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A Protocol of Infection Control For Mechanical Thrombectomy in Possible COVID-19 Patients: Tokai University COVID-19 Manual
A Protocol of Infection Control For Mechanical Thrombectomy in Possible COVID-19 Patients: Tokai University COVID-19 Manual
A Protocol of Infection Control For Mechanical Thrombectomy in Possible COVID-19 Patients: Tokai University COVID-19 Manual
DOI: 10.5797/jnet.sr.2020-0075
The crisis of the coronavirus disease (COVID-19) is causing damage to the social and medical community. However, extreme
emergency neuro-interventions such as mechanical thrombectomy still require the healthcare workers to offer the appropriate
treatment while preventing further spread of the infection. This article outlines the necessary steps in managing a possible
COVID-19 patient starting from patient screening to personnel infection and environmental contamination measures.
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Journal of Neuroendovascular Therapy Advance Published Date: April 21, 2020
Srivatanakul K, et al.
steps mentioned in the next section that should be followed peripheral distribution, consolidations, septal thicken-
according to the status of the COVID-19 in the area. ing, bronchial dilation, and wall thickening are found,
consider the patient as a highly suspected case of
Patient Screening COVID-19-positive case.
3) If neuro-intervention is to be performed under general
The following protocol was made based on recent reports anesthesia, the patient should be intubated in a desig-
and discussion with the emergency and critical care nated area (negative pressure room with staff in proper
department and radiology department, and a rehearsal was PPE) if possible. Also consider performing MT under
done in the actual angiography room environment. general anesthesia for patients with respiratory distress,
active cough, or restlessness.
For a COVID-19-positive patient, proceed with inter- A patient with chest CT finding(s) compatible with
ventions such as thrombectomy as usual as soon as the per- those described earlier should be managed with proper
sonal protection equipment (PPE) and zoning preparation PPE as described in the following. However, for those
are ready. Patients with an unknown status of COVID-19 without abnormal CT findings, COVID-19 still cannot be
should be screened using the following protocol. completely ruled out.
The chance of having an asymptomatic COVID-19
High risk of COVID-19-positive patient screening patient cannot be ruled out in any patient. Practice hand
criteria hygiene and wear surgical mask when in contact with
At first contact, if any suspicion arises, put a protective patients at all time. Use proper PPE according to epidemic-
mask on the patient. If needed to give oxygen, place an ity of COVID-19 in the area.
oxygen cannula under the mask.
A patient with any of the following criteria should be
considered as a suspected case of COVID-19:
Medical Staff and Equipment/
Environmental Protection
1) travel history within 14 days to places considered as
endemic areas (according to the data of the World To prevent further spread of infection to other patients and
Health Organization or other appropriate sources) or a a healthcare workers, the following infection prevention
history of close contact with a COVID-19-positive or protocol must be applied to each personnel and contami-
-suspected patient, nation prevention to the environment must be well
2) fever without other obvious causes, respected.
3) respiratory symptoms or signs without other obvious
causes, and Recommended PPE (Fig. 1)
4) cases in which information mentioned above cannot be —Operators, assistants, and nurses working close to the
obtained without delay. patient
Surgical gloves, N95 mask or surgical mask (N95 use
should be limited to cases with aerosol-producing proce-
Initial Evaluation dures, such as intratracheal aspiration, endotracheal intu-
bation/extubation, bronchoscopy, and obtaining swap
Chest CT has been shown to be beneficial in detecting
sample, as the number is limited. During such procedures,
COVID-19 in high-risk population, even in patients with
one must always wear a surgical mask with a face shield
minimal respiratory symptoms.6,7 However, chest CT
over an N95 mask in addition to the above), surgical mask
abnormalities can only be detected in 54% of asymptom-
with face shield, disposable cap, and surgical gown (Asso-
atic cases,7 suggesting that there is no highly reliable
ciation for the Advancement of Medical Instrumentation
screening test in this group. The steps involved in initial
level 3) are necessary.8 Attention must be paid not to have
evaluation are as follows:
a direct exposure to the patient body fluid (waterproof shoe
1) Perform a chest CT scan at the same time as initial intra- and leg covers should be used).
cranial imaging. To prevent infection among medical staff, limit the
2) If any of the chest CT findings such as ground-glass number of medical staff participating in the procedure. If
opacities, involvement of multiple lobes, subpleural or the number of staff is sufficient, work in separate teams.
158
Journal of Neuroendovascular Therapy Advance Published Date: April 21, 2020
surgical cap
surgical gown
(AAMI level 3 compatible)
surgical gloves
(must be worn properly covering the
gown sleeves to prevent body fluid contacts)
Fig. 1 A sample of PPE setup. A N95 mask must be of correct size and worn properly.
