooted through emergency only
5. To call attendants of admitted patients as required and make them stand at 1 meter distance in a row
Inside emergency
1. Stabilization of the patient
2. Patient with screening negative for COVID 19 should be en-routed to main emergency but after doffing
3. Patients requiring testing only to be routed to screening OPD 9am-5pm, but during 5pm to next morning
9am sample collection to be done in emergency 4bedded isolation room with home isolation/quarantine
advice and basic treatments with IDSP team follow-up similar to screening OPD
4. Mandatory investigations before shifting to isolation ward - ABG, RBS, CBC, KFT, LFT, ECG, CXR PA, HIV 1 &
2, HBs Ag, ANTI HCV Ab
5. Others investigations if required based on clinical scenario-TROP I, CPK MB, PROCALCITONIN, CT/MRI
BRAIN/CHEST, USG ABDOMEN/CHEST
6. Contact Isolation ward for availability of bed based on admission criteria
7. Ensure the patient is shifted to isolation ward in surgical disposable Gown/head cover/mask and
accompanied by HCW
8. Maintain a soft copy of all patients’ management on daily basis, better will be in excel

Quarantine policy
• All primary contacts will be traced by investigating officer and asked to come Screening
OPD/designated place for detail screening
• Individuals in category of primary contact with COVID 19 positive patient will be put on
quarantine for 14 days as per GOI guideline
• Covid testing will be done at D1 and D13 of quarantine unless symptomatic inbetween and at
that time another testing will be done
• All primary contacts will be asked for HCQ prophylaxis and if they want, then each has to come
to EHS OPD (room no 401) for exclusion of contraindication and HCQ as per institute policy.
• Decision of quarantine team (appointed through MS office) will be final
• Accommodation for quarantined personal will be provided by hospital administration either at
hostel or other separate facility
• Date of re-joining to duty will be decided by above personel
• Any patient or their attendants exposed to any positive HCW/patient, will be treated in same
way except they will be quarantined in our hospital quarantined facility and continue their
ongoing management. All will be re-tested at day 7 and if negative, they may be advised home
quarantined with consultation with Nodal officer
• All suspected or quarantined patient if died will be considered as positive patient and dead
body management is same as Covid positive patient.

COVID-19 PATIENT
ADMITTED IN
ISOLATION WARD
At security check in
A. To receive patient/HCWs with proper mask/surgical
grown/Head cover
B. Inform nursing officer at receiving desk
C. Data entry of all personnel entering and exiting from
isolation areas.
JUNIOR RESIDENT AT DOCTORS ROOM
• 1st contact Physician of the patient coming from
Emergency/Screening OPD
• Will enter of data of each patient and ensure
protocol being followed
JUNIOR RESIDENT AT BEDSIDE
• Will coordinate with the Doctor room resident when
patient is admitted from screening OPD/Emergency
• Will ensure work is being done according to
protocol given
SR will supervise all HCWs and take one-time round of all
patients on daily basis, overall co-ordinate among all ground
HCWs, and discuss with faculty incharge on daily basis
Faculty will be physically available 8am-2pm on daily basis
in Covid-19 areas except emergency and ICU areas where
24hrs presence is required, to co-ordinate SRs, JRs, Nursing
officers in all time, will be deciding signatory on 24hr basis,
and finally manage patient flow whether going in right
direction from gate 3 to screening OPD to emergency to
isolation ward or not.
SOP/Protocol of the specific dept will be followed as below.
Nursing officers will do work on three stations: one
reception, one pharmacy/desk in-charge, one in direct
patient care
All positive patient who are
admitted, repeat sample at
day 7 of illness/report if
asymptomatic, then on 10th
day, then every 4th
day till
negative. If any sample
becomes negative, then do
second sample every alternate
day for two conservative
samples, then discharge/shift
to non-suspect zone after
72hrs of clinical recovery and
10days of symptom onset

Work division of residents in isolation ward
• There are averagely two major stations for JRs in all Covid areas: One computer
room for data entry and another bedside patient area for treatment; sometimes extra
room as per ward type like Dialysis room, sample collection room, common pool
area or coffee room, etc.
• Reach 15min before duty start time, decide with other co-JR regarding station of
work during donning at appropriate place
• Take detail over from respective stations
• Ensure minimal movement in designated areas unless very essential
• Exchange of position in between two major stations in at least 3hrs in each station
in morning/evening hours and 4hrs in night hours unless breach occurs
• Sometime extra work may be required in special stations under the guidance of SR
• Patients will be divided into 2 groups - Suspect or confirmed and either critically ill
(any organ impairment) or stable
• Suspect pt to be kept in isolation single room but confirmed pt will be kept
combined in cubicle having 4 or more beds; Critically ill (mostly ventilator)
positive pt to be kept in ICU
• D1 area is only for stable pt, D3 is for preferably pediatric/Obstetric pt, D4&D6 for
critically ill suspect patients.
Few basic
principles to
be
remembere
d w.r.t.
precautions
• No fear inside
• Maintain 100% precautions as required
• All patient rooms are with 100% negative pressure, hence while working in
anteroom/corridor/entry point of any patient room, except N95 mask nothing is
required but physical distance of 1m among workers, hand hygiene, and standard
precautions to be maintained.
• Ensure 24 hours negative pressure in the room via exhaust fan
• If going inside a patient room transiently (<10min) and exhaust fan is on, no change
in PPE required if not directly touching patient or their environments
• Ensure complete set of new PPE while examining new patient/sick patient with close
contact

• When working in a composite patient area, make a flow in such a way that always
move from suspect patient area towards positive patient area, not reverse.
• All positive patients to be taken care with single PPE, while each suspect patients to
be taken care with one PPE if contact time is >10min. Hence work division among
residents help in taking care of multiple suspects in 24 time period with best use of
PPE (we have to use rationally so that we can save PPE a lot)
• Proper disposal of BMW as per protocol
Junior
resident in
doctors’
computer
room
• Ensure that you are wearing N95 Mask and in surgical scrub suit
• If any patient comes from screening OPD or Emergency area, informing the resident
inside the isolation room about the incoming patient
• Filling up the required form and scanning Covid-19 testing form, other forms when
applicable
• Update about the patient status in e-hospital with co-ordination with treating JR; this
will be better updated after coming from bedside working station
• Everyday census to be updated by duty JR at DDR(D4 area) sharp at 9am and 5 pm
in required format without fail (data to be collected from all Covid area by 8-8.30am
and 4-4.30pm, old data can be retrieved from computer saved data)
• Help SR in shifting of Covid-negative patient to respective area
• Daily file completion of discharged and dead patients if it is done during your duty
time
• To prepare death report and form as per guideline
• Overall all computer entry should be done along with preparing notices, letters, data
entry, protocol updating/designing, etc
• During night time take sleep 4hrs (11pm-7am) with exchange with another JR of 4hrs
if patient load is less

Junior
resident in
bedside
patient area
• Ensure that You are wearing full PPE (N95 Mask, Head cover, face shield, gloves,
gown, shoe cover)
• When new patient comes ensure patient is always wearing mask
• When new patient comes take detailed history and perform physical examination
• Check if Investigations done or not, If not done send Investigations (CBC, LFT, KFT,
Chest X-Ray, ECG, Viral markers, ABG)
• Collect Covid sample if not collected and before leaving the room complete all basic
thing whatever required in one flow (just think once before entering room)
• After coming out of new suspected patient room, doff all except N95
• For additional investigation discuss with SR/On call faculty and share with next
exchanging JR so that when he/she sees same patient will do all
• Write a basic treatment in a paper/tab placed in the anteroom and share with nursing
officer to start the treatment
• Daily - No round of stable patients but monitoring with nursing staff, however one
shift-one round for unstable patients and then SOS basis
• Daily progress note to be entered in e-Hospital after coming out of bedside area or
with coordination with computer room JR
• Treatment will be as per institute Protocol
• Antibiotics to be started after consultation with SR/On call faculty
• Avoid aerosol generating procedures (like Nebulization, high flow mask)
• Elective intubation when required (coordinate with anaesthesia resident posted in
same area or nearby area), otherwise call from ICU area
• If patient is in ventilator ensure 24 hours monitoring by ICU team (on call mostly)
• Coordinate shifting of Covid-negative patient to non-covid area on urgent basis
• In case patient collapses minimal personnel should perform CPR and ensure proper
PPE of all those involved in resuscitation
• If unsuccessful in resuscitation ensure proper disposal of IV lines, catheter, Tubes
and plug orifices of body with cotton and ensure body management by housekeeping
staff as per institute protocol

Senior
resident in
Covid
isolation
wards
• Ensure that you are wearing N95 Mask and full PPE (when required)
• Daily monitoring of treatment
• Once a day detailed round of critically ill Patient and guiding JR/nursing officers
throughout at any point of duty time
• Decision regarding investigation and treatment plan along with faculty
• Coordinate shifting of Covid-negative patient to non-covid area on urgent basis
• Ensure daily update of patient status at right time to the higher authority as asked for.
• Daily briefing of patient status and prognosis to the attendant
• Ensure daily completion of patient details in e-hopsital and maintainance of records.
• Supervision of work of JR and nursing officer whether protocol is followed or not
• Any issues inform on call faculty
Classification of patients
• Patients shall be classified into two groups – Suspect or Confirmed
• Further each group of patients are classified into two subgroups- Critical
illness or non-critical
Non-critical Illness • Patients with uncomplicated upper respiratory tract viral infection, may
have non-specific symptoms such as fever, cough, sore throat, nasal
congestion, malaise, headache.
• There is no hypoxia or radiographic evidence of pneumonia.
• The elderly and immunosuppressed may present with atypical
symptoms
Critical illness • Presence of hypoxia or radiographic evidence of pneumonia or ARDS
• Any single organ failure including Kidney, liver
• MOFS
• Sepsis/Shock
Acute Respiratory
Distress Syndrome
(ARDS)
• Onset: new or worsening respiratory symptoms within one week of
known clinical insult.
• Chest imaging (radiograph, CT scan, or lung ultrasound): bilateral
opacities, not fully explained by effusions, lobar or lung collapse, or
nodules.
• Origin of oedema: respiratory failure not fully explained by cardiac
failure or fluid overload
• PaO2/FiO2 ≤ 300 mmHg (with PEEP or CPAP ≥5 cm H2O, or non-
ventilated)

