Keywords: neurointerventional treatment - coronavirus infections - stroke
Palavras-chave: neurointervenção - infecções por coronavirus - acidente vascular cerebral
INTRODUCTION
The recent outbreak caused by the severe acute respiratory syndrome coronavirus 2
infection (SARS-CoV-2) and its high transmission rates resulted in a situation that
was officially declared as pandemic by the World Health Organization (WHO) on March
11, 2020[1 ]. Presently, there have been over 3 million confirmed cases and over 200,000 deaths
from SARS-CoV-2 Coronavirus Disease 2019 (COVID-19) worldwide[1 ]. According to the Brazilian Department of Health, the first case of COVID-19 in
Brazil was confirmed on February 26, 2020, and reached the community transmission
stage on March 20, 2020. The epidemic peak in Brazil has been estimated for late April
and early May 2020[2 ].
All regions of Brazil have been affected, leading to new challenges to ensure adequate
care for suspected or confirmed cases of COVID-19 and the safety of health professionals
and other patients, reducing their exposure to the risk of infection and safeguarding
the care of other potentially life-threatening conditions[2 ].
While the pandemic poses new challenges to the healthcare system to provide support
for thousands of COVID-19 cases (often requiring hospitalization and intensive care
admission), common medical emergencies, such as stroke, should also be considered,
because they will continue to occur and require adequate treatment. The allocation
of both material and human resources to fight the pandemic cannot overshadow the care
for those time-sensitive emergencies, because in the event of inefficient treatment,
they will further increase mortality, long-term disability, and costs.
Although we have few data to develop a robust and consistent guideline and acknowledging
that recommendations may need to be adapted according to the pandemic evolution and
each healthcare facility specificities, the purpose of this expert joint consensus
of the Scientific Department on Cerebrovascular Diseases of the Brazilian Academy
of Neurology, the Brazilian Society of Cerebrovascular Diseases and The Brazilian
Society of Neuroradiology is to provide an organization framework for acute stroke
patients’ healthcare and those who require urgent neuro-interventional procedures
in the COVID-19 pandemic setting.
COVID-19 AND THE NERVOUS SYSTEM
COVID-19 AND THE NERVOUS SYSTEM
Typical symptoms of COVID-19 (fever, cough, sore throat, dyspnea, anorexia, nausea,
vomiting, diarrhea, abdominal pain) have been well described in the literature, and
neurological symptoms may be seen in about one-third of the cases[3 ],[4 ],[5 ],[6 ],[7 ]. Neurologic involvement may be presented as central nervous system manifestations
(dizziness, headache, impaired consciousness, acute cerebrovascular disease, ataxia,
and seizure), peripheral nervous system manifestations (anosmia, ageusia, vision impairment,
nerve pain, and Guillain Barré Syndrome), and myopathies[3 ],[4 ],[5 ],[6 ],[8 ].
Focal neurological deficits due to cerebrovascular disease are less frequent (2.8%)
in the course of COVID-19, but they might occur more often amongst those who develop
a more severe form of the disease (5.7%)[5 ]. However, they can be an initial manifestation of the disease, and early recognition
of infection will significantly impact the line of care of these patients conciliating
healthcare professional's protection and proper treatment strategies, especially in
time-sensitive therapies like reperfusion for acute ischemic stroke[3 ],[4 ],[5 ],[6 ].
COVID-19 might increase the risk of cerebrovascular disease by several mechanisms.
It may predispose to both venous and arterial thromboembolic disease due to excessive
inflammation, hypoxia, immobilization, and disseminated intravascular coagulation.
The serum D-dimer level is generally increased, which could be a marker of embolic
vascular events[9 ]. Despite systematic thrombosis prophylaxis, the incidence of thrombotic complications
in intensive care unit (ICU) patients with COVID-19 was remarkably high (31%) in one
report[10 ]. Middle East Respiratory Syndrome (MERS- CoV) can cause acute myocarditis and heart
failure, and since COVID-19 has a similar pathogenicity may also predispose to brain
embolism from cardiac sources[11 ].
