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REVIEW ARTICLE
Year : 2020  |  Volume : 16  |  Issue : 5  |  Page : 974-978

Interventional radiology under the era of coronavirus disease 2019: Recommendations from the Chinese College of Interventionalists


1 Department of Radiology, Center of Interventional Radiology and Vascular Surgery, Zhongda Hospital, Southeast University, Nanjing, China
2 Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
3 Department of Interventional and Vascular Surgery, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, China
4 Department of Interventional Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China

Date of Submission20-May-2020
Date of Decision13-Jul-2020
Date of Acceptance19-Aug-2020
Date of Web Publication29-Sep-2020

Correspondence Address:
Gao-Jun Teng
87 Dingjiaqiao Road, Gulou District, Nanjing 210009
China
Zhong-Min Wang
Ruijin 2nd Road, Huangpu District, Shanghai 200025
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_659_20

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 > Abstract 


The pandemic of coronavirus disease 2019 (COVID-19) has become a major public health threat to the whole world. Although the control of COVID-19 has been in the forefront of interventional practice, most interventional radiologists (IRs) are not equipped adequately to cope with such a crisis. In this review, we share our experience from Chinese IRs' perspective, report on the acute measures instituted within interventional radiology (IR) units, and give recommendations to the prevention and control of COVID-19.

Keywords: Coronavirus disease 2019, interventional radiology, infection


How to cite this article:
Zhu HD, Xiong B, Jia ZZ, Lu J, Wang ZM, Teng GJ. Interventional radiology under the era of coronavirus disease 2019: Recommendations from the Chinese College of Interventionalists. J Can Res Ther 2020;16:974-8

How to cite this URL:
Zhu HD, Xiong B, Jia ZZ, Lu J, Wang ZM, Teng GJ. Interventional radiology under the era of coronavirus disease 2019: Recommendations from the Chinese College of Interventionalists. J Can Res Ther [serial online] 2020 [cited 2020 Oct 21];16:974-8. Available from: https://www.cancerjournal.net/text.asp?2020/16/5/974/296443

Hai-Dong Zhu, Bin Xiong, Zhong-Zhi Jia and Jian Lu contributed to the paper equally.





 > Introduction Top


The coronavirus disease 2019 (COVID-19) continues to rapidly spread throughout the world regardless of its unclear origin.[1],[2],[3],[4] During the past months, thousands of Chinese health-care workers, including interventional radiologists (IRs), have been fighting this emerging, rampantly evolving situation.[5] During the epidemic period, a large number of patients were in need of nonurgent elective or urgent interventional therapies, which could lift the chance of nosocomial infection and pose significant challenges to prevent and control the epidemic.[6],[7],[8] Based on previous practice in maintaining necessary IR services in such a context, the Chinese College of Interventionalists wishes to share our experiences in preventing and controlling COVID-19 when practicing IR and to make the following recommendations for IRs around the world.


 > General Principle Top


The overarching principles for IRs during the epidemic include urgent task force or crisis team management, prompt risk assessment and emergency priority, hierarchic personal protection management, and essential infrastructure modification and adjustment.

Task force or crisis team management

An Emergency IR Leadership Committee, being part of the Institutional Emergency Response System, is recommended to be launched as early as possible to guide the clinical practice, as well as education and training to all health-care workers, logistic personnel, patients, and visitors in IR units. The leadership team should have free access to instant effective communication within the team and with other units all the time.

Risk assessment and emergency procedure priority

Prompt risk assessment to patients and health-care workers in the IR units should always be completed to carefully weigh the advantages and disadvantages of the treatments while preventing virus transmission. Under the premise of minimizing the risk of COVID-19 transmission, all possible efforts should be put into treating patients with severe urgent diseases in a priority manner.[9] The triage mechanism is proposed to evaluate for the following: (1) emergency, subemergency, or elective; (2) COVID-19 confirmed, suspected, without exclusion, or uninfected; (3) benefits of the treatment; and (4) diagnosis and differential diagnosis of COVID-19 following different workflows.