` CRITICAL ILLNESS
1. Presence of hypoxia or radiographic evidence of
pneumonia
2. Any single organ failure like kidney, liver, etc
3. MOFS
4. Sepsis/Shock
Supportive care And one of the arms in sequence as
per availability, clinical response, and
contraindications
1. Lopinavir/Ritonavir (200/50 mg ) BD for 14 days
2. Hydroxychloroquine (loading dose of 600 mg PO
BD for 1 day , followed by 200 mg TDS for 10 days)
3. Lopinavir/Ritonavir(200/50) BD for 14 days plus
Interferon-beta (If available, 44 microgram s.c for
total 3 doses in 6 days , Day 1,3,6)
4.Tocilizumab (single dose of 400 mg via intravenous
infusion) if available
CONFIRMED
NON-CRITICAL
ILLNESS
CRITICAL
ILLNESS
Risk of treatment will be explained
to patient/ attendant
1. If patient gives consent, start
treatment as per protocol of the
institute (SEV-Covid trial) where
he will be placed in one of the
arms based on drug availability
2. If patient does not give consent
treatment will be similar to
Critical Illness as in suspected
cases
Monitoring
a. Daily monitoring of vitals, SpaO2 and new symptoms
b. Repeat routine investigations every 48-72 hourly (flexible depending on clinical scenario)
c. Monitoring for adverse drug reactions
TREATMENT
PROTOCOL after a
positive case admitted
SUSPECT NON-CRITICAL ILLNESS (no
hypoxia or radiographic
evidence of pneumonia)
Supportive
treatment
Supportive
treatment

GUIDELINE FOR REPEAT TESTING OF COVID 19 POSITIVE ADMITTED PATIENTS
For all admitted patients who are positive for COVID 19
Repeat testing for COVID 19 will be done at day 7 of illness
Positive Negative
Repeat test at day 10 Repeat test after 24 hours
Negative
Positive Repeat test at every 4th
day till negative

DRUGS DOSE , ROUTE
DURATION
CONTRAINDICATIONS ADRS
Lopinavir/Ritonavir (200/50 mg) BD for 10
days
Hypersensitive to drug
CYP 3A inducers
Dermatitis
Abdominal pain,
vomiting, diarrhea,
dermatitis,
transaminitis, URTI,
LRTI, fatigue,
headache
Hydroxychloroquine Loading dose of 600 mg
PO BD for 1 day ,
followed by 200 mg TDS
for 10 days
Hypersensitive to drug
Pre-existing retinopathy,
children <6 years,
weighing <35kg
Abdominal pain,
vomiting diarrhea,
dermatitis,
transaminitis,
hemolytic anemia
in G6PD-def
patient
Tocilizumab Single dose of 400 mg via
intravenous infusion
Hypersensitivity Injection site
reactions
Upper respiratory
tract infection
Nasopharyngitis
Headache
Hypertension
ALT increased
Interferon-beta 44 microgram s.c for
total 3 doses in 6 days ,
Day 1,3,6
Thyroid disorder ,
anemia, leucopenia,
depression, seizures,
liver disorder
Injection site
reactions ,
headache, fever ,
diarrhea

Flowchart for Mx of Intubation / Ventilated Patients
1. The Anesthesia and Critical Care SRs/Faculty are available round the clock in trauma ICU.
2. They shall guide respective areas as and when required.
Patient requiring
Elective Intubation in
COVID Isolation
wards
To be intubated by
Senior JR/SR
(Anesthesia) + On
duty JR/SR (COVID)
To be Mx by
SR (Critical Care) + On
duty JR/SR (COVID) +
Faculty (Critical Care)
Ventilatory Mx in
COVID (ICU)
To be intubated by
concerned treating
Team; Any difficulties,
anesthesia team will
be contacted
Patient in Covid-19
center requiring
Emergency
Intubation

Supportive management of critically ill patients
1. Give supplemental oxygen therapy immediately to patients with SARI (Severe acute
respiratory illness) and respiratory distress, hypoxaemia, or shock: Initiate oxygen
therapy at 5 L/min and titrate flow rates to reach target SpO2 ≥90% in non-pregnant
adults and SpO2 ≥92-95 % in pregnant patients
2. Use conservative fluid management in patients with SARI when there is no
evidence of shock: Patients with SARI should be treated cautiously with intravenous
fluids, because aggressive fluid resuscitation may worsen oxygenation
3. Do not routinely give systemic corticosteroids for treatment of viral pneumonia or
ARDS unless they are indicated for another reason
4. Closely monitor patients with SARI for signs of clinical deterioration, such as rapidly
progressive respiratory failure and sepsis, and apply supportive care interventions like
mechanical intubation immediately
5. During intensive care management of SARI, determine which chronic therapies
should be continued and which therapies should be stopped temporarily.
6. 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 < 2mmol/L, in absence of hypovolemia
7. In resuscitation from septic shock in adults, give at least 30 ml/kg of isotonic
crystalloid in adults in the first 3 hours
8. Administer vasopressors when shock persists during or after fluid resuscitation. The
initial blood pressure target is MAP ≥65 mmHg in adults
9. Give empiric antimicrobials to treat all likely pathogens causing SARI. Give
antimicrobials within one hour of initial patient assessment for patients with sepsis:
Although the patient may be suspected to have COVID - 19, Administer appropriate
empiric antimicrobials within ONE hour of identification of sepsis

Risk Mitigation: Attempt to use ventilation equipment and methods
with the least aerosol generation
Noninvasive ventilation and High Flow Nasal Cannula: They
have a higher risk of aerosol generation therefore to be best avoided
Indications of Invasive Ventilation:
1. Worsening oxygenation PaO2/FIO2 or SpO2/FiO2 <150
2. Hypercapnia/acidosis with a pH <7.3
3. High work of breathing
4. Altered mental status attributed to respiratory failure
Ventilatory Settings:
1. Ventilation Mode – Assist Control Mode or SIMV
2. Inspiratory Time – 0.7 – 1.2 s
3. Flow rate – initially 25 lit/min (range 15-60 lit/min)
4. Tidal Volume – Tidal volume: initially 6mL/kg predicted body wt. (range 4-8)
5. PEEP – PEEP 10 cm H2O: Monitor hemodynamics with increasing PEEP
6. Respiratory rate: Initially15/min. (Range 15-35)
7. Plateau pressures of ≤30 cm H2O (reflects respiratory system compliance)
8. Peak inspiratory pressure <35 cm H2O
9. FIO2 to maintain a SpO2 of 88-98%
a. FIO2 <0.6
b. Try to avoid 100% oxygen, which favors de-nitrogen atelectasis
c. Lower FIO2 of 0.7-0.9 may not drastically change oxygenation due to high
level shunts 10.Sedation Analgesia
a. Fentanyl – 100 µg bolus followed by 50µg/hr continuous infusion
b. Midazolam – 0.5 mg/kg bolus followed by 0.02mg/kg/hr
continuous infusion 11.Goals to be achieved
a. Oxygenation
i. PaO2 >60 / SpO2 88-98%
b. Ventilation
Ventilatory Protocol for COVID-19 at AIIMS Rishikesh

12. Precautions
a. Avoid disconnecting the patient from the ventilator, to avoid loss of PEEP andatelectasis
b. Reduce incidence of venous thromboembolism by
c. Pharmacological prophylaxis
i. Low molecular-weight heparin 40 mg SC/day
ii. For those with contraindications, use mechanical prophylaxis
13. Troubleshooting
a. Peak airway pressure >35 cm H2O / Plateau Pressure > 30 cm H2O
i. Evaluate for pneumothorax
ii. Consider Neuromuscular Blockade
iii. Consider diuresis
iv. Reduce Tidal Volume by 1ml/kg (not < 4ml/kg)
v. Reduce Respiratory Rate by 2-4 / min/change (Not < 8/min)
vi. Consider closed ET suctioning
b. FiO2 > 0.6 with SpO2<88%
i. Increase PEEP by 2 (max 25)
ii. Consider
diuresis c. pH<7.25
i. increase Respiratory Rate by 2-4 / min/change (max 35)
d. pH>7.42
i. decrease Respiratory Rate by 2-4 / min/change (min 8)

Management protocol for ARDS Patient
1. Implement mechanical ventilation using lower tidal volumes (4–8 ml/kg
predicted body weight, PBW) and lower inspiratory pressures (plateau pressure
2. Hypercapnia is permitted if meeting the pH goal of 7.30-7.45. Ventilator
protocols are available.
3. The use of deep sedation may be required to control respiratory drive and
achieve tidal volume targets
4. In patients with severe ARDS, prone ventilation for >12 hours per day is
recommended
5. Use a conservative fluid management strategy for ARDS patients without tissue
hypoperfusion.
6. In patients with moderate or severe ARDS, higher PEEP instead of lower PEEP is
suggested. Tables are available to guide PEEP titration based on the FiO2
required to maintain SpO2.
7. A related intervention of recruitment manoeuvres (RMs) is delivered as
episodic periods of high continuous positive airway pressure [30–40 cm H2O],
progressive incremental increases in PEEP with constant driving pressure, or
high driving pressure
8. In settings with access to expertise in extracorporeal life support (ECLS),
consider referral of patients with refractory hypoxemia despite lung protective
ventilation.
9. Avoid disconnecting the patient from the ventilator, which results in loss of
PEEP and atelectasis.
10. Use in-line catheters for airway suctioning and clamp endotracheal tube when
disconnection is required
11.Use of corticosteroid in selected patient is permitted only after consultation
with on-call faculty

Prevention of Complications
Anticipated
Outcome
Interventions
1. Reduce days of
invasive mechanical
ventilation
• Use weaning protocols that include daily assessment for
readiness to breathe spontaneously
• Minimize continuous or intermittent sedation, targeting
specific titration endpoints (light sedation unless
contraindicated) or with daily interruption of continuous
sedative infusions
2. Reduce incidence
of ventilator
associated
pneumonia
• Keep patient in semi-recumbent position (head of bed
elevation 30-45º)
• Use a closed suctioning system; periodically drain and
discard condensate in tubing
• Change heat moisture exchanger when it malfunctions,
when soiled, or every 5–7 days
3. Reduce incidence
of venous
thromboembolism
• Use pharmacological prophylaxis (low molecular-weight
heparin[preferred if available] or heparin 5000 units
subcutaneously twice daily) in adolescents and adults
without contraindications.
• For those with contraindications, use mechanical
prophylaxis (intermittent pneumatic compression
devices)
4. Reduce incidence
of catheter related
bloodstream
infection
• Use a checklist with completion verified by a real-time
observer as reminder of each step needed for sterile
insertion and as a daily reminder to remove catheter if
no longer needed
5. Reduce incidence
of pressure
• Turn patient every two hours
6. Reduce incidence
of stress ulcers and
gastrointestinal
bleeding
• Give early enteral nutrition (within 24–48 hours of
admission)
• Administer histamine-2 receptor blockers or proton-
pump inhibitors in patients with risk factors for GI
bleeding.