PATIENT CARE IN THE ISCHEMIC STROKE ACUTE PHASE
PATIENT CARE IN THE ISCHEMIC STROKE ACUTE PHASE
Triage
Patient-specific considerations should be balanced in conjunction with the safety
of healthcare professionals who are engaged in the triage, assessment, and treatment
of patients during the acute stroke phase. Besides the current screening and triage
for stroke, healthcare professionals should further examine the COVID-19 pandemic
and include an infection control screen, which should check for recent signs and symptoms
listed in [Table 1 ]
[3 ],[5 ]. As community transmission started to be established, screening for recent trips
became irrelevant. However, history of contact with a confirmed case during the previous
14 days might be beneficial for screening COVID-19 infected individuals, especially
in areas with a limited number of infected subjects. This recommended screening may
not always be feasible as patients may not be able to communicate reliably due to
stroke symptoms (such as aphasia, severe dysarthria, and decreased level of consciousness),
and family members may not be on the scene. In such cases, we recommend proceeding
with usual COVID-19 safety precautions until the screening can be reliably completed
or infection is excluded by formal testing. Screening should be completed during the
emergency department (ED) stay using all available sources of information (including
telephone contact) to provide the adequate patient transfer.
Table 1
Initial infectious screening for COVID-19 infection.
Potential indicators of COVID-19 infection
Common initial symptoms of COVID-19
Fever
Headache
Cough/Sneezing
Anorexia/Adynamia/Myalgias
Sore throat
•Gastrointestinal symptoms
•(including vomiting and diarrhea).
Chest pain
Anosmia
Dyspnea
Ageusia
Contact with a confirmed case during the previous 14 days*
*: areas with a limited number of infected subjects.
Patients might be admitted as a spontaneous demand or as a referral from other centers,
requiring a reliable triage performed upfront by pre-hospital healthcare professionals
and the hospital triage staff. Communication across sites before patient transfer
and consistent implementation of local screening protocols are paramount.
Ideally, every stroke patient admitted should be tested for COVID-19 through the reverse
transcription polymerase chain reaction (RT-PCR) or rapid serological tests. However,
considering the limitation of tests in under-resourced countries, only symptomatic
cases have been tested. It is noteworthy that massive testing has not been feasible
in our reality, so there is a high proportion of asymptomatic patients or patients
with seasonal flu-like symptoms who have been infected by SARS-CoV-2. Recent data
estimate that the percentage of pre-symptomatic transmission ranged from 46 to 55%,
and infectiousness peaks at zero to two days before symptom onset[12 ],[13 ]. Consequently, the proposed screening is not able to effectively exclude COVID-19,
and protective measures are advisable for every stroke patient. Furthermore, the triage,
as mentioned ([Table 1 ], [Figure 1 ]), may be useful to guide patient transfer to the most appropriate clinical unit
(COVID unit or stroke/ICU).
Figure 1 Protected Code Stroke during the COVID-19 pandemic (flowchart).
Protected code stroke
Code stroke is a well-known term used to prioritize hyperacute assessment and care
of patients with a suspected stroke. The word ‘code’ promotes efficient multi-player,
tiered communication among healthcare professionals setting up a process of measured
urgent actions during the hyperacute management of a patient with stroke signs and
symptoms[14 ]. In the COVID-19 pandemic, code stroke (along with similar medical emergencies)
is being modified to the protected designation (Protected Code Stroke - PCS) to provide
an extra layer of protection for healthcare professionals and patients.
The appropriate use of personal protective equipment (PPE) by all team members is
essential in the PCS. After community transmission, routine PCS should include contact
and droplet precautions for all patients. Proper protection requires a full-sleeved
gown, eye protection (face shield), gloves, and head covering ([Table 2 ]). Since aerosol-generating events might occur in acute stroke, we recommend the
use of N95 or KN95 face masks for all stroke team members directly involved in patient’s
care at the ED.
Table 2
Personal protective equipment for the assistance of patients with stroke and confirmed/suspected
cases of COVID-19.
