March 27, 2020

SIR Issues Clinical Notification on Aerosol-Generating Procedures

March 27, 2020—The Society of Interventional Radiology (SIR) has issued a clinical notification to provide medical decision-making guidance on how to perform aerosol-generating procedures (AGP) safely in the interventional radiology suite.

SIR advised that emerging data indicates that COVID-19 is primarily spread via respiratory droplets produced when an infected person coughs or sneezes and has a “significant association with AGPs.”

The notification, online here, stated that health care workers may be exposed to these particles through the inhalation of droplets, conjunctival/mucosal contact, and touch contamination when:

  • Performing AGPs, which are defined as procedures that mechanically create and disperse aerosols. These procedures include those involving the respiratory tract or those that may irritate the airway causing a patient to cough or those that involve the use of high-speed devices that may aerosolize pathogens (ie, bone saw).
  • Performing procedures on patients who are receiving noninvasive ventilation (bilevel positive airway pressure, continuous positive airway pressure, high-frequency oscillatory ventilation), manual ventilation, active suctioning, or cardiopulmonary resuscitation, all of which are associated with the mechanical dispersal of aerosols.

According to SIR, the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) first defined AGPs during its response to the Ebola crisis, taking into consideration the high mortality and morbidity of Ebola, the high risk of human-to-human transmission, and the lack of an FDA-approved therapeutic or vaccine as reasoning to justify the expansion of respiratory protection recommendations.

The notification provides a table listing AGPs commonly performed in the interventional radiology suite. The CDC and WHO have acknowledged that the AGP procedure list may not be complete.

Therefore, stated the SIR notification, there is a need to expand the AGP procedure list beyond what is currently listed by the CDC and WHO to ensure that respiratory protection and other required personal protective equipment (PPE) are available for and allocated to health care workers performing AGPs or any procedure in a patient receiving ventilatory support associated with the possible mechanical dispersal of aerosols. In consideration of the current COVID-19 pandemic, any procedure that is “likely to induce coughing should be performed cautiously and avoided if possible.”

Following CDC guidance, the SIR strongly advocates for and recommends the use of appropriate PPE for interventional radiology when:

  • Performing any AGP (ie, any procedure that is likely to induce coughing)
  • Caring for patients who are at risk for the mechanical dispersal of aerosols in the interventional radiology suite
  • During cardiopulmonary resuscitative efforts

Appropriate PPE in these situations is defined as N95 or higher level respirator, eye protection (face shield with appropriate coverage and/or goggles), gloves, and a disposable, waterproof, surgical gown. In addition, it is recommended that N95 or higher level respirators be routinely stocked in the interventional radiology suite crash carts for code situations.

SIR recognizes the ongoing nationwide shortages of appropriate PPE and in the document proposes a triage mechanism for resource allocation for AGPs. In such a triage situation, the availability of proper PPE to interventional radiologists should be commensurate with availability to other providers of care to patients at high risk for dispersal of respiratory aerosols, stated SIR.


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