Procedural sedation in the COVID-19 era

WHEN TO RESUME ELECTIVE PROCEDURAL SEDATION

According to government and healthcare officials’ recommendations, before a facility resumes elective procedures, the community should have either a low incidence of COVID-19 cases or a sustained downward trajectory of COVID-19-like illnesses or positive tests within a 14-day period. Hospitals should have the capacity to treat all patients without crisis care protocols and have a robust testing program in place. Healthcare facilities should have sufficient resources including PPE, medications, supplies, surgical and anesthetic equipment, and workforce availability to provide care of non-COVID-19 patients without jeopardizing surge capacity (Table 1).²

PRE-PROCEDURAL COVID-19 SCREENING AND TESTING

Pre-procedural screening and testing for COVID-19 are necessary before all non-emergency procedures to ensure the safety of patients and healthcare providers. Patients with COVID-19 symptoms (Table 2) should be referred for appropriate care and have their procedure rescheduled. Patients without symptoms should have a laboratory COVID-19 test 24 to 72 hours before their scheduled procedure. Once tested, patients should be encouraged to self-isolate until the procedure and report any change in symptoms. Figure 1 shows an algorithm for screening and testing patients.

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Figure 1

Pre-procedural flowchart for pre-procedural screening and testing patients for COVID-19.

Pre-procedural COVID-19 testing is necessary as patients may become infected and have viral transmission up to 3 days before becoming symptomatic.⁶ Infected patients undergoing surgery who were asymptomatic have been found to have more significant disease progression, a higher incidence of ICU admission, and higher mortality.⁷

PERSONAL PROTECTIVE EQUIPMENT

Although COVID-19 testing will help identify patients who are infected, the reported sensitivity varies in different anatomical sites (eg, bronchoalveolar, nasopharyngeal, and sputum), leaving significant possibility for false-negative results.⁸ Additionally, patients may become infected between the test and the procedure. Due to these possibilities, even for COVID-19 negative patients, droplet precautions (eye protection, surgical mask, and gloves) should be used for non-aerosolizing procedures and airborne precautions (eye protection, N95 mask, gown, and gloves) should be used for aerosol-generating procedures (AGPs).^2,3 These procedures involve mucous membranes such as those in the respiratory, naso-oropharyngeal, and gastrointestinal tracts. AGPs include intubation, extubation, bronchoscopy, upper and lower endoscopy, airway surgeries, and interventions such as using high-flow nasal cannula oxygen, positive-pressure mask ventilation, or continuous positive airway pressure (CPAP) ventilation.^4,9–11

REDUCING SARS-COV-2 TRANSMISSION

Appropriate sanitation protocols should be in place for common areas and procedural suites to reduce the risk of virus transmission. In addition to standard cleaning between cases, extra environmental cleaning (waiting areas, door handles, common surfaces, and elevator surfaces) should be implemented.^2,3 For aerosol-generating procedures, allow adequate time between cases for appropriate room air exchange to reduce the risk of transmission from residual aerosolized particles.³ This time frame should be based on the time required for air exchange in individual procedural suites.

Social distancing should continue to be observed among patients and visitors in waiting areas and both pre- and post-procedure areas. This may require lower patient volumes. Visitors should only be allowed if their presence is necessary for patient care, and they should be screened for symptoms or COVID-19 exposure. Visitors accompanying patients may benefit from the option to leave and be contacted by phone to return to pick up the patient. Patients and visitors should wear cloth or surgical masks at all times unless not feasible during the procedure.^2,3

For staff, establish distancing between workstations and limit interactions. Dividing the staff into dedicated teams per area may be helpful. Non-COVID-care zones can be established, if feasible, to further reduce the risk of transmission. Staff in this zone should not cross over into COVID-19 areas. All staff members should be routinely screened for COVID-19 symptoms and, if positive, appropriately quarantined and tested. Additionally, staff should wear surgical face masks at all times and consistently practice proper hand hygiene.