SOP of Blood Collection and processing for Biochemical analysis of COVID-19 patients
T This SOP describes procedure for blood collection, transport and processing for biochemical analysis.
R Responsibility
It It is the responsibility of the personnel carrying out this procedure to ensure that all steps are completed.
• Blood collection system
• Hand sanitization with 70% alcohol
• To wear personal protective equipment (PPE), gloves, protective glasses and mask
• Blood collection tube: Plain tube (red cap) for routine biochemistry
: Sodium fluoride & oxalate (grey cap) for Plasma glucose
• CSF protein and glucose: Plain tube (red cap)
• A polystyrene container: For packaging and transport of specimen.
• Refrigerator (2-4°C), if sample storage is required
Procedure of Blood collection
A. Patient preparation
( Before proceeding with blood collection, review first if the patient needs special preparation or any special
instruction such as fasting sample.
(I Absolute patient identity must be established prior to phlebotomy.
(I Inspect Requisitions/testing and Tube type.
B. Sample Collection
1. Locate the area for blood collection (e.g Antecubital vein) and sterilize the area with spirit cotton
2. Draw blood directly into vacutainer. Fill the tube to the black mark on the tube or ensure minimum 4 ml
blood.
3. Do not invert or mix the plain tube (red top). For plasma glucose analysis
(Grey top), Invert the tube 8–10 times immediately after collection.
4. Blood collection tube is labelled appropriately with a unique study identification number generated and/or
a bar code label generated electronically

S 5. Record the time at which sample was taken in data management system.
C. Procedure of Sample Transport
Transport all specimens or containers of blood and other potentially infectious materials in a secondary
container (e.g., plastic bag or other container having a liquid-tight seal).
Secondary container may be put in separate plastic bag with biohazard symbol for transportation.
Transport samples (within 4 hours) directly to POCT laboratory for processing.
Ensure good communication with laboratory personal and provide needed information.
D. Sample receiving and processing
1. Laboratory staff must wear personal protective equipment (PPE) when conducting work in laboratory.
Following precautions may be used to prevent aerosol generation during centrifugation:
➢ Use unbreakable tubes (i.e., not glass).
➢ Avoid overfilling the tubes.
➢ Ensure that the centrifuge is properly balanced.
➢ Use outer, sealable safety cups and load/unload them preferably in a biological safety cabinet.
A certified biological safety cabinet (class I or II) is the primary barrier to protect worker from
aerosols.
➢ DO NOT open lid during or immediately after operation. Allow the centrifuge to come to a
complete stop and wait at least 30 minutes before opening. This allows time for aerosols to
settle if leakage or breakage occurred during the centrifugation run.
➢ Never exceed the specified speed limitations of rotor as listed in the owner’s manual.
➢ Decontaminate the inside and outside of the cups or buckets before and after use and inspect
seals regularly for deterioration. Replace as needed.
➢ When possible, install the centrifuge in an enclosed, specially ventilated area that discharges air
from the space through a HEPA filter
2. Handle all blood specimens as potentially infectious material. External surfaces of specimen containers
and vials must be decontaminated using a 0.1% sodium hypochlorite.
3. Use 1% hypochlorite for blood spill with 30 min retention time.
4. Decontaminate of all surfaces with 0.5% hypochlorite after every batch analysis.
5. Auto-analysers should be disinfected according to manufacturer instructions before and after sample
processing
6. Turnaround time for routine biochemistry reports is 4 hours.
7. Irrespective of infectious sample or not, work surfaces and equipment must be decontaminated after
specimens have been processed.

S
8. Discard all used needles, blood collection tubes, pipette tips in puncture-resistant coloured containers for
safe disposal.
9. Dispose of clinical waste according to local and national policies in to different waste plastic containers
with different colours.
10. Labelled yellow bag for discard of samples received may be used.
11. PPE must be removed according to biomedical waste management guidelines and hygiene practices
including hand washing must be rigorously maintained.
Note: 1% sodium hypochlorite to clean up any spills of blood, serum or urine. Use this solution on all work
surfaces at the end of each day.

INVESTIGATIONS FACILITIES AVAILABLE FOR COVID PATIENTS
1. TRAUMA LABORATORY : for all patients
LABORATORY INVESTIGATIONS TIMING
Hematology CBC, PT, APTT, Urine R/M, CSF(TLC+DLC)
24x7
Biochemistry LFT, KFT, HBA1C, Lipid profile, CRP, Amylase,
Lipase, LDH, Blood Sugar, NT Pro-BNP, D-
Dimer, fibrinogen, CPK MB, Trop I
Microbiology Viral Marker (HIV, HBSAg, HCV), Procalcitonin,
Thyroid profile
ABG
2. TRAUMA RADIOLOGY : for all patients
INVESTIGATIONS TIMING
X-ray/CT Scan/MRI/USG 24x7
3. FOR COVID-NEGATIVE PATIENT AT ICU OF TRAUMA BUILDING:
CSF/ASCITIC FLUID/PLEURAL FLUID-
TLC/DLC/PROTEIN/SUGAR/LDH
24x7
4. MICROBIOLOGY LAB (MAIN BUILDING): for all patients
Nasal Swab & Oral Swab for Covid-19 Testing 8AM TO 10 PM
• Blood culture
• Urine culture
• CSF culture
• Other fluid culture except Respiratory
fluids
8AM TO 5 PM

5. HISTOPATHOLOGY (MAIN BUILDING): for all patients
All biopsy samples (formalin fixed for 24
hours)
8AM TO 5 PM
Procedure of sample transport:
• Transport all specimens or containers of blood and other potentially
infectious materials in a secondary container (e.g., plastic bag or other
container having a liquid-tight seal).
• Secondary container may be put in separate plastic bag with biohazard
symbol for transportation. Transport samples (within 4 hours) directly to
POCT laboratory for processing.
• Ensure good communication with laboratory personal and provide needed
information.
• For HPE all samples to be fixed in formalin solution for at least 24 hours
before sending to lab for further processing
• Ensure proper face mask and surgical gown for patients being transported
for radiological investigations.
• All the fluids have to be sent in 10% Formalin.
• Please ask for formalin from Dept of pathology and keep them in the
respective wards. And while collecting of sample add equal volume of
formalin to the sample collected before sending to the lab.

SOPS for Radiological services w.r.t. Covid-19
• X ray, USG and CT services would be available.
• It is advisable to accumulate cases if possible and do them during later half of their duty hours so as to
reduce duration of exposure and this would decrease the need of number of PPE.
• In each shift technician will be present in the waiting room in COVID 19 ward. No technician will remain
continuously for more than 6 hrs.
➢ They will receive call from referral department.
➢ They will donup on call for portable X ray or CT as case may be.
➢ If not urgent, they should wait to do the X rays towards the later half of their shift, preferably
towards finishing time so that after the procedure, they can don off, change and go out of the
hospital to their staying places.
➢ If called up early in their shift for a procedure, they should wait in a different area in CT or X ray
area donned up till their shift ends. This room should be separate from usual working area in CT
or X ray area.
➢ At the end of their shift, they will go out of the area as directed and don off in the designated
area.
➢ They will then leave the trauma building and leave hospital from the exit gates.
➢ The persons who are travelling from haridwar, jolly grant and dehradun are presently working
from home till lockdown but may be called for duty in case need arises.
➢ Technicians will always wear TLD batch below PPE.
• PORTABLE X –RAY
➢ One portable X ray machine is being used for isolation ward in trauma building.
➢ On CR reader has been shifted to ground floor in trauma building in triage area and this is being used only
for isolation ward.
➢ Technicians will be doing bed side X rays.
➢ On called for a portable X ray technician will donup in PPE, do bed side X-ray with protective layer over
the cassette and develop it in the CR reader.
➢ Technicians are posted in rotational duties with each batch doing duty for one week followed by one
week off.
➢ Turnaround time will be 4 hrs for reporting. Reporting to be preferable done in main department from CD
prepared by technician and results conveyed to referring department at the earliest.

• CT scans
➢ Technician will be doing shift duties.
➢ Residents and faculty will be reporting this CT on call.
➢ One Technician will donup and go to CT room, perform the CT with minimal contact with the
patient (shifting etc will be done by attendant bringing the patients from isolation ward).
➢ At the end CT films will be printed by the technician.
➢ As per guidelines CT of isolation patient should be done at interval of one hour for passive air
exchange.
➢ After every scan equipment should be thoroughly cleaned as per institutional guidelines.
➢ Turnaround time will be 4 hrs for reporting. Reporting to be preferable done in main
department from CD prepared by technician and results conveyed to referring department at
the earliest.
• USG (point of care)
➢ One USG machine is shifted in triage area for bed side ultrasound.
➢ For effusion/pneumothorax USG may be done by the clinician on duty.
➢ For other USG senior resident from radiology may be called.
➢ Scans to be done only after donup in PPE.
➢ After every scan equipment should be thoroughly cleaned as per institutional guidelines.
➢ Reporting will be done stat and conveyed.
** Imaging should be used judiciously only when required with proper justification of any change in
management plan and not for making diagnosis of COVID 19.
*** If imaging is required X ray should be done first followed by CT. USG should be avoided whenever
possible.

