Issues in the cath lab during COVID-19 outbreak
Catheterization Laboratory Considerations During the Coronavirus (COVID-19) Pandemic: From ACC’s Interventional Council and SCAILiterature - Welt FGP, Shah PB, Aronow HD, et al. - JACC 2020, doi.org/10.1016/j.jacc.2020.03.021
The ACC Interventional Council and the Society of Cardiovascular Angiography and Intervention (SCAI) have published a joint article to discuss issues that catheterization laboratory personnel face during the COVID-19 pandemic. There is a need for this, because the current COVID-19 outbreak is a dynamic situation with limited available data and for which local conditions may differ quite substantially.
Elective patients for the catheterization laboratory
It seems acceptable to avoid elective procedures on patients with significant comorbidities or in whom hospitalization is expected to be >1 to 2 days, or in whom requirement of intensive care unit is anticipated. Procedures that can be postponed are: PCI for stable ischemic heart disease, endovascular intervention for ilio-femoral disease in claudicants or PFO closure. Postponing of procedures in some patients may have adverse effects and therefore individualized decisions should be made, weighting risk of COVID-19 exposure vs. risk of delay in diagnosis or therapy.
A report from China described a protocol of rapid nucleic acid testing and fibrinolytic therapy in COVID-19 patients with STEMI . However, in many countries primary PCI is routine procedure in STEMI patients and there a limitation in access to rapid nucleic testing. In relatively stable STEMI patients infected with COVID-10, fibrinolysis can be a therapeutic option. When primary PCI is performed in STEMI patients with active COVID-19, personnel should wear personal protective equipment (PPE). Use of Powered Air Purifying Respirator (PAPR) systems is also reasonable, in particular for vomiting patients or those who require CPR and/or intubation.
There is time for diagnostic testing for COVID-19 in most patients with NSTEMI before they will undergo cardiac catheterization, resulting in more information in relation to infection control. In those who have been revascularized, rapid discharge is important to maximize bed availability and reduce exposure in the hospital for the NSTEMI patients. In appropriately selected NSTEMI patients with COVID-19 infection, particularly those with type 2 MI and patients who are hemodynamically stable, conservative therapy has been suggested. Recent reports published a 7% rate of acute cardiac injury in COVID-19 patients, representing type 2 MI or myocarditis . Risks and benefits of infection control need to be weighted considering all mentioned factors.
Patients requiring intubation, suctioning or CPR
Risk of exposure to infection of personnel is increased with procedures as intubation, suction and active CPR (due to aerosolization of respiratory secretions). Intubation of (suspected) infected patients should be done prior to arrival at the catheterization lab. HEPA filters between tube and bag when bagging a patient have been suggested. Other suggestions include use of closed circuit BIPAP machines, close coordination with critical care, ID and anesthesia teams to prevent spread of infection.
Resource allocation and protection of the team of healthcare workers
Staff could become infected/exposed/quarantined and in combination with strain on home situation due to school closures, this could result in staff shortages. Specific considerations for care subspecialty teams seems reasonable, such as separation of individuals with overlapping skillsets.
Some procedures (pulmonary artery catheter placement, pericardiocentesis and intra-aortic balloon pump insertion) now need to be considered to be performed in bed, to avoid transport of patients. If possible, cases of (suspected) COVID-19 should be done at the end of working day when considering the requirement for terminal cleaning. Or one lab should be designated for COVID-19 patients.
Protection of healthcare workers and PPE
Personnel should be fit-tested for N95 masks and skilled in doffing and donning PPE. In some situations, PAPR systems may be needed. Working together with institutional infection control group is essential to ensure adequate availability and training in use of PPE. Patients with (suspected) COVID-19 undergoing procedure in the catheterization lab should wear a surgical mask and personnel should don PPE. A shortage of N95 masks, as well as gowns, gloves, regular surgical masks supports deferral of elective cases and reduction of personnel during procedures.