COVID-19-RELATED CONSIDERATIONS IN PROCEDURAL SEDATION

The risk of viral transmission during procedures can be significantly reduced with planning and implementing recommended interventions (Figure 2).^3,4 However, procedural sedation may present unique challenges to risk reduction, such as the need to provide high-flow oxygen supplementation via nasal cannula or face mask, repetitive coughing, patient disinhibition, or unforeseen complications. The dis persion distance of exhaled air is a function of the oxygen flow rate through the nasal cannula and can reach up to 1 meter at flow rates of 5 L/min. Dispersion distance from a leaky noninvasive ventilation full face mask can be even further and is a function of the amount of positive pressure used to achieve adequate ventilation.¹³

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Figure 2

Intervention for safe procedural sedation during COVID-19 pandemic.

To minimize the need for supplemental oxygen and the risk of aerosolization, practitioners should evaluate patients for the opportunity to reduce the dose requirement of systemic sedatives (benzodiazepines) and opioid analgesics. This may be achieved with multimodal analgesia and opioid-sparing strategies, which have been used successfully in the perioperative setting.¹⁴

When clinically appropriate, patients should be given nonopioid analgesia pre- and post-procedure, including acetaminophen and nonsteroidal anti-inflammatory medications. Nonopioid analgesics have been shown to reduce postoperative opioid requirements in opioid-naive patients while providing acceptable pain control and high patient satisfaction.¹³ Local anesthetics such as lidocaine can be subcutaneously administered or applied topically to mucous membranes to provide analgesia to decrease the need for systemic opioid.

Efforts should be made to alleviate fears and anxiety during the preoperative visit, through discussion and reassurance. Other non-pharmacologic sedative-sparing interventions prior to procedures could be beneficial for anxiety relief, including music therapy, aromatherapy, massage, or other relaxation techniques.^15,16

ALTERNATIVE APPROACHES TO PROCEDURAL SEDATION

Certain circumstances may warrant careful consideration of whether procedural sedation is the best approach due to risk of droplet or aerosol contamination. Patients who are already on home oxygen therapy or those who require preoperative oxygen may require above average oxygen flows via nasal cannula or face mask during their procedural sedation. Some procedures (eg, repetitive, painful, or complex) may require sedation levels that will necessitate above-minimal supplemental oxygen (2-3 L/min). Certain patient factors may require increased oxygen flow or airway manipulation, such as significant comorbidities, a physical exam that suggests a difficult airway, or a history of high-sedation requirements or failed sedation procedures. In such cases, consultation with an anesthesiologist and scheduling the procedure under general anesthesia could be a reasonable alternative.

PROCEDURAL SEDATION FOR COVID-19 POSITIVE PATIENTS

For time-sensitive or urgent procedures in patients who are COVID-19 positive or for patients who do not meet CDC criteria for discontinuation of transmission-based precautions, their procedures should be performed without delay. There are recommendations for reducing the transmission risk.^2–4 Patients with COVID-19 should wear a mask at all times and be isolated from other patients, visitors, and non-COVID care zones. To reduce the risk of cross-contamination, have designated COVID-only care areas and healthcare teams, if feasible.² Personal protective equipment, including gowns, eye protection, and fitted N95 masks or powered air-purifier respirator, should be used by all team members.

The procedure area should be prepared in advance by limiting exposure of supplies and equipment. This can be achieved by placing only the necessary supplies, equipment, and medications in the room and by keeping all storage cabinets and doors closed during the procedure. Use plastic sheets to cover items that cannot be stored away and dispose them after the case. After the procedure, the room should be thoroughly (ie, terminally) cleaned and equipment disinfected. Allow adequate time between cases for droplets and aerosols to settle or be eliminated by air turnover.

Considerations should be given to the most appropriate healthcare setting for performing procedures in COVID-19 positive patients. Specifically, for patients at risk of sudden clinical deterioration requiring escalation of care or emergency intervention, including intubation and mechanical ventilation, appropriate support and inpatient resources should be immediately available.