Clinical settings
Emergency Room
Scenarios
•Staff in the room
•(e.g. neurologist, nurse)
•Suspected/confirmed COVID-19 patient
•OR
•Asymptomatic patients in whom an aerosol-generating procedurea will be performed
(open suctioning of airways, manual ventilation, intubation, among others)
•N95
•Face shield
•Non-sterile, disposable, full-sleeved isolation gown
•Two pairs of gloves
•Surgical cap
•Shoe covers
Asymptomatic patients in whom an aerosol-generatinga procedure will NOT be performed
•Surgical maskb
•Goggles or face shield
•Sterile, disposable, full-sleeved isolation gown
•One pair of gloves
•Surgical cap
•Shoe covers
Angiographic Suite
Scenarios
•Staff in the room
•(e.g. anesthesiologist, neuroradiologist, nurse)
•Suspected/confirmed COVID-19 patient
•OR
•Asymptomatic patients that will undergo a neurointerventional procedure under general
anesthesia or an aerosol-generating procedurea (e.g. open suctioning of airways, manual
ventilation)
•N95
•Face shield
•Sterile, disposable, full-sleeved waterproof gown
•02 pairs of gloves
•Surgical cap
•Shoe covers
Asymptomatic patients that will undergo a neurointerventional procedure, but an aerosol-generating
procedurea will NOT be performed
•Surgical maskb
•Goggles or face shield
•Sterile, disposable, full-sleeved isolation gown
•One pair of gloves
•Surgical cap
•Shoe covers
Stroke Unit
Scenarios
•Staff in the room
•(e.g. neurologist, nurse, physiotherapist)
•Suspected/confirmed COVID-19 patient
•OR
•Asymptomatic patients in whom aerosol-generating procedurea will be performed (open
suctioning of airways, manual ventilation, intubation)
•N95
•Face shield
•Non-sterile, disposable, full-sleeved isolation gown
•Two pairs of gloves
•Surgical cap
•Shoe covers
Asymptomatic patients in whom an aerosol-generating procedurea will NOT be performed
•Surgical maskb
•Face shield
•Sterile, disposable, full-sleeved isolation gown
•One pair of gloves
•Surgical cap
•Shoe covers
a Procedures at high risk for generating aerosol: tracheal intubation (OR=6.6 (2.3,
18.9); 39.6%), manual ventilation before intubation (OR=2.8 (1.3, 6.4), manipulation
of oxygen mask (OR=4.6 (0.6, 32.5); 64.8%), non-invasive ventilation (OR=3.1 (1.4,
6.8); 0%), defibrillation (OR=2.5 (0.1, 43.9); 55.3%), suction before intubation (OR=3.5
(0.5, 24.6); 59.2%), collection of sputum sample (OR=2.7 (0.9, 8.2), manipulation
of BiPAP mask (OR=6.2 (2.2, 18.1), chest compressions (one case-control study) 4.5
(1.5, 13.8). For further details: Tran et al.[15 ].
b It is reasonable to always use a N95 mask in areas of high incidence of COVID-19.
Aerosol-generating medical procedures during a code stroke include oropharyngeal/nasal
(open) suctioning, bag-valve-mask ventilation, nebulization, high flow oxygen masks,
and noninvasive positive pressure ventilation. As such, these events should be avoided
or minimized as much as possible. Highly aerosol-generating procedures, such as intubation
and chest compressions, should be performed in the appropriate setting according to
local/regional protocols[15 ]. Placement of a surgical mask in non-intubated patients is also recommended[16 ].
After initial triage, patients should be referred to the most appropriate location
in the ED (ED of COVID unit or regular ED) for urgent neurological assessment, laboratory
collection (including rapid serological tests or RT-PCR), and early stabilization.
When patients present signs of respiratory distress, are obtunded or require high
fractions of oxygen (FiO2 >0.5), we recommend early consultation with an emergency care or intensive care physician
for proper airway management. High flow oxygen masks and noninvasive positive pressure
ventilation should be avoided; therefore, early orotracheal intubation should be considered
for those patients.
The COVID-19 should not change the indications for acute ischemic stroke reperfusion
therapies. In patients eligible for IV thrombolysis and/or mechanical thrombectomy,
usual care should be taken following local/regional protocols[17 ],[18 ]. An individual with COVID-19 can be asymptomatic, but be a significant source of
infection[13 ],[14 ],[15 ].
