Jun 10th 2020

Resuscitation of the COVID-19 Patient in or en Route to the Cath Lab

Occupational Health

By: Huu Tam Truong, MD, FSCAI, Jason Bartos, MD, PhD, FSCAI, Karl B. Kern, MD, FSCAI
Contributors: Jay Bagai, MD, FSCAI; Faisal Latif, MD, FSCAI; Rajesh V. Swaminathan, MD, FSCAI

Introduction

Patients with COVID-19 and underlying cardiovascular disease have increased risk for cardiac arrest and death.1 Many of these patients will need cardiovascular procedures, and the interventional cardiology team should be prepared to perform resuscitation. This Tip of the Month focuses on streamlining the resuscitation process of COVID-19 patients in or en route to the cardiac catheterization laboratory (CCL).

I. Identifying Patients for Whom Cardiopulmonary Resuscitation (CPR) Would Be Medically Inappropriate

The outcomes of cardiac arrest in COVID-19 patients are poor with 30-day survival as low as 3 percent2. Thus, it is imperative that detailed goals of care discussions are performed with these patients and their family members—ideally, prior to the development of severe illness.

II. Strategies to Reduce the Number of Health Care Workers (HCWs) Exposed

A. Minimize the number of personnel in the CCL.
Unless critical to the procedure or resuscitation effort, nonessential personnel should stay outside the CCL.

B. Wear wireless communication headsets if available.
Wearing wireless communication headsets will provide clear communication with closed doors to the procedure room and will minimize exposure to personnel in the control room.

C. Use a mechanical chest compression device (MCD).
A preclinical study evaluating the use of MCDs, specifically in the CCL, demonstrated superior survival with improved neurologic recovery compared with manual compressions.3 Consider MCD use in the COVID-19 patient, if available, to reduce infection and radiation exposure while maintaining compressions throughout the procedure (Figures 1 and 2).

D. Identify a “COVID-19 Lab” and stock it with common equipment.
This reduces the need to call for equipment stored outside the CCL, and minimizes the number of times the CCL door is opened, even during resuscitation.

III. Strategies to Minimize Risks to Personnel Involved  

A. Manage airways.
Performing CPR is an aerosol-generating procedure, and specific guidance on airway management is provided by a recent multisociety statement.4 Consideration should be made to electively intubate borderline patients in a negative-pressure room prior to arrival to the CCL to avoid emergent intubation.Place exhalation valves as close to the patient as possible, to minimize uncontrolled escape of exhaled gases if tubing becomes detached or must be connected to a different ventilator in the cath lab.

B. Wear full personal protective equipment (PPE).
Wearing PPE, including N95 masks or powered air-purifying respirators (PAPRs), gowns, caps, shoe covers, and gloves is recommended for all personnel involved during the resuscitation effort. Donning and doffing procedures for the CCL have been reported in a recent Tip of the Month.

C. Perform extracorporeal cardiopulmonary resuscitation (ECPR).
The outcomes of ECPR for COVID-19 patients remain unknown but may be considered in experienced centers with careful patient selection.  The best outcomes for ECPR prior to COVID-19 pandemic were in patients with cardiac arrest of presumed cardiac cause6. ECPR allows for cessation of CPR, which may reduce aerosol risks and provide the interventionalist the opportunity to revascularize severe coronary disease.

Summary

CPR is a high-stress procedure that is heightened during the COVID-19 pandemic due to the additional concerns of exposure of HCWs and contamination of workspaces. It is imperative to establish a COVID-19 CCL protocol with considerations for cardiac arrest to provide effective resuscitation while protecting HCWs.

References

  1. Guo T, Fan Y, Chen M, et al. Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19). JAMA Cardiol. 2020 Mar 27;e201017.
  2. Shao F, Xu S, Ma X, et al. In-hospital Cardiac Arrest Outcomes Among Patients With COVID-19 Pneumonia in Wuhan, China. Resuscitation. 2020 Jun;151:18‐23 [published online ahead of print, 2020 Apr 10].
  3. Lotun K, Truong HT, Cha K-C, et al. Cardiac Arrest in the Cardiac Catheterization Laboratory: Combining Mechanical Chest Compressions and Percutaneous LV Assistance. JACC Cardiovasc Interv. 2019 Sep 23;12(18):1840-1849.
  4. Edelson DP, Sasson C, Chan PS, et al. Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19Circulation. 2020 Apr 9 [published online ahead of print, 2020 Apr 9].
  5. Mahmud E, Dauerman HL, Welt FG, et al. Management of Acute Myocardial Infarction During the COVID-19 Pandemic. J Am Coll Cardiol. 2020 Apr 21;S0375-1097(20)35026-9.
  6. Bartos JA, Grunau B, Carlson C, et al. Improved Survival With Extracorporeal Cardiopulmonary Resuscitation Despite Progressive Metabolic Derangement Associated With Prolonged Resuscitation. Circulation. 2020 Mar 17;141(11):877-886.

 

Figure 1. Undesirable direct radiation exposure during manual compression in the cath lab. Aerosol exposure to the rescuer is also expected during resuscitation of a COVID-19 patient.

 

Figure 2. Angiogram performed during active mechanical chest compression.

 

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