Performing the EP procedure
Since the majority of cases performed during the present era of
exponentially rising COVID-19 infections are implantable devices, the
rule for us has been single-operator cases only. Our academic attending
role as educator currently plays a secondary role to efficiency and
safety at this time. Performing single-operator cases has been adopted
to preserve the critically low PPE supply. For more complex procedures
such as unstable VT or system extraction, the EP fellow assists either
by running the console stimulator or lending an extra set of operative
hands. Our EP fellows have served as scrub nurses and circulating nurses
since there has been redeployment of our highly trained nurses to the
emergency room or ICU. If available, a negative pressure procedure room
is ideal for treating COVID-19 infected patients. In emergent cases,
where there is no COVID testing and little patient medical history
available, it may be prudent to treat the patient as COVID-19 positive,
since coughing or vomiting during emergent circumstances may pose an
exposure threat to the health care providers.
If anesthesia deems a patient to be at high-risk of respiratory failure,
it is prudent to perform endotracheal intubation prior to the procedure
(i.e. in the patient’s room) to prevent aerosolization of viral
particles in the case of emergent intra-procedure intubation and
suctioning. The closed-system mechanical ventilator is preferred to the
higher-risk bi level positive airway pressure or nonrebreather systems.
Additionally, during ablations or extractions, it is advisable for the
proceduralist to use intracardiac echocardiography instead of
anesthesia-operated transesophageal echocardiography in order to prevent
aerolization
Prior to the case, the procedure attending, scrub nurse or technician
should don the appropriate PPE after proper hand hygiene is performed as
recommended by ID prevention and control. We have adopted using N95 for
both intubated and non-intubated COVID+ patients for two main reasons:
(1) dislodgement of the endotracheal tube may occur during movement of
the patient onto or off the operating table, or during emergency
resuscitation and (2) previous studies on human papilloma virus suggest
that laser or electrosurgery plume may cause infectious aerosol hazards
resulting in viral transmission.9 We don a surgical
mask on top of the N95 mask as per NYPH recommendation to preserve the
length of use of the N95. Our surgical PPE includes goggles that form a
seal around the eyes for splash protection, a surgical cap, shoe
coverings, at least two layers of sterile gloves and a sterile surgical
gown. We have all been trained in proper doffing of PPE which is
deliberate and meticulous to adhere to the strict protocol of doffing
with proper hand hygiene between steps.