SOP of Blood products’ transfusions during COVID-19 pandemic
Number Effective
date
Pages Authors Authorized by
TM/COV/07 01/04/2020 04 Dr. Pandeep Kaur Dr. Gita Negi
Version Review
period
Date of
review
Reviewed by Number of
copies
1 2 years 01/04/2022 Dr. Ashish Jain 1
Transfusion Guidelines for patients during COVID-19 pandemic
Need for blood transfusion support in COVID-19 pneumonia patients.
Most of the patients with covid-19 pneumonia present with respiratory insufficiency but
some of them progress to more systemic disease and multiple organ dysfunctions
(MODS). One of the most significant poor prognostic features in those patients is the
development of coagulopathy. High D-dimer levels and more severe lymphopenia have
been associated with mortality. In addition to this severe COVID-19 might have a
cytokine storm syndrome, condition mimics hyper inflammatory syndrome
characterised by a fulminant and fatal hypercytokinaemia with multi-organ failure.
Coagulopathy in COVID-19 can be corrected by appropriate blood component
transfusion depending upon the results of point of care testing. Bleeding is rare in the
setting of COVID-19. If bleeding develops, similar principles as septic Coagulopathy to be
followed for blood transfusion.
Precautions:
• Transfusion should be performed in isolation only.
• All the clerical checks should perform before transfusion
• Blood /Blood component transfusion should be done slowly, under strict medical
supervision.
• Vital monitoring during transfusion is must.
• Observe for any adverse transfusion reaction.
• In case of adverse transfusion reaction report in the blood bank along with
necessary documents and samples.
Note: All clinicians are requested to use alternatives to transfusion keeping in mind short supply of
blood

How to proceed for transfusion support in case of coagulopathy and MODS associated with COVID-19?
Point of care testing-ROTEM based transfusion guidance*(3-4)

Standard Operating Procedure

SOP for collection of Convalescent plasma from
Covid-19 recovered individuals
1. Prior to obtaining approval ICMR/ DCGI/CDSCO through proper channel, the following shall be
done:
- A complete form including brief clinical history of the patient, diagnosis, current therapy,
and rationale for requesting the proposed investigational treatment would be sent to ICMR/
DCGI/CDSCO through proper channel. The form will include information regarding the site
of COVID-19 convalescent plasma collection.
- In the event of an emergency that is highly time sensitive (response required in less than 4-
6 hours) or where the provider is unable to complete and submit the form due to
extenuating circumstances, the authorities shall be contacted telephonically to seek verbal
authorization.
2. Convalescent plasma will be collected from donors who have recovered from confirmed
infection with COVID-19 Virus (SARS COV-2) and have subsequently tested negative for the
presence of virus (Nucleic acid tests negative twice consecutively on respiratory tract samples
such as nasopharyngeal swabs, sampling interval being at least 24 hours) before plasma
collection and have no detectable evidence of persistence.
3. COVID-19 convalescent plasma (CCP) shall only be collected from recovered individuals if they
are eligible to donate blood.
4. ELIGIBLE PATIENTS FOR DONATION:
Inclusion criteria
Recovered individuals if they are eligible to donate blood as per Drugs and Cosmetic Act & Rules
1940 and amendments thereafter.
Additional considerations for donor eligibility:
- Prior diagnosis of COVID-19 as documented by a laboratory test
- Complete resolution of symptoms at least 28 days prior to donation
- Negative nucleic acid test results for COVID-19 twice preferably 24 hours apart following
recovery
- Accept Male donors and to discourage Female plasma donors in view of risk of TRALI

- Prospective donors will be explained and counselled about the need for collecting blood
or plasma emphasizing that this could be useful as an empirical treatment for the COVID-
19 affected patients and that there will be no payment to them for their blood or plasma
donation.
- Potential donors who meet the criteria of recovery from COVID-19 infection and also
meet the National guidelines for blood donor selection criteria and have given informed
consent will then be subjected to pre-donation testing to assess final suitability for
donation. Some criteria e.g. age and weight may be relaxed depending upon the patient’s
status.
- Written consent will be obtained for same from patient/attendant /guardian.
- Pre-donation testing will include:
1. ABO and RhD grouping, mandatory blood screening tests for HIV, HBV, HCV, syphilis
and Malaria, Haemoglobin estimation (unless performed as part of the initial donor
selection process)
2. If feasible, neutralizing antibody titration will be done if available.
- Twobloodsamples willbecollectedfor thesetests, oneinEDTA andthe other one in a plain
vacutainer. Residual serum from these blood samples will be stored in aliquots for
retrospective antibody testing or any other tests, as required. The container label of
COVID-19 convalescent plasma units will include the following statement, “Caution: IND"
(Investigational new drug).
5. PLASMA COLLECTION METHODS:
- Plasmapheresis will be the preferred method.
- Whole Blood Donation
- Plasmapheresis will enable collection and storage of large volumes of CP that may be
used for more than one patient.
- Any adverse donor reactions will be adequately and promptly managed and recorded.
- The inter-donation interval between two plasmapheresis procedures if needed will be 14
days.
- Whole blood donation will be collected in a double blood collection bag for the
separation of plasma from the red cells by centrifugation.
- A minimum interval period of 3months for males and4months for females will be
considered before a further whole blood donation is collected.

Following a whole blood donation or a failed return of red cells during apheresis, the minimum interval
before a plasmapheresis donation would be four weeks.
- Potential donors with abnormal TTI test results will be referred to appropriate health-care
institutions for further investigation, confirmation, counselling, treatment and care like
routine blood donors.
STORAGE
- CCP will be stored in a separate freezer / blood bank refrigerator dedicated to CCP units
fitted with a temperature monitoring system and alarm.
- Alternatively, it may be frozen either within 8 hours of collection as ‘Fresh Frozen
Convalescent Plasma’ or within 18-24 hours of collection as ‘Plasma FrozenWithin 24 hours’
and stored for up to 12 months.
- CCP separated from whole blood donations or collected by apheresis may be stored as
‘Liquid Plasma’ between +20
C and +60
C in blood bank refrigerators for up to 40 days.
TRANSFUSION
- Preferably, ABO and RhD matched plasma units will be selected for transfusion. CCP units
will be transfused to the COVID-19 patients using standard clinical transfusion procedures.
- 500ml of CCP as collected from plasmapheresis procedure will be transfused to an adult
patient.
- 400-500 mL of CCP in two doses of 200-250 mL each, separated from two different whole
blood donations, will be considered for adult patients in case plasmapheresis is not feasible.
- For pediatric CCP transfusion, a dose of 10 mL/kg could be used.
- If frozen plasma is being used for transfusion, it will be thawed in a water bath between
+300
C and +370
C and transfused using a blood administration set as soon as possible after
thawing.
CAUTION
- The scope of plasma collection is only related to the use for COVID-19 patients and not as a
plasma for clinical use.
- If stored CCP unit is not utilized for any COVID patient then it will be discarded as per BMW
policy.
DOCUMENTATION
- Records shall be kept to ensure traceability between donors and recipients.

SOP for anaesthesia management with COVID 19 infection
1. Emergency life threatening surgeries such as obstetric emergencies, severe hemorrhage or airway
emergencies require consideration of a designated closed Operation Room with negative pressure and
air exchanges with signs posted on the doors to minimize staff entry; immediate availability of PPE; and
team formulation. In case of emergency/semi-emergency surgeries, patient should be directed to
dedicated theatre without any entry to pre-operative area. Routine care in all Covid positive/suspect
patients requires postponement of elective non-urgent surgical, therapeutic or diagnostic procedure
that can be performed at any time or date, though many cases such as cancer, heart surgeries are
considered time-sensitive. We recommend close collaboration between surgeons, anesthesiologists,
and hospital administration to balance individual patient needs with system resource constraints.
2. We recommend designating experienced anesthesia professional for intubation, wearing of
PPE which include an N95 mask, for which one has been fit-tested, or a powered air-purifying
respirator (PAPR); a face shield or goggles; a gown and gloves for all procedures requiring
aerosolization of droplet particles. All procedures generating aerosol particles include high
flow nasal cannula (above 6 liters per minute), nebulisers, awake fibreoptic intubation,
entonox/inhalational sedation, non-invasive ventilation, bag and mask, use of a T-piece or any
other open circuit and open suction.
3. Staff in the area should be minimum and must include a primary anesthesiologist wearing full
(airborne) PPE for intubation, second professional wearing full airborne PPE, assistant
wearing full airborne PPE and a ‘runner’. Runner should be available in immediate vicinity
outside the OR and should be approachable at all times, he should have important contacts of
on call duty doctors of ENT and anesthesia department for “call for help” situations.
Consideration should be given to avoid exposure of staff members who are over the age of 60,
pregnant, immunosuppressed or with cardiovascular or respiratory co-morbidity in procedures
causing direct airborne exposure.
4. Preparation for any airway manipulation mandate the use of a pre-induction checklist
specific to COVID-19 airway management, ensure adequate time to prepare (donning PPE,
provide checklist, supervision by an assistant) - Fit tested

mask or powered air purifying device, double Glove and replace outer gloves when contaminated,
minimizing staff numbers in room. Advance planning and clear communication are paramount.
Ideally place the patient in a negative pressure room. If a negative room is not available, place the
patient in a single room and close the door. If no rooms are available (e.g., ED), isolate the patient
and ensure that other patients/HCW maintain > 6 feet (2 m) distance. Ensure availability of HEPA
filter, extra filter on the expiratory limb. Preloading of the ETT onto a stylette or bougie -improve
the chance of successful intubation first time, drugs for ‘rapid sequence induction’ and airway
equipment’s. We suggest to cover essential equipment’s to be covered by disposable plastic sheets
and ensure appropriately labeled bin for disposables
5. We recommend the following for intubation guidelines in Covid positive and suspect patients-
• Patient should wear a surgical facemask until pre-oxygenation. Standard ASA monitoring
including electrograph, noninvasive blood pressure, end tidal carbon dioxide and peripheral
saturation is must. Ensure that a well-functioning intravenous line is available. Intravenous
cannulation must be done with sterile drape and gloves to prevent any spillage. It is
recommended to administer anti-emetics or prokinetics in every case as prophylaxis for
vomiting
• Although basic, a very brief airway assessment is vital to first pass success in the context of
a critically unwell patient and minimizing the time to intubation and cuff inflation. It is
accepted that MACOCHA score (Malampatti, obstructive sleep apnoea, C‐spine movement,
mouth opening, coma, hypoxaemia, non‐anaesthetist intubator) is not widely used but it is
validated and recommended. Create and mandate the use of a pre-induction checklist specific
to COVID-19 airway management.