Personal protection management

According to the potential risks of infection in different situations, three levels of personal protection equipment (PPE) are recommended during clinical practice [Table 1].[3],[8],[10],[11],[12]
Table 1: Three levels of the protection during interventional radiologist procedures

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Infrastructure modification and adjustment

Normal allocation of facilities may not meet the stringent requirements for COVID-19. Re-allocations and modifications of IR theaters and inpatient wards are must-haves. The adjustments and modifications should be made based on the principles of quarantined space and facilities with high-standard decontamination measures. Meanwhile, the actual condition and specific local features of the epidemic in different regions should also be considered.


 > Recommendations for Procedural Preparation Top


Patient preparation

Patient and family members must be informed on prevention and control of COVID-19 before the procedure. For confirmed or suspected patients, the consent form must be signed by a family member without close contact with the patient. In the case where the family member was in close contact with the patient, he or she must stay in a quarantined area and the consent should be obtained over the phone or internet.

The patient must be transferred to the IR theater by specifically trained medical staff. The number of accompanying medical staff should be kept minimal. The transportation route should be predesigned and least time-consuming. No stopover can be allowed on the way.

Site and instrument preparation

The IR operation zone should be demarcated into three regions, including a contaminated area for confirmed or suspected patients, a clean area for uninfected patients, and a buffer area in between. Negative-pressure (below − 5 Pascal) IR operating theater is recommended for confirmed or suspected patients. If no negative-pressure operating theater is available, the procedure should be carried out in a designated contaminated area. The fresh air and air conditioning systems should be turned off before patient arrival. Human-machine coexistence disinfection cabinet could be utilized for air purification.

The mandatory supplies to be used for IR procedure should be prepared, and medical staff movement during the procedure should be limited at a minimal level. C-arm, flat panel detector, and other procedure-related equipment, such as high-pressure syringe, must be covered with customized disposable plastic films and sterilized afterward. The operating table and stretcher should be covered by double-sheet drape. The contaminant tub should be covered with double-deck medical waste bags to prevent contamination caused by breakage. A warning sign should be hung outside of the operating theater to indicate the presence of a confirmed or suspected patient inside.

Medical staff preparation

The number of involved medical staff should stay minimal for safety purpose. Medical staff presenting with fever, respiratory symptoms, or skin injuries are not allowed to participate in the procedure. Only medical staff wearing proper PPE in the designated clean area are permitted to enter the operating theater.

For aerosol-generating procedures (AGPs), especially for confirmed, suspected, or probable COVID-19 patients receiving noninvasive ventilation, manual ventilation, active suctioning, or cardiopulmonary resuscitation, medical staff must don Level III PPE. Speaking of potential AGPs, Level II PPE and lead aprons should be adopted. Effective PPE should be donned in the following order: hand hygiene in the buffer zone, antiseepage sterile surgical gowns, disposable medical respirator (fit tested), disposable surgical cap, goggles, first pair of disposable latex gloves, disposable medical protective gown, comprehensive respirator or positive-pressure head cover, disposable inner layer boot cover, lead garment, and outer layer disposable shoe cover. Procedures for uninfected patients should be performed in the clean area. After peer check and confirmation, medical staff are considered safe to enter the operating theater. Of note, when a full respirator or positive-pressure headgear is used, protective glasses and medical respirator can be omitted.