Changes in high-resolution chest computed tomography (HRCCT) before viral symptoms
can be detected in about 20% of the patients[16 ]. Thus, a HRCCT may be recommended after an initial non-contrast head computed tomography
(NCCT) assessment for patients with a suspected stroke. Nonetheless, the feasibility
of this recommendation should be assessed by each institution, weighing the availability
of resources and the potential risk of silent COVID-19 spreaders. In the event of
a positive HRCCT, the patient should be considered a suspected case of COVID-19 infection,
and the appropriate protocol should be followed[19 ]. The HRCCT findings will be more frequent in the intermediate (three to six days)
and late (from seven days) phases from symptoms onset[17 ]. If the HRCCT is negative, COVID-19 cannot be excluded, particularly in pre-symptomatic
and early phases, but it may help to guide the transfer of the patient to an appropriate
unit (COVID or non-COVID units).
Definition criteria for COVID-19 disease
According to the WHO, a COVID-19 case may be defined as suspected, probable, or confirmed
([Table 3 ])[20 ]. For acute stroke management, the decision-making process should be very expeditious,
but sometimes a full triage is not feasible. Therefore, we adapted the WHO classification,
and patients should be considered at low risk for COVID-19 infection if the screening
for COVID-19 is negative ([Table 1 ]).
Table 3
World Health Organization definition criteria for the COVID-19 disease.
Suspected case
Scenario 1
A patient with acute respiratory illness (fever and at least one sign/symptom of respiratory
disease, e.g. cough, shortness of breath, AND a history of travel to or residence
in a location reported community transmission of COVID-19 disease during the 14 days
prior to symptom onset.
Scenario 2
A patient with any acute respiratory illness AND having been in contact with a confirmed
or probable COVID-19 case (see definition of contact) in the last 14 days prior to
symptom onset.
Scenario 3
A patient with severe acute respiratory illness (fever and at least one sign/symptom
of respiratory disease, e.g. cough, shortness of breath, AND requiring hospitalization,
AND in the absence of an alternative diagnosis that fully explains the clinical presentation.
Probable case
Scenario 1
A suspect case for whom testing for the COVID-19 virus is inconclusive. Inconclusive
is the test result reported by the laboratory.
Scenario 2
A suspect case for whom testing could not be performed for any reason.
Confirmed case
Scenario 1
A person with laboratory confirmation of COVID-19 infection, irrespective of clinical
signs and symptoms.
Patients should be considered a suspected case of COVID-19 in case of:
Positive screening for COVID-19 ([Table 1 ]).
HRCCT with findings compatible with COVID-19.
Inability to answer COVID-19 screening questions, due to neurological impairment of
patients (e.g. coma, aphasia) or in case of non-availability of family members.
Patients should be considered a possible case of COVID-19 if:
A suspect case in which the COVID-19 virus testing is inconclusive (description of
“inconclusive” reported by the laboratory).
A suspect case in which the testing could not be performed for whatsoever reason.
Patients should be considered a confirmed case of COVID-19 infection if:
A RT- PCR for COVID-19 was positive in less than 21 days after the onset of symptoms
(or laboratory confirmation for asymptomatic patients), which is considered the gold
standard method of diagnosis in clinical practice[3 ].
A serological test for COVID-19 is positive less than 21 days after the onset of symptoms
(or laboratory confirmation for asymptomatic patients).
Medical management of acute ischemic stroke in COVID-19 patients
Patients with transient ischemic attack that do not necessarily require hospital admission
may be appropriately managed at an outpatient level if the appropriate etiological
investigation and secondary prevention can be performed in a timely fashion. Careful
assessment needs to balance the risk/benefit ratio[21 ].
Patient evaluation with extended acute CT angiography protocols (angio-CT), including
great vessels and cardiac CT, might help to expedite the assessment of stroke etiology
and decrease the risk of infections associated with additional in-hospitals transfers
for exams, such as carotid ultrasonography and echocardiography[22 ]. However, based on current evidence, cardiac CT is not routinely recommended for
the evaluation of intracardiac structures in stroke patients.
It is noteworthy that the appropriate use of PPE by all team members (including stroke
unit/ICU physicians, nursing staff, physical therapists, and speech therapists) involved
in patient care is critical ([Table 2 ]).