• All breathing circuits must be fitted with an appropriate, high efficiency hydrophobic
HEPA filter. Place an extra filter on the expiratory limb of the breathing circuit at the
machine end. This will protect the anesthetic machine should the circuit accidentally be
attached directly to the airway without an HEPA filter, either during pre-oxygenation or after
intubation.
• Optimize the patient position, 45-degree head up is desirable though due consideration
should be given to vitals. Pre-oxygenate with passive breathing of supplemental oxygen via
a well-fitting/well sealed facemask with 100% oxygen for 5 minutes. Long pre-oxygenation,
ultra-rapid RSI or small tidal volumes with manual ventilation may be considered if needed.
Avoid positive pressure ventilation and high flow nasal oxygenation more than 6L/minutes.
If manual ventilation is required (e.g. rapid desaturation, prolonged airway management)
then use a two-handed technique, vice grip (also known as V and E grip, in which operator
places thumbs and thenar eminences longitudinally along each side of mask) to ensure the
best possible facemask

• seal and apply small tidal volumes if possible. Ensure a square wave capnograph to ensure “no
leaks”, during bag and mask ventilation by two handed techniques.
• RSI is recommended using appropriate induction agent in the form of propofol or ketamine (to
be decided case based), we suggest to avoid thiopentone as it is known to cause histamine release
and undue coughing will be disadvantageous, muscle relaxants either 1.5 mg/kg TBW succinyl
choline or 1.5 mg/kg IBW rocuronium bromide. We suggest 2-person ventilation with vice grip
and PEEP during the onset of neuromuscular blockade. Wait 60 seconds for paralysis to take
place, avoid triggering cough. In any doubt of difficult airway, use succinylcholine and consider
supplement with long acting muscle relaxant soon after intubation. We suggest to avoid
histamine releasing drugs such as atracurium for muscle relaxation. Consider giving opioids after
paralysis has been achieved to avoid coughing/chest rigidity. We suggest to consider
glycopyrrolate before induction to decrease salivation and hence decreasing the possibility of
suctioning. All drugs should be available in one arm reach. Cricoid compression or
displacement is needed when exposure of the cord is difficult and the patient’s fasting time is
unknown; it is critical that suction is readily available.
• Preloading of the ETT onto a stylette or bougie may improve the chance of successful intubation
first time. All airway equipment’s should be available in one arm reach. If available, use a video
laryngoscope (indirect view on screen), irrespective of difficulty of airway assessment with a
disposable blade and separate screen to reduce staff exposure to airway secretions may be
considered. We recommend providers perform intubations with the greatest chances of
success on the first attempt, be it with video laryngoscope or direct laryngoscope. This must
be balanced with the supply chain availability. We recommend usage of laryngoscope with
which operators are usually successful in first attempt, if a resident is well versed with direct
laryngoscope, they must proceed with the same. The laryngoscope should be placed as soon as
muscle relaxation is achieved, and tracheal intubation should be accomplished and
confirmed as soon as possible (less than 15 to 20 s). pass the cuff 1-2 cm below the cords to
avoid bronchial placement.

• It is recommended for confirmation of endotracheal tube placement be made by observing
bilateral chest expansion, ventilator breathing waveform, and respiratory parameters and
avoid auscultation. Continuous wave capnography or End-tidal CO2 is a better indicator
over peripheral saturation to confirm successful tracheal intubation, as peripheral oxygen
saturation may be low owing to their clinical condition. Push twist all connections.
• Once the ET tube is inserted, clamp the ETT until the cuff is sufficiently inflated and well-sealed
before reconnecting the filter to the ET tube, connecting to the breathing circuit and test
ventilating. We suggest monitoring cuff pressure to minimize leak. Keep all connections firmly
tight. If the anesthesiologist has worn ‘double gloves’ the outside gloves should be removed as
soon as successful intubation has been confirmed. Re-sheath the laryngoscope blade
immediately post-intubation and seal all used equipment in a double zip-locked bag. Remove
for decontamination and disinfection.
• If there is difficulty with tracheal intubation consider minimising number of attempts at each
technique Declare difficulty or failure to the team at each stage AND call for help. Mask
ventilation may be deferred initially and a second‐generation supraglottic airway (SGA) used as
an alternative between attempts at laryngoscopy. Repeated tracheal intubation attempts could
potentially increase virus spread, so a SGA should be inserted after an intubation failure If an
emergency front of neck access is required, the scalpel‐bougie‐tube technique is particularly
preferred in COVID‐19 patients due to the risk of aerosolisation with the oxygen insufflation
associated with cannula techniques. Consider scalpel bougie crico-thyroidotomy in can’t
intubate can’t oxygenate situations (CICO). Communicate clearly, closed loop
communications, simple instructions with adequate volume and no shouting.
• Accidental disconnection- Pause the ventilator. Clamp the tracheal tube. Reconnect promptly
and unclamp the tracheal tube.

• Accidental extubation- This should be managed as usual, but management should be
preceded by full careful donning of PPE before attending to the patient, irrespective of
clinical urgency.
• OT cleaning- Remove and dispose of PPE in a clinical waste bin as per local protocol.
Remove and discard filters and breathing circuits. Ensure the operating theatre is cleaned as
per local protocol. The theatre should be left empty for half an hour after use before the final
clean, although this does depend on airflow. Any staff entering the theatre within half an
hour of the patient leaving must wear full PPE. Staff to complete personal log book of clinical
exposures. All unused items on the drug tray and airway trolley should be assumed to be
contaminated and discarded. Discard breathing circuit, mask, tracheal tube, HEPA filters,
gas sampling line and soda lime after every patient. Water trap to be changed if it becomes
potentially contaminated. Seal all used airway equipment in a double zip-locked plastic bag.
It must then be removed for decontamination and disinfection. After removing protective
equipment, avoid touching your hair or face before washing hands. All staff has to take
shower before resuming their regular duties. A minimum of half to one hour is planned
between cases to allow OT staff to send the patient back to the ward, conduct through
decontamination of all surfaces, screens, keyboard, cables, monitors and anaesthesia
machine with 2 to 3% hydrogen peroxide spray disinfection, 2% Sodium hypochlorite
disinfectant, or 75% alcohol wiping of solid surfaces of the equipment and floor. The
hydrogen peroxide vaporizer is an added precaution to decontaminate the OT.
• We recognize the risk that airway management has when a patient cough during intubation
or extubation, leading to contaminated mist and droplet formation. All authorities
recommend that you do not touch your hands to your face. A face shield will protect your
eyes and also the N95 mask from surface contamination.
• Extubation is equally responsible for aerosol spread, we recommend avoiding
aerosolisation and minimize staff exposure. Undertake appropriate physiotherapy and
tracheal and oral suction as normal before extubation. Prepare and check all necessary
equipment for mask or low flow (< 5 l.min−1)

nasal cannula oxygen delivery before extubation. We suggest use of xylocard before extubation
to decrease extubation response though risk/benefit ratio can be weighed in specific subsets. We
also suggest the use of anti-aspiration prophylaxis. Techniques to consider include: use of
transparent sheaths, placement of nasal prongs with 2 L/min oxygen to provide para oxygenation,
we suggest that extubation be done with patient’s head turned laterally, with extubating
anesthesiologist standing opposite to reduce direct exposure. We strongly recommend
spontaneously breathing deep extubation to reduce coughing and LMA exchange using a close
circuit to avoid coughing/straining. Extubated patients should be covered with a mask. Post-
operative recovery is recommended in OT and patient is directly sent to ward/ICU. The use of
an airway exchange catheter is relatively contra‐indicated in a patient with COVID‐19 due to
potential coughing etc.
6. For patients requiring transfer, for example to ICU, we recommend minimizing the number and duration
of breathing circuit disconnections, paralyzing before any disconnection of breathing circuit. When
disconnecting and reconnecting to a ventilator, leave the filter attached to patient end. The endotracheal
tube should be clamped and the ventilator disabled to prevent aerosolisation. Use a transport ventilator
or self-inflating bag with a filter. Use inline (closed) suction if available.
7. Regarding cases under monitored anesthesia care (MAC), If dispersion of potentially contaminated
exhaled gases from an open airway (e.g. “MAC”) is a risk, consider alternate anesthesia plans. Potential
contamination of your workspace and the room should be considered. The safety of you and your
colleagues is paramount.
8. Regarding cases to be conducted under regional anesthesia, still there are not enough literature if
coronavirus is a contraindication to a neuraxial block. Patient undergoing regional anesthesia procedure
should wear mask. Spinals and epidurals should take into consideration appropriate precautions,
especially regarding COVID-19 patients or those suspected of having COVID-19. Such precautions may
include isolating the infected or suspected patient and placing them in rooms identified for that purpose
as well as having a dedicated operating room. Ideally, these operating rooms would be negative pressure
rooms. We also recommend the use of N95 masks, double gloves,

