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Guidance for Image-Guided Procedures and Diagnostic Imaging under Anesthesia During the COVID-19 PandemicLast Updated: 4/24/20Background: This document provides guidance for the management of patients and facilities during image-guided interventions and diagnostic imaging performed under anesthesia in the Department of Radiology and Biomedical Imaging. This document updates previously published interim guidance on the same topic. The interim guidance was created in the context of a new UCSF Anesthesia and Perioperative Care policy approved on March 26, 2020. The goal of this guidance is to align our practice with UCSF Health practice and national standards.Several important concepts underpin the anesthesia and radiology guidelines. These include: 1) asymptomatic patients may be sources of SARS-CoV-2 disease transmission, 2) disease transmission may occur by aerosol inhalation in addition to droplet spread, 3) certain surgeries and procedures carry higher risk than others for disease transmission to healthcare workers due to aerosolization of virus, and 4) intubation, extubation, and certain forms of respiratory support are aerosol-generating. Key changes incorporated into this update include:Incorporation of COVID-19 test results: Based on current estimates of COVID-19 prevalence among asymptomatic patients in San Francisco and surrounding areas and the performance of the UCSF RT-PCR test, the likelihood is very high that a patient with a negative test result does not have COVID-19 infection (~99.7% negative predictive value) (see Appendix A). Pre-procedural testing has begun for all patients undergoing anesthesia and for selected patients undergoing image-guided interventions under local anesthetic or conscious sedation. Pre-visit testing is expected to expand in coming weeks.Incorporation of site-specific air exchange into room downtime guidance: At the time of interim guidance publication, air exchange data was not available for the majority of imaging suites. These data are now available (see Appendix B).Incorporation of changes in the UCSF Anesthesia and Perioperative Guidance: An updated guidance document was published on 4/21/20. This document reflects these changes while providing additional information to allow this policy to be operationalized in the Department of Radiology and Biomedical Imaging.Definitions: High-Risk Surgeries: Any procedures on the airway, throat, mouth or sinuses (bronchoscopy, tracheostomy, glossectomy, laryngoscopy procedure…etc) Endoscopy, Transesophageal echocardiography, Electroconvulsive therapySurgery under regional anesthetic with high likelihood of requiring GAActive CPRThoracic surgery/proceduresSee Appendix C for Society of Interventional Radiology list of procedures performed by radiologists that should be considered aerosol-generatingSymptomatic or High-Risk Patient:Any of the following new acute symptoms:Fever (objective or subjective)MyalgiasRespiratory symptoms (dyspnea or cough)URI symptoms (headache, rhinorrhea, sore throat)GI symptoms (diarrhea, nausea, vomiting)ENT symptoms (loss of taste or smell)Eye symptoms (conjunctivitis)Other clinical concern for COVID-19 Chest imaging findings suggestive of COVID-19 (bilateral, ground glass, peripheral distribution)Sustained close contact (e.g. household contact) with a known case of COVID-19Unable to provide history and no collateral regarding symptoms availableNewborns born to mothers with known COVID-19Asymptomatic patient:Meets none of the Symptomatic or High-Risk patient criteriaGuidance: Tables 1-4 summarize recommended personal protective equipment (PPE) use and imaging suite management for each scenario in adult and pediatric patients. Please continue to follow UCSF Health guidelines for safe re-use of PPE. For any individual case, critical information to know when consulting these tables:COVID-19 testing status and resultsCategory of image-guided intervention (High Risk = aerosol-generating procedure (AGP))Anesthetic plan For procedures or imaging under general anesthesia, whether the patient will be intubated and extubated in the imaging suite or elsewhere and then transported to/from the imaging suiteAdditional operational details:At Parnassus, Fluoroscopy Rooms 5 and 6 (M345 and M347, respectively) have been outfitted as independent negative pressure suites. Whenever possible, these suites should be used for intubation and extubation of patients undergoing general anesthesia for diagnostic imaging or intervention in CT or body interventional radiology, provided a negative COVID-19 test is not available within the last 4 days. At Mission Bay, the MRI induction room (C1755) has very fast air exchange. Whenever possible, asymptomatic pediatric patients without a negative COVID-19 RT-PCR test within the last 4 days should enter and emerge from anesthesia in this room and be transported to and from imaging suite on the 1st floor of Mission Bay Hospital (Table 4, Scenario 2b). This applies only to diagnostic imaging under anesthesia in pediatric patients. Pediatric patients undergoing interventional radiology and neurointerventional radiology procedures should be anesthetized in the interventional suites on the 2nd floor of Mission Bay Hospital. For all pediatric cases under anesthesia