 > Recommendations during Procedure Top


For emergency procedure

Workflow and protection level

A comprehensive assessment completed by the COVID-19 expert group and IRs is a prerequisite for performing emergency IR procedures. According to the clinical guidelines for COVID-19 diagnosis and treatment issued by the National Health Commission of China,[13] a special workflow should be made at short notice and timely updated with institution-wide measures according to the necessity or urgency of IR procedure and patient condition [Figure 1].
Figure 1: Workflow for emergency interventional radiology procedures personal protection equipment means personal protective equipment; aerosol-generating procedures means aerosol-generating procedures; coronavirus disease 2019 means Coronavirus disease 2019

Click here to view


Protection during procedure

A simple and effective procedure is recommended to avoid cross contamination and shorten the duration. IR procedures should be performed gently. Any unnecessary movement or contact shall be frozen to reduce the risks of body fluid splashing or sharps piercing the protective clothing and gloves. The contaminated waste should be collected in sterile garbage bags. Any blood or body fluid contamination must be completely covered by a disposable absorbent material at once. The absorbent material should then be immersed with 5000–10,000 mg/L chlorine-containing disinfecting solution for more than 30 min and cleaned up with care after the procedures.

Submitted specimens should be checked, collected, and registered carefully. The sample bags of confirmed or suspected patients should be double-sealed and prominently labeled when cautiously transported. The inspection shall be carried out by trained staff with proper PPE donned.

Protection after procedure

After the procedure, the participants must doff all disposable PPE and lead aprons in the contaminated area in the appropriate order. The removed disposable PPE should be put into a double-layer biohazard waste bag for centralized disposal. The lead aprons should be wiped and disinfected directly with 75% ethanol or other qualified disinfectants for future use.

The floor and wall should be splashed or immersed in 1000 mg/L or higher effective chlorine solution for at least 30 min before wiping with clean water. The surface of the surgical table and stretcher should be wiped with 1000 mg/L or higher effective chlorine solution. If there was blood or secretion contamination on the floor, wall, or other surfaces, the contaminating material must be completely removed before spraying, wiping, or soaking as above. The remaining floor and wall should be wiped with 5000 mg/L effective chlorinated disinfectant solution. After complete disinfection in the negative-pressure operating theater or contaminated area, the risk of nosocomial infection should be assessed before the next use.

More attention should be paid to sorting and standardizing medical waste. All medical wastes should be discarded in a double-layer biohazard waste bag and stored separately until centralized disposal.

Subemergency or elective interventional radiology procedures

It is advisable to assign senior personnel to vet requests and optimize procedure planning based on clinical needs/urgency and operational capability. For all procedures, facilities for COVID-19 patients should be predesignated, preferably in locations with low footfall.

Subemergency patients should be screened for COVID-19 in accordance with guidelines of the National Health Commission of the involved country.[14],[15] It is advisable to defer the procedure till the swabs are cleared off. If the subemergency IR procedure is deemed necessary for confirmed or suspected patients, the procedure should be performed in accordance with guidelines of the National Health Commission of the involved country or institutional policy. The workflow and demands of emergency IR procedures for confirmed or suspected patients [Figure 1] provide a detailed protocol for reference. If COVID-19 has been ruled out, the procedures should be performed routinely. Of note, procedures are performed in the outpatient setting as much as possible to reduce the risk of nosocomial infection and free up inpatient beds.

During the COVID-19 pandemic, all the elective IR procedures should be canceled until further notice. In addition, hospital admission should also be limited to patients without COVID-19 for maximum protection and safety.


 > Postprocedural Management Top


IRs must be fully aware of the institutional policy on where to send patients after the procedure. Patients with COVID-19 should be referred to departments specialized in combatting COVID-19 after IR procedures.[16] Patients suspected of COVID-19 should be referred to the designated buffer ward for further screening of COVID-19, whereas those cleared of COVID-19 are transferred to the general ward for further care and observation.

To protect patient safety and reduce the incidence of nosocomial infection of COVID-19, the interventional ward should be closely managed 24/7. Patients are not allowed to leave the ward during hospitalization. Only one family member is permitted to look after the patient and not allowed to leave the ward, either. Visitors are barred during the pandemic. To reduce the incidence of nosocomial infection, the interventional ward should be managed by one or two appointed IRs.