gowns and protective eyewear as appropriate. We suggest monitoring stable patients under regional
anesthesia to be monitored from a safe distance.
9. Cardio pulmonary resuscitation- Detected no signs of life/ spontaneous breathing. Confirmed by
absence of Carotid Pulse. “The minimum PPE requirements to assess a patient, start chest
compressions and establish monitoring of the cardiac arrest rhythm are an FFP3 facemask, eye
protection, plastic apron, and gloves.” Avoid listening or feeling for breathing by placing your ear and
cheek close to the patient's mouth. In the presence of a trained airway manager early tracheal intubation
with a cuffed tracheal tube should be the aim. No mouth to mouth / pocket mask breathing. If patient is
on O2 mask, leave it on. If patient is not on O2 by mask, apply a face mask over his/her face. In the
absence of a trained airway manager, rescuers should use those airway techniques they are trained in.
Insertion of an SGA should take priority over facemask ventilation to minimise aerosol generation. An
SGA with a high seal pressure should be used in preference to one with a low seal. This will usually be
a second‐generation SGA where available. Restrict staff entry. Rapid defibrillation if shockable rhythm.
Airway interventions (SGA, ETT) only by experienced persons. Treatment of underlying cause.
10. Dexamethasone as prophylactic agent for Post-Operative Nausea and Vomiting- In general, low
doses/single dose dexamethasone would not be regarded as clinically significant or sustained
immunosuppression and should be decided based on patient’s characteristics.
11. For providing oxygen supplementation to Covid patients, the first consideration is for your safety and
the safety of everyone in the room. PPE is required for aerosol-generating procedures should be worn.
Being at the COVID-positive patient’s head there is always risk of coughing and supporting the airway.
Nasal prongs can be placed under surgical mask with low-flow oxygen or simple face mask over
surgical mask might suffice. Each patient will need to be evaluated on a case-by-case basis to consider
the balance of aerosolization at the oxygen flow needed to maintain a satisfactory oxygen saturation,
and whether to convert to a more closed airway system (SGA or ETT).
12. SGA use- At this time, no studies exist that assess risk of various airway techniques and anesthetic
choices. However, SGA use may carry greater risk of generating aerosols when compared to tracheal
intubation. While SGA usually seals the airway at low

pressures, there is concern that higher positive pressure, if used, might create a leak with aerosol
production. SGA may be an acceptable option with selected patients because of the lower risk of
coughing.
13. Difficult intubation- In the non-perioperative area, in the event of a difficult intubation, additional
personnel and tools may not be immediately available. In the event of a failed intubation attempt, a
laryngeal mask should be used as a temporary bridging method. Under these circumstances a bedside
tracheostomy should be considered as early as possible.
14. We do not have specific guidance on pregnant anesthesia professionals, their risk of contracting
COVID-19 or if it will affect their pregnancy. While pregnant women are more susceptible to viral
infections like influenza, their susceptibility to SARS-CoV is unclear. At this time, pregnant women do
not appear to be more affected. The CDC recommends that “facilities may want to consider limiting
exposure of pregnant healthcare providers to patients with confirmed or suspected COVID-19,
especially during aerosol-generating procedures.”
15. Probable case- The decision on whether a patient is suspected of COVID-19 infection should be made
individually based on clinical, history and testing criteria where possible. The suspicion of
asymptomatic COVID-19 infection should be considered in areas with community spread. Droplet,
direct contact and contaminated surface contact precautions should be taken. Training in infection
control and donning and doffing PPE, Appropriate hand hygiene, signs on entry doors to warn
staff, keep doors closed.
16. In case devices like point-of-care ultrasound (USG) have been used during the procedure, the machine
and the probe along with the wire must be covered with a plastic sheath which is removed and discarded
after use. Any invasive procedures like putting a central venous line should be done under USG guidance
to prevent chances of failure.
17. Social distancing in OR-Minimize talking in OR and ICU rooms because phonation may generate
aerosolization of respiratory and oral-nasal secretions. Only those conversations necessary for patient
care should occur. Only people with active duties should remain in OR and ICU rooms. Within OR
rooms, breaks are an important part of patient safety for anesthesia professionals. Staff should continue
to work collaboratively to facilitate breaks, especially those involved in prolonged surgical procedures.

Protocol for Department of Anaesthesia
18. Self-Care/Coping with the Stress Caused by a Health Crisis- it is very important to maintain
perspective and remind yourself of the facts – how real is this threat to me right now? Try to follow as
many routine activities as possible, as this enhances comfort and predictability. Talk with friends,
family, coworkers or a counselor about your feelings and concerns. Engage in some form of exercise
daily; this is very effective in reducing stress. Do meditation/ yoga and deep breathing exercises to de-
stress yourself. Limit your intake of news related to the virus. Do things you enjoy. Part of taking care
of yourself is making time to let go and engage in positive activities; this helps give your mind a break
from worry and helps to maintain balance. Relax; use deep breathing, meditation, prayer or other
relaxation techniques that work for you.
19. Stay safe- The precautions that we take at work, that help minimize the risk of our contracting the virus
(effective hand-washing, not touching our faces and hair, proper donning and doffing of personal
protective equipment) in turn decrease the risk of our transmitting the virus to others, including those
at home. We should make sure scrubs are kept at work; and decrease the chance of contamination via
footwear by either using shoe covers at work or wearing dedicated footwear at work that do not travel
home. In this way, the risk of our transmitting COVID-19 should not be any greater than community-
acquired spread.

SOPs FOR FLEXIBLE BRONCHOSCOPY
If fail to manage
Figure. Algorithm to select a patient for bronchoscopy.
General considerations for bronchoscopy in COVID suspect/confirmed case:
1. In the times of COVID-19 pandemic, a non-bronchoscopic approach should be preferred over bronchoscopic
approach as far as possible. The decision to perform a bronchoscopy should be weighed cautiously. An
algorithm in this regard is given in Figure 1. (UPP)
Patient needs bronchoscopic
intervention
‘COVID-19 suspect’ /
‘laboratory-confirmed
COVID-19 case’
Yes
No
*Urgent
indication
**Non-urgent
indication
*Urgent
indication
**Non-urgent
indication
Go for bronchoscopy
with standard COVID
precautions
Go for bronchoscopy
with standard precautions
Prioritize as per
available resources
Use alternative
measures

*Urgent indication –
1. Lung collapse with significant hypoxemia due to mucous plug or blood clot, which cannot be managed by conservative methods.
2. Life-threatening hemoptysis.
3. Symptomatic/difficult-to-ventilate central airway obstruction due to airway stenosis, endobronchial growth or extrinsic airway
compression.
4. For obtaining BAL if diagnosis cannot be established with other less invasive techniques. (eg. sputum analysis in non-intubated
patients, ET aspirate/mini-BAL in intubated patients).
**Non urgent indication – Other indications for bronchoscopy.
2. Patients with suspected COVID-19 disease should NOT undergo bronchoscopy for purposes of establishing a diagnosis of COVID-19. (3A)
3. Patients with suspected or diagnosed COVID-19 disease with additional non-urgent pulmonary pathologies (e.g. new consolidation, mild
hemoptysis) should undergo a non-bronchoscopic intervention for evaluation preferentially. (UPP)
Comments for 1-3: Research for treatment of COVID-19 is currently in its early phase, and at present, there is no evidence-backed treatment
available. Hence, the most effective method of epidemiological control presently is prevention. Upper respiratory tract sampling for diagnosis of COVID-
19 is the method of choice. Bronchoscopy is classified as a procedure with high risk for aerosolization of infected material.[1] Thereby it is best advised
avoiding a bronchoscopic evaluation for purely diagnostic purposes. With a negative upper respiratory sampling and persistent suspicion, repeat upper
respiratory sampling is advisable. Similarly, suspects or proven COVID-19 cases with non-life-threatening indications for bronchoscopy are best
managed with conservative or empirical management rather than a routine bronchoscopic evaluation.
4. Patients with suspected or diagnosed COVID-19 disease with additional urgent pulmonary pathologies, or those with non-urgent pathologies
not resolved by all possible non-bronchoscopic means, should undergo a bronchoscopic evaluation as per a priority list based on the anticipated
outcome. (UPP)
Comments for 4: Some cases with suspected or diagnosed COVID-19 disease may have life-threatening pathologies needing urgent bronchoscopic
evaluation or where despite all methods of non-bronchoscopic evaluation there persists a treatment-dictating pathology which can be evaluated by
bronchoscopy. In times of pandemics, it is likely that there will be multiple such cases and limited resources. Thereby a priority list is essential before
proceeding for a bronchoscopy. This can be done keeping in mind the possible clinical outcome of the patient (in terms of salvageability) and availability
of resources.

(For this section, we write “without COVID disease,” so that means we have tested all.? Do we recommend checking
all before bronchoscopy, or do we term them as “not a COVID suspect,” and in that case, how?
5. Patients who are neither ‘COVID-19 suspects’ nor ‘laboratory-confirmed COVID-19 cases’, and present with
urgent pulmonary pathologies requiring bronchoscopic management, should undergo an evaluation as per
human and equipment resource availability in individual centres. (UPP)
6. Patients who are neither ‘COVID-19 suspects’ nor ‘laboratory-confirmed COVID-19 cases’, and present with
non-urgent pulmonary pathologies requiring bronchoscopic management, should be deferred and a priority list
for the same established for assessment in the post-pandemic period. (UPP)
Comments for 5&6: Patients with pulmonary pathologies but without COVID-19 are also likely to visit the hospital in
the times of a pandemic. Those with urgent pulmonary pathologies needing an assessment will have to be catered to as
per the availability of resources at the centre in question.
Those with non-urgent pathologies must be counselled regarding the same and deferred for post-pandemic
assessment. Given the possibility that the pandemic might extend over months, the list will also require prioritization to
appropriately address the backlog after tackling the pandemic.
7. Bronchoscopy should be performed in a negative pressure ventilation room with a minimum of 12 air exchanges
per hour and preferably at the patient’s place of care. (3A)
Comments for 7: As per Occupational Safety and Health Administration (OSHA)[1] and WHO[2] recommendations, for
aerosol-generating procedures (which include bronchoscopies), additional engineering controls as a part of airborne
precautions for prevention of exposure are essential. These include negative pressure ventilation rooms, installation of
high-efficiency particulate air (HEPA) filters, and increased ventilation rates.