Another surgical mask with a face shield is worn over the N95 mask to prevent the
N95 mask from being contaminated. The N95 mask, when used properly, can be
reused for up to 1 month. Gloves must be worn so that they cover the sleeves and not
leave any skin in contact with the body fluid of the patient. Great care must be taken
when removing the PPE, not to contaminate oneself or the surrounding. Any equip-
ment not fully covered by the surgical gown, such as X-ray thyroid shields, should be
disinfected after the procedure. PPE: personal protective equipment
—Circulating nurses and other assistants outside the oper- Angiography room area
ative field Zoning
Wash hands. Use a surgical mask, a long sleeve gown, and To prevent the contamination of the the room and the
gloves. For splash/spray-producing procedure, use protec- equipment, proper zoning has to be planned in advance and
tion for the face and the eyes (mask with face shield or gog- well respected during and after the procedure.
gles). For any aerosol-producing procedure, in addition to There should be lines demonstrating the contaminated
the abovementioned equipment, use also an N95 mask. An zone, intermediate zone, and clean zone on the floor of the
N95 mask may be reused up to 1 month if not contaminated. rooms and corridors.
Staff with PPE working directly on the patient must not
Zoning and cleaning leave the contaminated zone with the contaminated PPE.
During transporting of the patient and for CT/MRI rooms, The circulating nurse can go in and out of the angiosuite
the following precautions are to be taken: for necessary assistance but must not enter the contami-
1) When transporting the patient, try to use a path sepa- nated zone (Fig. 2).
rated from other patients.
2) CT and MRI rooms must be disinfected after each Cleaning and disinfecting of the environment
examination. In AIS of COVID-19-suspected case, con- The length of the time spent in the area of the angiography
sider using only CT and CTA to prevent contamination room is usually longer than that in other areas. This time
to the MRI room. includes a special attention in cleaning. Effective disinfection
159
Journal of Neuroendovascular Therapy Advance Published Date: April 21, 2020
Srivatanakul K, et al.
patient screening
Anesthesia
machine at first contact, put a face mask on any patient
Tool rack
look for recent travelling history, respiratory
Patient table
symptoms/signs include patients with status unknown
Tool rack
Chest CT helps identify asymptomatic COVID-19
patient but sensitivity is not high in asymptomatic patients
biohazard
waste bin
personal protective equipment (PPE)
Medical
Console Ns record
Surgical gloves, N95 mask or surgical mask
computer
(N95 use should be limited to cases with aerosol producing
procedures as the number is limited),
T
surgical mask with face shield, disposable cap,
surgical gown, shoe covers (refer to figure 1)
160
Journal of Neuroendovascular Therapy Advance Published Date: April 21, 2020
using the suggested PPE will depend on the epidemicity 3) Folsom AR, Gottesman RF, Appiah D, et al: Plasma d-Di-
in the area or the availability of PPE. COVID-19 is a new mer and incident ischemic stroke and coronary heart dis-
disease with growing evidence. The more we learn about ease: the Atherosclerosis Risk in Communities Study. Stroke
it, the more efficient we can be in protecting our environ- 2016; 47: 18–23.
4) Fraser FJ, Authur A, Chen M, et al: Society of NeuroInter-
ment. We stress, for one more time, the importance of
ventional Surgery recommendations for the care of emergent
keeping the N95 masks for reusage when the supply is
neurointerventional patients in the setting of COVID-19. 2020
low and the importance of training for proper use of PPE.
March. https://www.snisonline.org/wp-content/uploads/2020/
03/SNIS-COVID-Stroke-Protocol.pdf (Accessed: March
Acknowledgments 30, 2020).
5) Goyal M, Menon BK, van Zwam WH, et al: Endovascu-
The authors deeply thank Dr. Shinichi Matsuda, a pediatri- lar thrombectomy after large-vessel ischaemic stroke: a
cian in our hospital, for the inspiration for starting this meta-analysis of individual patient data from five random-
ized trials. Lancet 2016; 23: 1723–1731.
project. The authors also thank Michiko Kobayashi, an
6) Inui S, Fujikawa A, Jitsu M, et al: Chest CT findings in
infection control nurse in our hospital, for providing help
cases from the cruise ship “Diamond Princess” with coro-
in training the staff according to this protocol. All authors
navirus disease 2019 (COVID-19). Radiol Cardiothorac
pledge that this manuscript does not contain previously
Imaging 2020; 2. doi.org/10.1148/ryct.2020200110.
published material and is not under consideration for pub- 7) Fang Y, Zhang H, Xie J, et al: Sensitivity of chest CT
lication elsewhere. for COVID-19: comparison to RT-PCR. Radiology Feb 19,
2020. doi.org/10.1148/radiol.2020200432. [Epub ahead of
print]
Disclosure Statement 8) Cheng VCC, Wong SC, Chen JHK, et al: Escalating infec-
tion control response to the rapidly evolving epidemiology
The authors declare no conflicts of interest.
of the coronavirus disease 2019 (COVID-19) due to SARS-
CoV-2 in Hong Kong. Infect Control Hosp Epidemiol March
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