on the 1st and 2nd floors: Pediatric anesthesiologists may elect to use manage the airway with an endotracheal tube or a laryngeal mask airway (LMA). Alternatively spontaneous mask ventilation or simple nasal cannula may be used. General rules (see also Table 4): Intubation with placement and removal of an endotracheal (ET) tube will always be considered aerosol-generating. LMA placement and removal will usually not be aerosol-generating, however these may be aerosol-generating under certain conditions that cannot be predicted prior to placement/removal. Therefore airborne PPE should be used by any providers present in the room where LMA placement and removal occurs. Pediatric anesthesia staff will make a determination in every case to guide room management and PPE use for providers not present during placement and removal.Spontaneous mask ventilation or simple nasal cannula will not be considered aerosol-generating. Minimize opening doors whenever an aerosol-generating procedure is underway. When caring for asymptomatic patients in whom a recent COVID-19 test is NOT available, providers and patients may quickly exit the imaging suites during the imaging suite downtime. When doing so they should minimize the time that the door is open in order to prevent possible contamination of adjacent airspaces.Room-specific downtimes are posted inside of every room where an aerosol-generating procedure might occur in the department. Imaging suites should be marked on outside doors with signs indicating that an aerosol-generating procedure is underway. The start time for room downtime is the time that the last aerosol-generating procedure occurs in the room. If this is not indicated by the proceduralist team and/or the anesthesia team, then this should begin upon patient departure. See Appendix D for sign templates currently in use.Table 1: PPE And Radiology Guidance for ADULT PATIENTS with COVID-19 test results within last 4 days Scenario Anesthesia PPERadiology Personnel PPERoom Management Room Cleaning1. COVID-19 Positive/PUI for ANY image-guided intervention (diagnostic imaging will continue to follow existing guidelines)Reusable N95 + face shield/goggles or PAPR GownDouble GlovesReusable N95 + face shield/goggles or PAPRGownDouble GlovesMinimize number of providers presentNo radiology trainees presentLast case of day preferableRoom downtime 1 hour after patient departureTechnologist cleans equipment 1 hour after patient departureTerminal clean2. COVID-19 test negative within last 4 days, any procedureStandard PPEStandard procedural PPENo room downtime requiredRoutine cleaning upon patient departureTable 2: PPE And Radiology Guidance for ADULT PATIENTS without COVID-19 test results within last 4 days Scenario Anesthesia PPERadiology Personnel PPERoom Management Room Cleaning1. Asymptomatic patient for HIGH RISK procedure (aerosol-generating procedure (AGP)) under local anesthetic, conscious sedation, or general anesthesiaReusable N95 + face shield/goggles or PAPRGownDouble GlovesReusable N95 + face shield/goggles or PAPR GownDouble GlovesNon-anesthesia personnel should leave room for intubation and extubationMinimize number of providers presentRoom-specific downtime after last AGP, per signs in room and Appendix BRoutine cleaning after downtime complete2a. Asymptomatic patient for LOW RISK procedure (non-aerosol-generating) or diagnostic imaging under general anesthesia, intubation/extubation take place in imaging suiteReusable N95 + face shield/goggles or PAPRGownDouble GlovesFor rooms with 15 minute downtime, enter after 15 minutes with standard PPEFor all other rooms, enter after intubation with:Reusable N95 + face shield/goggles or PAPR GownDouble GlovesNon-anesthesia personnel should leave room for intubation and extubationRoom-specific downtime after last AGP, per signs in room and Appendix BRoutine cleaning after downtime complete2b. Asymptomatic patient for LOW RISK procedure (non-aerosol-generating) or diagnostic imaging under general anesthesia, intubation/extubation take place elsewhere and patient is transported to/from imaging suiteReusable N95 + face shield/goggles or PAPRGownDouble GlovesStandard procedural PPENo room downtime requiredRoutine cleaning after patient departure3. Asymptomatic patient for LOW RISK (non-aerosol-generating) procedure under local anesthetic, conscious sedation, or monitored anesthesia careStandard procedural PPEStandard procedural PPEConscious sedation/MAC: if airway rescue is necessary, support patient and transition to #2a PPE instructionNo room downtime requiredRoutine cleaning after patient departureTable 3: PPE And Radiology Guidance for PEDIATRIC PATIENTS with COVID-19 test results within last 4 days at BCHSFScenario Anesthesia PPERadiology Personnel PPERoom Management Room Cleaning1. COVID-19 Positive/PUI for ANY image-guided intervention (diagnostic imaging will continue to follow existing guidelines)Reusable N95 + face shield/goggles or PAPR GownDouble GlovesReusable N95 + face shield/goggles or PAPRGownDouble GlovesMinimize number of providers presentNo radiology trainees to be presentLast case of day preferableRoom downtime 1 hour after patient departureTechnologist cleans equipment 1 hour after patient departureTerminal clean2. COVID-19 test negative within last 4 days, any