Pre-bronchoscopy preparation:
1. The number of personnel for bronchoscopy should be restricted, preferably to two. For intubated patients, if the
bronchoscopist is not an intensivist, then intensivist may be included in the bronchoscopy team for assistance in
sedation and paralysis. (UPP)
2. Arrange all necessary bronchoscopy accessories, including drugs on the sterile trolley, before entering the isolation
room. (UPP) Use a disposable bronchoscope if possible; otherwise follow the routine recommendation for
sterilization of bronchoscope as per manufacturer instruction. (3A)
3. The complete plan of the procedure, including the role of each member, must be discussed within the team, and a
short rehearsal can be done outside the bronchoscopy room. (UPP)
4. For intubated patients, always check the size of the endotracheal tube/tracheostomy. The inner diameter of the
endotracheal/tracheostomy tube should be at least 2 mm more than the outer diameter of the bronchoscope to facilitate
smooth entry of the bronchoscope and for optimal ventilation during the procedure.[3] (3A)
5. Donning and doffing of PPE should be in a designated place outside the bronchoscopy room. All personnel for
bronchoscopy should wear full PPE including Filtering Face Piece (FFP) - 3, eyeshield/goggles, hood/cap, gown,
shoe covers, and double gloves. (3A)
6. The patient should be draped completely with sterile sheet. (UPP)
Comments: The minimum necessary personnel and equipment should be kept during the procedure so as to reduce the
risk of infection. As per CDC[4], WHO[2] and OSHA[1] guidelines, full PPE inclusive of an FFP3, eye shield/goggles, hood,
gown, shoe covers, and double gloves, should be made available for all involved personnel.[1,2,4] Given the limited
evidence currently available for the virus, a separate or disposable bronchoscope[5] must be considered for procedures in
COVID-19 suspected or proven cases. The recommendations for sterilization during the previous SARS epidemics have
varied, however, practicing high-level disinfection with routine bronchoscope reprocessing advice as per manufacturer
should continue till further evidence is available. Adequate planning of the procedure with role identification is essential
to minimize the duration of the procedure and ensure smooth entry and exit. An ante-room to the bronchoscopy area is
advisable as suggested by the CDC for airborne infection isolation measures,[6] which can serve the dual purpose of a
planning area and an area for donning and doffing of PPE.
7.

During the procedure:
During the procedure:
1. Position the sterile trolley and team members as decided outside of the procedure area (Figure 2). All team members
should position themselves at an arm’s length from the patient bed. (UPP)
Figure 2. Position of personnel during bronchoscopy.
2. The risk of aerosolization in bronchoscopy is higher in a patient who coughs during the procedure, thereby
appropriate measures to prevent the same need to be in place. These include:
a) Bronchoscopy should be done preferably in deep sedation (with an airway conduit if resources are available)
to minimize coughing and aerosol generation. (UPP) For intubated patients, pre-bronchoscopy medication
should include sedation and paralytic agents unless contraindicated otherwise. (3A)
b) For bronchoscopy, use of a trans-nasal approach[7,8] with a surgical face-mask is preferred over a transoral
approach.

3. In intubated patients, a three-way (swivel) adapter (Figure 3) for bronchoscope entry is recommended. This
avoids disconnection of ventilator circuit during bronchoscope introduction. Besides, it also helps in
maintaining positive end expiratory pressure. (UPP)
In intubated patients, use of a swivel adapter (Figure 3) allows optimal simultaneous ventilation and the snug
fit limits the air leak, thereby also the exposure during bronchoscopy.[9]
Figure. Swivel/three-way adapter
4. Procedure duration should be minimized as far as possible, and to achieve this, the following measures can be
taken:
a. Cricothyroid administration of local anaesthetic is advisable over the spray-as-you-go method, as the
former is associated with better patient comfort in terms of lesser cough and lower cumulative dose
of the local anaesthetic agent.[10]
b. Consider the evaluation of only those bronchopulmonary segments suspected to be involved as against
screening normal airways as well. (UPP)
c. In intubated patients, avoid instillation of local anaesthetic if patient is in complete paralysis. (UPP)

5. Bronchoscopist should hold the bronchoscope at an arm’s length from himself. (UPP)
6. There is an increased possibility of aerosol generation when oxygen is administered by nasal cannula at a flow
rate >6 Litres/min. To minimize this risk, oxygen should preferably be given through the working channel of
bronchoscope when this channel is not being used for any sampling procedures. During sampling, oxygen can
be continued through the oronasal route. (UPP)
7. Suctioning may lead to airway inflammation/oedema which may deteriorate the overall condition of the
patient. To minimize this risk:
a. Keep suction pressure as low as possible; (UPP)
b. Avoid unnecessary endotracheal/endobronchial suctioning. (UPP)
8. For BAL, use manual suction preferably in place of wall/machine suction and use in-line mucus extractor (as
shown in Figure 4). (UPP)
Figure. Representative image of manual suction technique using in-line mucus extractor. A three-way
connector is used to channelize the flow of saline during instillation, back-suction, and sample collection
into the mucus extractor. This prevents disconnection of circuit during sampling, thus minimizing the risk of
aerosolization.

After the procedure:
1. Handle the bronchoscopy samples (if taken) as per infection control guidelines.[11] (3A)
2. Doffing of all personnel and disposal of PPE must be as per guidelines. (3A)
(https://www.cdc.gov/hai/prevent/ppe.html)
3. Standard disinfection protocols should be followed for cleaning the flexible bronchoscope and
accessories. (3A)
4. Post-procedure sterilization for reusable bronchoscopes should be as per routine recommendation for
sterilization of bronchoscope (as per manufacturer’s instruction).
5. For all personnel involved in the bronchoscopy, post-procedure decontamination with a shower is
recommended. (3A)
Comments: Given the highly infectious nature of the virus, lower respiratory tract samples should be handled
with utmost care. The ACCP recommendations for the same during the SARS epidemic may be followed.[11]

SOP for GI Endoscopy Procedures
1. Scheduling of endoscopic procedures
• The treating clinician/ doctor on duty should ascertain the indication of endoscopy,
based on their urgency and category into three categories, as follow:
Category Category Example Timing of
Endoscopy
Emergency Diseases/conditions
requiring emergency
Endoscopic procedures
(life-saving measures)
Acute upper GI or
lower GI bleeding,
removal of impacted
foreign body,
cholangitis,
gastrointestinal
perforations
Done on
emergency basis,
as usual
Urgent Diseases/conditions
where a significant
impact may be achieved
on the clinical outcome in
one-month time by an
endoscopic procedure
Nutritional support by
NJ tube / PEG
placement, stenting
for malignant luminal
obstruction (growth
in esophagus, colon
and duodenum),
draining of malignant
biliary obstruction,
diagnosis and staging
of GI cancers
Done on urgent
basis
Routine All those endoscopic
procedures that do not
fall in either of the above
two categories are
considered routine
endoscopic procedures
All routine referrals
for endoscopy
procedures, screening
and surveillance
endoscopy
Postponed until
the corona
pandemic is over
unless the
category changes
in the intervening
period

1.1. The clinician should contact the endoscopy team telephonically to schedule the endoscopy procedure and
ensure that all the requisite advice and preparation for the endoscopic procedure have been met.
2. Endoscopic procedures
1.2. Procedure room
1.2.1. All endoscopic procedures for COVID-19 positive or high/intermediate risk cases to be done in a
separate and designated endoscopy theatre by a dedicated endoscopy system in COVID isolation
center (Trauma center building) only. One endoscopy system shall be placed in Trauma center
during the time period COVID -19 pandemic continues
1.2.2. For ERCP and fluoroscopic guided procedures to be done in designated operation theatre only either
at trauma center or at Level 4 OT in main building
1.2.3. COVID-19 negative/low risk cases to be done in a separate endoscopy theatre by a separate
endoscopy system in B -block.
1.2.4.The number of staff members present in the endoscopy area during the procedure will be reduced
to the minimum required.
1.2.5. All members of the endoscopy team will wear appropriate personal protective equipment (PPE),
such as gloves, mask, eye shield/goggles, face shields, and gown, as appropriate, based on risk
assessment and stratification.
1.2.6.For high-risk cases, ensure that appropriate personal protective equipment (PPE) is available and
worn by all members of the endoscopy team: gloves, mask, eye shield/goggles, face shields, and
gown. In such cases, the sequence of wearing and removal of PPE must follow the prescribed
standard protocol.
1.2.7. The recommended protocols for disinfection techniques for endoscope reprocessing must be
strictly adhered to.
1.2.8.As far as possible, only disposable endoscopic accessories shall be used.
1.2.9.For patients with intermediate or high risk of COVID-19 infection, non-critical environmental surfaces
frequently touched by hand (e.g. bedside tables, bed rails, cell phones, and computers) and
endoscopy furniture and floor will be disinfected at the end of each procedure.
1.2.10. Standard endoscopy room disinfection policy should be followed for non- COVID-19 or low-risk
patients undergoing endoscopy.
1.3. Post-procedure observation
1.3.1.During patient observation in the post-procedure area or a recovery room, adequate spacing
between beds (at least 6 feet) should be ensured.
1.3.2.Surgical masks should be provided for patients with respiratory symptoms.
3. Other recommendations relevant to gastroenterology practice
1.4. Non-urgent consultations may be postponed or rescheduled after COVID-19 pandemic gets over (unless
change in symptoms or clinical situation warrants an earlier consultation during the intervening period).

