IJCS | Volume 33, Nº3, May / June 2020

292 COVID-19 SAFETY RECOMMENDATIONS FOR CCL PROCEDURES Ergonomics 9 Tailor the workplace: layout, position of the devices, room temperature (to prevent work-related osteomuscular disorders and repetitive strain injury). 9 Maintain correct body posture, use keyboards properly and maintain screen at eye level; refine the use of hands during injections, in managing the manifold, guidewires and catheters; stretch and relax at regular intervals. Personal protective equipment 9 The apron’s size, model and cover area should be tailored, as should its length of use and its donning, dofng and storing, to prevent cracks that hinder its effectiveness. 9 “Zero Gravity” lead apron – suspended radiation protection system for the body and head that allows freedom of movement (alternative to the conventional lead apron). 9 Use of individual dosimeters, goggles for X-ray radiation protection, thyroid lead collars, non-slip closed shoes, impermeable aprons, shoe covers, cap, face mask, and hand gloves to avoid contact with biological agents (blood, secretions). 9 Robot-assisted intervention provides protection against radiation and better ergonomics to the physician (CorPath Robotic System). Case Review 9 CCL team meetings, which are useful and effective tools to assess and solve CCL events, should be conducted virtually during the COVID-19 pandemic. Equipment 9 Power generator to support occasional drop in energy supply. 9 The equipment should be tested daily before initiating the procedures (defibrillator, monitors, image generation and storage). 9 Procedure room with suitable dimensions and well-placed equipment, allowing better flow of workers and patients, avoiding impact accidents and orthopedic lesions of healthcare professionals. 9 Avoid accidents with piercing-cutting materials by discarding them in a specific waste container; at the end of the procedure, their amount should be checked with the professional who prepared the table. Chemical and biological hazards 9 Optimized plant regarding air quality. 9 Automated hand washing sites close to the procedure room. 9 Keep to a minimum the circulation in the procedure room, which should remain closed. 9 Prefer disposable materials and correctly reprocess the reusable ones. 9 Routine antibiotic prophylaxis is not recommended, except for specific procedures. 9 SARS-CoV-2, a single-strand RNA virus, is sensitive to ultraviolet radiation and heat, being inactivated by lipid solvents, such as ether (75%), ethanol, sanitizers containing chlorine, peroxyacetic acid and chloroform, except for chlorhexidine. 9 Terminal disinfection should be performed at the end of each procedure. 9 Disposable PPE, sheets, fabric, and sponges contaminated with blood should be placed into a waste container marked with the biological hazard symbol and disposed into a waste bin labeled as ‘COVID-19’. Ionizing radiation 9 Adhere to CCL safety rules: protection against radiation in the walls, doors, and control cabin; transparent lead screen; CCL table with lead protection to arms and legs (skirt) and lead screen attached to ceiling; light and sound radiation warnings. Professionals should keep the largest possible distance from the radiation source. 9 Keep radiation as low as reasonably achievable (ALARA). 9 Minimize fluoroscopy time and use low- dose fluoroscopy. 9 Limit frame rate (15 to 7.5 fps) 9 Minimize the use of magnifications; use filters and radiation field collimation; use image already acquired as reference in an additional screen; and limit cineangiography. 9 Adjust table height and image intensifier/ flat-panel detector close to the patient. 9 Avoid wide angulations in image acquisition. 9 Minimize the time of X-ray emission and check the monitor for radiation dose. 9 Perform preventive maintenance of the equipment in accordance with the International Commission on Radiological Protection guidelines. 9 Intravascular ultrasound (IVUS) and optical coherence tomography (OCT/ OFDI) reduce the radiation doses and contrast amount used in long procedures; contrast-free techniques are available. 9 Pregnant patients should only be exposed in case of extreme need, such as acute myocardial infarction, with lead shielding on the abdominal and pelvic regions. 9 Pregnant healthcare workers should wear double lead apron, according to each region’s legislation. Figure 2 – General safety items for cardiac catheterization laboratory (CCL) procedures during the COVID-19 pandemic. The recommendations written in bold letters apply to the COVID-19 pandemic. 3-5,7,8,10-13-28 extraordinarymeasures. It is essential to revisit the different aspects of protection forpatients andhealthcarepersonnel in the CCL, as well as to tailor them to the COVID-19 scenario. Healthsystemsaroundtheworldhavebeenoverwhelmed for months. However, unlike ventilators and wards, healthcare personnel cannot be ‘manufactured’ urgently, mainlyhighly specializedprofessionals, suchasCCL staff. 32 All activities performed in CCL rooms need to be restructured, and registries should be kept to quantify the effects of COVID-19 on the treatment of patients with cardiovascular diseases. In doing so, we will be able to learn from this pandemic and thereby both add value to this field and contribute to a rapidly growing body of knowledge on COVID-19. Mariano et al. Covid-19 and safety in the cath lab Int J Cardiovasc Sci. 2020; 33(3):288-294 Viewpoint