Stroke telemedicine
Telemedicine has a great potential for triage and management of stroke patients during
the COVID-10 pandemic, and its implementation at a pre-hospital and outpatient level
should be encouraged. Stroke teleconsultations might spare the use of PPE, avoid unnecessary
inter-facility transfers, and reduce exposure risk for the stroke team[21 ]. The current available evidence supports the use of a modified neurological examination
and reliable National Institutes of Health Stroke Scale (NIHSS) assessment using telemedicine[23 ],[24 ]. A low-cost smartphone-based teleconsultation system for acute stroke has been validated
in Brazil[25 ].
NEUROINTERVENTION PROCEDURES DURING THE PANDEMIC
NEUROINTERVENTION PROCEDURES DURING THE PANDEMIC
Mechanical thrombectomy (MT) for acute ischemic stroke due to large vessel occlusion
is a well-established procedure for the early and late time window[26 ],[27 ],[28 ]. COVID-19 should not modify inclusion and exclusion criteria for endovascular reperfusion.
As a time-sensitive procedure, MT protocols should be reorganized to minimize the
exposure risk of patients and healthcare professionals, but without compromising the
speed of evaluation and treatment.
The neurointervention team should define if the procedure is elective (e.g. unruptured cerebral aneurysm) or urgent, considering the risks/benefits of the procedure
in relation to the likelihood of contamination and/or activation of the viral infection
in asymptomatic individuals. It is a consensus among several Societies and Organizations,
such as WHO, American College of Surgeons, Society of Vascular and Interventional
Neurology, Society of Neurointerventional Surgery, French Society of Neuroradiology,
Brazilian College of Surgeons, National Agency for Supplementary Health Service and
the Brazilian Department of Health, that elective surgeries should be temporarily
postponed during the COVID-19 pandemic, concentrating material resources, specialized
teams, and ICU beds for the most severe cases[8 ],[9 ],[10 ],[11 ],[12 ].
There are only a few articles regarding elective surgery with COVID-19 related complications
in asymptomatic patients[29 ]. Lei et al. reported 34 patients that underwent different surgeries, of whom 15
(44.1%) developed respiratory insufficiency requiring intensive care assistance and
7 (20.5%) died[30 ]. In such retrospective report, the authors attribute the decreased cell-mediated
immunological response to surgical stress, leading to accelerated viral replication,
as demonstrated by the shorter incubation time of the disease (average of 2.5 days).
Older age, prolonged surgical time, procedure complexity, high blood pressure, diabetes,
and cardiac disease were associated with a worse prognosis.
On the other hand, an elective procedure can evolve into an emergency, depending on
the type of vascular brain lesion and waiting time. Physicians are responsible for
deciding the most appropriate moment for intervention. According to the National Agency
of Supplementary Health, doctor and patient must keep a communication channel, using
new technologies that allow non-presential evaluation and follow-up during the new
coronavirus pandemic.
Thus, even though there is a growing number of confirmed cases and deaths, the following
urgent/emergency procedures are recommended in case of cerebrovascular diseases:
Endovascular treatment of acute ischemic stroke (MT).
Endovascular treatment of ruptured brain aneurysms.
Endovascular treatment of symptomatic carotid stenosis associated with a recent ischemic
event.
Endovascular treatment of ruptured cerebral arteriovenous malformations (AVMs), if
the multidisciplinary team (Neurosurgery, Vascular Neurology, and Neuroradiology)
identifies a high risk of rebleeding.
Endovascular treatment of posttraumatic, post-surgical or tumor bleeding.
Endovascular treatment of carotid-cavernous fistulas.
Cerebral angiography to determine the etiology of non-hypertensive hemorrhagic stroke
or subarachnoid hemorrhage.
RECOMMENDATIONS FOR NEUROINTERVENTIONAL PROCEDURES IN PATIENTS AT LOW RISK FOR COVID-19
RECOMMENDATIONS FOR NEUROINTERVENTIONAL PROCEDURES IN PATIENTS AT LOW RISK FOR COVID-19
A patient is considered at low risk for COVID-19 infection if the screening for COVID-19
is negative ([Table 1 ]). In such situation, individuals should undergo the procedure in the angiography
room for patients without COVID-19 (if applicable) and wear a surgical mask during
the entire hospitalization. Usual care, including protective measures for COVID-19,
should be adapted according to the procedure, local standards, and aerosolization
risk ([Table 2 ]). After the procedure, the patient should be admitted to the most appropriate unit
of care (Stroke Unit or ICU), based on local protocols.