Cardiology Care in COVID-19 Crisis
• Medical therapy should be optimized(OMT) in patients with emergent cardiovascular issues
• invasive strategies for diagnosis and therapy to be used with caution.
Cardiovascular emergencies
• For patients with acute coronary syndrome, ordinary electrocardiography and standard biomarkers for
cardiac injury are preferred
• For patients with acute aortic syndrome or acute pulmonary embolism, this means CT angiography.
• When acute pulmonary embolism is suspected, D-dimer testing and deep vein ultrasound can be
employed, and
Conditions for which conservative medical treatment is recommended during COVID-
19 pandemic
1. ST-segment elevation myocardial infarction (STEMI) where thrombolytic therapy is indicated
2. STEMI when the optimal window for revascularization has passed
3. High risk non-STEMI (NSTEMI)
4. Patients with uncomplicated Stanford type B aortic dissection
5. Acute pulmonary embolism,
6. Acute exacerbation of heart failure
7. Hypertensive emergency
Diagnosis warranting invasive intervention
1. Life-threatening NSTEMI,
2. Stanford type A or complex type B acute aortic dissection
3. Bradyarrhythmia complicated by syncope or unstable hemodynamics mandating implantation of a
device
4. pulmonary embolism with hemodynamic instability for whom IV thrombolytics are too risky
5.Cardiac tamponade

General Measures
1. Cancellation of elective procedures
2. Conversion of most elective visits to TELEMEDICINE
3. The use of PPEs
Echocardiography
1. Cancel elective echocardiography
2. Use Bedside studies
3.Clean the machine and probe appropriately before and after each study
4.Shorten exam length
5. Use airborne PPE during TEE
In Patient cardiology Care
1. Limit In-patient Consultation
2. Avoid large group rounds
3. Minimize non-essential staff
4. PPE as per Guidelines
5. Utilize Telehealth and develop over the phone rounds
Measures for Cathlab
1. Interventions should be done in a cath lab or operating room with negative-pressure
ventilation, 2.
Strict periprocedural disinfection.
3. PPE should also be of the strictest level.
4. If negative-pressure ventilation is not available, air conditioning (e.g., laminar flow and
ventilation) should be stopped

SOP of acute neurological emergency in suspected COVID 19
General principles
1. Patient to be kept in a separate room with negative pressure. (At least exhaust fans if no negative
pressure room.)
2. Inform the Neurology team regarding the arrival of such patient as soon as possible.
3. Assessment of severity of COVID 19 signs and symptoms by a multidisciplinary approach including
an infectious disease specialist, pulmonologist and a critical care specialist. Also keep an Anesthesiologist
and Radiologist informed about the same.
4. Restrict entry of staff and visitors into the room to only essentials.
5. Kindly screen a close relative and make available for detailed history taking and arrange previous
medical records if any.
6. Standard universal precautions to be followed to prevent contact with body fluids.
7. Patient monitoring including temperature, BP, Respiratory rate, O2 saturation, GCS (Glasgow coma
scale), pupil size with reactivity and single breath count (in conscious patients).
8. Instrumentations like Ryle’s tube, Foley’s catheterization etc. should be done with standard sterile
precautions and minimum contact.
9. While taking the patient for imaging, one nursing staff and one resident will accompany with 100%
precautions.
Special conditions
Altered sensorium including neuroinfections
1. Head injury, metabolic causes (electrolyte imbalance, hypoglycemia), hypoxemia, hepatic or uremic
encephalopathy or poisoning to be ruled out.
1. Initiate general supportive care.
2. Plan urgent Neuroimaging (CT/MRI)
3. Plan CSF analysis if required after clinical and neuroimaging assessment
Acute stroke (window period 3-4.5 hours)
1. Reconfirm onset of signs/symptoms and brief history taking.
2. Urgent blood sugar and BP monitoring and Inj labetolol 10 mg iv stat if Systolic BP more than 220
mmHg.
3. Urgent serum electrolytes, ECG
4. Inform the radiology team for urgent neuroimaging (CT/MRI).
5. Patient to be kept in lateral position and initiation of general supportive care

Myasthenia Gravis/ crisis
1. Asses respiratory parameter (respiratory rate, single breath count, oxygen saturation, ABG) and bulbar
dysfunction (swallowing, cough).
2. Elective intubation if required.
3. Avoid following drugs: fluroquinolone, aminoglycosides, macrolides, quinine, muscle relaxants, beta
blocker
4. Urgent serum electrolytes, ECG and chest x-ray
Acute flaccid weakness/ GBS/ transverse myelitis
1.Asses respiratory parameter (respiratory rate, single breath count, O2 saturation, ABG) and bulbar
dysfunction (swallowing, cough).
2.Elective intubation if required.
3. Rule out dyselectrolytemia especially hypokalemia
4. Plan CSF analysis and neuroimaging (MRI brain and spine)
5. Plan Neurophysiological studies in Neurology lab. Patient has to be shifted to Neurology lab with all
the standard precautions as per the COVID guidelines of our institute.
Seizure/Epilepsy/ Status epilepticus
1. Urgent serum electrolytes, ABG, Blood sugar, renal function test and neuroimaging (preferably
contrast enhanced MRI brain).
2. Follow the standard “status epilepticus management protocol” with close monitoring of respiratory
parameter.
3. Elective intubation and SOS mechanical ventilation if
required.
4. Plan Electroencephalogram in Neurology lab as and when required. Patient has to be shifted to
Neurology lab with all the standard precautions as per the COVID guidelines of our institute.

FLOW CHART OF MAINTENANCE DIALYSIS PATIENTS
Hospital entry
Screening at parking area in front of trauma centre
COVID suspect COVID non suspect
2
nd
screening at dialysis centre
COVID suspect COVID non suspect
COVID emergency as per
guidelines
Entry in dialysis centre
Admission as per guidelines
of covid task force team
Separate dialysis facility in D4
area of isolation ward

SOPs for hemodialysis of a suspected or confirmed case
S Haemodialysis of such patients to be done in a separate closed room in Covid Ward
1. Minimum required people to enter in that room
2. Patient to wear face mask
3. To be performed by Dialysis team if treating resident is not having experiences on
putting the central line and busy in doing other patient care.
4. HCWs to wear complete PPE(level 2 protection) during all dialysis related procedures
with special care during cannulation; Universal precautions to be taken
5. All used consumables e.g dialyzers, dialysis tubing needles etc to be disposed off
properly in respective BMW bags
6. Routine cleaning and disinfection of HD machines with 5% sodium hypochlorite and with
hot water (40 degree Celsius) to be done. Routine RO disinfection with 1% sodium
hypochlorite to be done
7. Any surface, supplies or equipment located within 6 feet of such patients should be
disinfected (with 70% alcohol based or 1% sodium hypochlorite based solutions) or
discarded, if possible

PROTOCOL FOR NEONATAL COVID INFECTION
Testing protocol for neonates born to mother with suspected/confirm COVID 19
Neonate reaches the COVID Centre
History and examination of the neonate and classification as Suspect/Confirm and
Symptomatic/Asymptomatic
Suspected/Confirm asymptomatic management:
1. When resource of isolation of suspected/confirm mother is not available:
• Healthy neonate may be roomed-in with mother. The mother-baby dyad must be isolated from other suspected
and infected cases and healthy uninfected mothers and neonates
• Direct breastfeeding can be given. Mother should wash hands frequently including before breastfeeding and
wear mask. If needed due to neonatal condition, expressed breast milk may also be fed
2. When resource of isolation of suspected/confirm mother is available:
• Baby to be kept under isolation
• Mother can express milk after washing hands and breasts and while wearing mask. This expressed milk can be
fed to her own baby without pasteurization.
• Mother and baby can be roomed-in once mother has been tested and declared to be clear of infection.
• To facilitate early rooming-in, viral testing in mothers with suspected infection should be conducted and
reported on priority.
Baby should be managed symptomatically
Management of symptomatic neonates born to suspected/confirm mothers:
• Neonates who are symptomatic/ sick and are born to a mother with suspected or proven COVID-19 infection
should be managed in separate isolation facility
• This area should be separate from the NICU/SNCU with a transitional area in-between. These single rooms can be
single closed rooms
• In case if enough single rooms are not available, closed incubators (preferred) or radiant warmers could be placed
in a common isolation ward for neonates. The neonatal beds should be at a distance of at least 1 meter from one
another. Suspected COVID-19 cases and confirmed COVID-19 cases should ideally be managed in separate
isolations. If not feasible to have separate facilities and the neonates with suspected and confirmed infection are in
a single isolation facility, they should be segregated by leaving enough space between the two cohorts.
• Negative air borne isolation rooms are preferred for patients requiring aerosolization procedures (respiratory
support, suction, and nebulization). If not available, negative pressure could also be created by 2-4 exhaust fans
driving air out of the room.
• Isolation rooms should have adequate ventilation. If room is air-conditioned, ensure 12 air changes/ hour and
filtering of exhaust air. These areas should not be a part of the central air-conditioning
• The doctors, nursing and other support staff working in these isolation rooms should be separate from the ones
who are working in regular NICU/SNCU. The staff should be provided with adequate supplies of PPE. The staffs also
need to be trained for safe use and disposal of PPE
• SYMPTOMATIC MANAGEMENT OF THE BABY SHOULD BE DONE, NO SPECIFIC DRUG/TREATMENT IS APPROVED
FOR TREATING SUSPECTED/CONFIRM NEONATAL COVID-19 INFECTION
Suspected 2019-nCoV infection: Neonates born to the mothers with history of 2019-nCoV infection between 14 days
before and 28 days after delivery, or the newborns directly exposed to those infected with 2019-nCoV (including family
members, caregivers, medical staff, and visitors), regardless of whether they present with symptoms or not.
Confirmed 2019-nCoV infection: If 1 of the following etiological criteria is met: 1. Respiratory tract or blood specimens
tested by real-time fluorescence polymerase chain reaction (RT-PCR) are positive for 2019-nCoV nucleic acid, 2. Virus
gene sequencing of the respiratory tract or blood specimens is highly homologous to that of the known 2019-nCoV
specimens.

Updated management protocol covid 19-aiims rishikesh_version 4.0

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