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.