RECOMMENDATIONS FOR PROCEDURES IN PATIENTS WITH SUSPECTED, POSSIBLE, AND CONFIRMED
COVID-19
RECOMMENDATIONS FOR PROCEDURES IN PATIENTS WITH SUSPECTED, POSSIBLE, AND CONFIRMED
COVID-19
Patients should be placed on contact and droplet precautions. During procedures, chiefly
those generating aerosols, healthcare personnel should wear full protection ([Table 2 ]).
It is crucial to follow the items below when dealing with patients with suspected/documented
COVID-19.
Pre-procedure
Patients should wear a surgical mask during the entire hospitalization.
Initial care should be taken in areas allocated for COVID-19 patients (local protocols
should be followed).
A swab sample for SARS-CoV-2 RT-PCR should be collected.
A rapid serological test may also be used for suspected cases requiring procedures
that are not time-sensitive and can wait for the result (e.g. carotid artery stenting), to guide appropriate use of PPE and cleaning process:
In the angiography suite
In institutions with more than one angiography suite, one must be dedicated specifically
to patients with COVID-19.
The angiographic room should contain only essential equipment, furniture, and medicines
to simplify cleaning.
The anesthesia workstation, monitors, and equipment should be covered with plastic
wrap to reduce the risk of contamination and simplify cleaning.
All medications and materials required for the procedure should remain outside the
room. If necessary, their delivery can be done by outside healthcare personnel who
should not go inside the angiographic suite.
Personal items should be kept outside the room. If necessary, cell phones can be protected
in plastic bags.
The angiographic suite must be kept closed during the entire procedure.
Recommended warnings for precautions must be visible at the door of the angiographic
suite.
Only the required number of professionals should be in the room.
Healthcare personnel directly involved in the procedure should wear N95 protective
masks.
Healthcare personnel should follow a strict checklist for PPE donning and doffing
([Table 4 ]).
Face shield, waterproof gown, surgical cap, and two gloves should be provided for
the physician in direct contact with the patient's fluids (local protocols should
be followed).
In cases when orotracheal intubation is considered necessary for the procedure, it
should ideally be performed in a dedicated room before transport, which should be
performed with a closed ventilator circuit.
In cases of MT, consider early orotracheal intubation if the patient shows at least
one of the following conditions:
Acute respiratory distress/hypoxemia/high oxygen requirement.
Inability of airway/low Glasgow Coma Scale - GCS (<9) protection.
Agitation, no cooperation.
Active vomiting.
Active cough.
Posterior circulation occlusions with poor handling of secretions/airway.
Table 4
Operational Manual for Doffing and Donning of personal protective equipment in a COVID-19
patient for neurointerventional procedures.
Sequence for donning PPE
Wash hands or use an alcohol-based hand sanitizer.
Put on lead gown and accessories (radiation protection eyewear).
Wash hands or use an alcohol-based hand sanitizer.
We recommend N95 (ffp2) surgical cap, or powered air-purifying respirator (PAPR) and
face shield, not only glasses.
Scrub hands for surgical procedures.
In the angiography suite, put on gloves (first gloves).
Surgical waterproof gown and gloves (second) extend to cover the wrist of isolation
gown. After that, the procedure can be started.
Wash hands or use an alcohol-based hand sanitizer.
Put on lead gown and accessories (radiation protection eyewear).
Wash hands or use an alcohol-based hand sanitizer.
Sequence for doffing PPE
Inside of the angiography suite, take out the gown and gloves.
Wash hands or use an alcohol-based hand sanitizer.
Take out the X-ray lead apron.
Wash hands or use an alcohol-based hand sanitizer.
Remove goggles and face shield from the back by lifting head band or earpieces and
surgical cap.
Wash hands or use an alcohol-based hand sanitizer.
Get out from the angiography suite and take out the radiation protection eyewear.
Wash hands or use an alcohol-based hand sanitizer.
Grasp bottom ties or elastics of the N95 mask/respirator, then the ones at the top,
and remove them without touching the front.
Wash hands or use an alcohol-based hand sanitizer.
PPE: personal protective equipment.