 > Other Considerations Top


In addition, other issues should also be taken into account based on the actual situation in different hospitals, including but not limited to: (1) persistent on-site or online training and education; (2) telemedicine and online outpatient clinic; (3) workload adjustment; (4) research activities; (5) education to residents and fellows; (6) logistics and stockpiles; and (7) medical staff morale and psychological pressure.


 > Summary Top


The feasibility and efficacy of the above recommended measures have been successfully verified in Chinese medical institutions since the beginning of COVID-19. As one of the parties who stand in the front line, IRs must pay close attention to our own safety using the proper protection measures to avoid cross infection, so as to better serve our patients and protect our beloved families. We earnestly hope that these recommended measures will be of value to help IRs in the world to maintain IR services when we have no other choice but to face this unexpected crisis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med 2020;382:727-33.  Back to cited text no. 1
    
2.
Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020;323:1061-9.  Back to cited text no. 2
    
3.
Velavan TP, Meyer CG. The COVID-19 epidemic. Trop Med Int Health 2020;25:278-80.  Back to cited text no. 3
    
4.
WHO Director-General's Opening Remarks at the Media Briefing on COVID-19; 30 March, 2020. Available from: http://www.iams-covid-19.org/en/index.php/news-118.html.  Back to cited text no. 4
    
5.
Checklist for Preparing your IR Service for COVID-19. Available from: https://www.cirse.org/education/covid-19-resource-centre/.  Back to cited text no. 5
    
6.
Chu J, Yang N, Wei Y, Yue H, Zhang F, Zhao J, et al. Clinical characteristics of 54 medical staff with COVID-19: A retrospective study in a single center in Wuhan, China. J Med Virol 2020;92:807-13.  Back to cited text no. 6
    
7.
COVID-19 Resource Centre. Available from: https://www.cirse.org/education/covid-19-resource-centre/.  Back to cited text no. 7
    
8.
COVID-19 Resources for IRs. Available from: https://www.sirweb.org/practice-resources/covid-19-resources/.  Back to cited text no. 8
    
9.
Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19). Available from: file:///C:/Users/DELL/Documents/WeChat%20Files/wxid_8604896059812/FileStorage/File/2020-09/10_CDC_Management-of-Patients-with-Confirmed_2019_nCoV_CDC.pdf.  Back to cited text no. 9
    
10.
National Health Committee of People's Republic of China. Regulation for Prevention and Control of Healthcare Associated Infection of Airborne Transmission Disease in Healthcare Facilities; 27 December, 2016.  Back to cited text no. 10
    
11.
Too CW, Wen DW, Patel A, Abdul Syafiq AR, Liu J, Leong S, et al. Interventional Radiology Procedures for COVID-19 Patients: How we Do it. Cardiovasc Intervent Radiol 2020;43:827-36.  Back to cited text no. 11
    
12.
Shen Y, Cheng CS, Wang P, Zhu X, Lei G, Fang Y, et al. CSCO ablation expert workshop report: Recommendations for the management of tumor ablation during the coronavirus disease 2019 epidemic. J Cancer Res Ther 2020;16:350-5.  Back to cited text no. 12
    
13.
National Health Committee of the People's Republic of China. Chinese Clinical Guideline for COVID-19 Diagnosis and Treatment. 7th ed. China: National Health Committee; 3 March, 2020.  Back to cited text no. 13
    
14.
Chinese Center for Disease Control and Prevention. Guidelines for COVID-19 Epidemiological Investigations. China CDC Weekly 2020;2:327-8.  Back to cited text no. 14
    
15.
Country & Technical Guidance Coronavirus Disease (COVID-19). Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance.  Back to cited text no. 15
    
16.
Gogna A, Punamiya S, Gopinathan A, Irani F, Toh LHW, Wen Cheong LH, et al. Preparing IR for COVID-19: The Singapore experience. J Vasc Interv Radiol 2020;31:869-75.  Back to cited text no. 16
    


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