Notably, some authors have suggested that patients with dominant cerebral hemisphere
occlusions and/or aphasia, as well as those with high NIHSS (>15), be considered for
early intubation[18 ]. However, no reliable evidence supports this suggestion, as none of these factors
have been demonstrated to be predictors of conversion from sedation to general anesthesia.
Therefore, we discourage the preemptive intubation of these patients in the absence
of agitation or any of the other aforementioned conditions, as this would lead to
a high number of unnecessary intubations during a time of crisis when we should strive
to optimize the use of our resources. The main idea behind the recommendations for
early intubation is to minimize the risk of intra-procedural intubation, considering
it is a less controlled intervention and, as such, carries a higher risk of contamination.
However, this needs to be balanced against the higher exposure of medical teams that
intubate and extubate these patients, as well as to the additional use of time and
resources. Thus, teams are encouraged to consider their local experiences in these
decisions.
Post-procedure
Confirmed and suspect COVID-19 patients should be transferred to a COVID unit.
Institutions are encouraged to divide these COVID units into confirmed/high- and low-risk
COVID patients. When this is not feasible, low-risk COVID patients should be transferred
to the stroke unit or ICU (following institutional guidelines).
Patients should not be extubated in the angiography suite. Instead, they should be
transported to an appropriate ICU room for planned extubation.
Transport of these patients should be limited as much as possible, and follow-up imaging
should be restricted to cases with neurological deterioration.
Patients that are not under mechanical ventilation during transport should wear a
surgical mask. Oxygen can be administered through a nasal cannula under the mask during
transport.
If the patient is intubated, a closed ventilatory circuit must be used.
Full PPE must be worn by the transport team in case of direct contact with the patient
or contaminated equipment.
A member of the transport team, without direct contact with the patient or contaminated
equipment, should not wear PPE to interact with the environment (e.g. touch elevator buttons).
After the procedure, the ventilatory circuit and contents of the soda-lime container
must be discarded.
After the procedure, perform terminal cleaning of the angiographic room as recommended,
but it is mandatory that the cleaning staff wears respiratory and contact PPE. Details
on disinfectants for use against SARS-CoV-2 should be consulted elsewhere.
Since there is no precise data on how long the air inside a room occupied by someone
with confirmed COVID-19 remains potentially infectious, the decision on how long a
room used by a COVID-19 patient should be closed-off will depend on the evaluation
of room size, the ventilation system design, and if the procedure generated aerosol
or not. Nevertheless, it is currently accepted that the room should remain with the
doors closed for at least three hours if they are not working under negative pressure
before another patient is admitted or personnel is allowed to enter without PPE.
INFORMED CONSENT
The risk of COVID-19 contamination is higher in hospitalization, and this additional
risk factor should be made explicit in the consent form, especially in cases where
urgency/emergency is not undoubtedly characterized, as for example in unruptured aneurysms.
TRAINING
During care of COVID-19 patients, many protocol violations are possible in doffing
and donning of PPE. Additionally, health professionals may not be familiar with the
required procedures and use of the equipment (such as fogging of the “face shield”
impairing visibility).
In this setting, training with on-site simulation is highly recommended to ensure
proper execution of protocols and to avoid unnecessary stress, especially among professionals
involved in aerosol-generating procedures, such as orotracheal intubation, nasogastric
tube insertion, among others. All healthcare professionals should be fit-tested for
N95 masks, especially those who deal directly with aerosol-generating procedures.
The N95 masks used in aerosol-generating procedures or contaminated with blood, respiratory
or nasal secretions should be preferably discarded, although this recommendation might
be impractical in most centers due to limited availability of resources. N95 respirators
contaminated with blood, respiratory or nasal secretions, or other bodily fluids from
patients, should also be discarded. Extended use of N95 masks is permitted, but it
still carries a risk of contamination during donning and doffing, because virus particles
may be viable up to six days in porous surfaces[31 ]. Accordingly, training on donning, doffing, and proper storing of N95 facial masks
is essential to avoid contamination of healthcare professionals while handling these
PPE. The use of a cleanable face shield over an N95 respirator reduces the risk of
surface contamination. Hospitals should ensure adequate storage area or keep the masks
in a clean and breathable container, such as a paper bag[32 ].