procedureStandard PPEStandard procedural PPENo room downtime requiredRoutine cleaning upon patient departureTable 4: PPE And Radiology Guidance for PEDIATRIC PATIENTS without COVID-19 test results within last 4 days at BCHSFScenario Anesthesia PPERadiology Personnel PPERoom Management Room Cleaning1. Asymptomatic patient for HIGH RISK procedure (aerosol-generating*) under local anesthetic, conscious sedation, or general anesthesiaReusable N95 + face shield/goggles or PAPRGownDouble GlovesReusable N95 + face shield/goggles or PAPR GownDouble GlovesNon-anesthesia personnel should leave room for intubation and extubationMinimize number of providers presentRoom-specific downtime after last AGP, per signs in room and Appendix BRoutine cleaning after downtime complete2a. Asymptomatic patient for LOW RISK procedure (non-aerosol-generating) or diagnostic imaging involving general anesthesia, induction and emergence take place in imaging suiteReusable N95 + face shield/goggles or PAPRGownDouble GlovesET tube used, room downtime = 15 minutes: enter 15 minutes after intubation with standard PPEET tube used, room downtime ≧ 30 minutes: Reusable N95 + face shield/goggles or PAPR GownDouble GlovesSome forms of anesthesia will not be aerosol-generating. Follow anesthesia provider instructions for safe timing of entry in standard PPENon-anesthesia personnel should leave room for intubation/ extubationRoom-specific downtime after last AGP, per signs in room and Appendix BIf anesthesia provider does not place endotracheal tube and confirms absence of aerosol generation, no room downtime requiredRoutine cleaning after downtime complete2b. Asymptomatic patient for LOW RISK procedure (non-aerosol-generating) or diagnostic imaging involving general anesthesia, induction and emergence from anesthesia take place elsewhere and patient is transported to/from imaging suiteReusable N95 + face shield/goggles or PAPRGownDouble GlovesStandard procedural PPENo room downtime requiredRoutine cleaning after patient departureAppendix A: Performance of the COVID-19 RT-PCR testCOVID-19 Diagnostic Testing in Perioperative Setting:Reverse transcriptase PCR (RT-PCR) testing for COVID-19 detects RNA from SARS-Coronavirus-2 and is the primary test used for diagnosis of acute infection. Analytical sensitivity of PCR testing is very high at >98% ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"QmmxLbCV","properties":{"formattedCitation":"\\super 1\\nosupersub{}","plainCitation":"1","noteIndex":0},"citationItems":[{"id":2086,"uris":[""],"uri":[""],"itemData":{"id":2086,"type":"article-journal","container-title":"Clinical Microbiology Reviews","DOI":"10.1128/CMR.00037-07","ISSN":"0893-8512, 1098-6618","issue":"4","language":"en","page":"716-747","source":"Crossref","title":"Detection of Respiratory Viruses by Molecular Methods","volume":"21","author":[{"family":"Mahony","given":"James B."}],"issued":{"date-parts":[["2008",10]]}}}],"schema":""} 1. Clinical sensitivity of RT-PCR varies by site of sampling, likely due to variation in quality of sampling technique, time of sampling with respect to disease course (viral titers are highest early in infection ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"uBh9zJD5","properties":{"formattedCitation":"\\super 2\\nosupersub{}","plainCitation":"2","noteIndex":0},"citationItems":[{"id":2051,"uris":[""],"uri":[""],"itemData":{"id":2051,"type":"report","abstract":"Background: The outbreak of novel coronavirus pneumonia (NCP) caused by 2019-nCoV spread rapidly, and elucidation the diagnostic accuracy of different respiratory specimens is crucial for the control and treatment of this diseases. \nMethods: Respiratory samples including nasal swabs, throat swabs, sputum and bronchoalveolar lavage fluid (BALF) were collected from Guangdong CDC confirmed NCP patients, and viral RNAs were detected using a CFDA approved detection kit. Results were analyzed in combination with sample collection date and clinical information. \nFinding: Except for BALF, the sputum possessed the highest positive rate (74.4%~88.9%), followed by nasal swabs (53.6%~73.3%) for both severe and mild cases during the first 14 days after illness onset (d.a.o). For samples collected ≥ 15 d.a.o, sputum and nasal swabs still possessed a high positive rate ranging from 42.9%~61.1%. The positive rate of throat swabs collected ≥ 8 d.a.o was low, especially in samples from mild cases. Viral RNAs could be detected in all the lower respiratory tract of severe cases, but not the mild cases. CT scan of cases 02, 07 and 13 showed typical viral pneumonia with ground glass opacity, while no viral RNAs were detected in first three or all the upper respiratory samples. \nInterpretation: Sputum is most accurate for laboratory diagnosis of NCP, followed by nasal swabs. Detection of viral RNAs in BLAF is necessary for diagnosis and monitoring of viruses in severe cases. CT scan could serve as an important make up for the diagnosis of NCP. \nFunding National Science and Technology Major Project, Sanming Project of Medicine and China Postdoctoral Science Foundation.","genre":"preprint","language":"en","note":"DOI: 10.1101/2020.02.11.20021493","publisher":"Infectious Diseases (except HIV/AIDS)","source":" (Crossref)","title":"Evaluating the accuracy of different respiratory specimens in the laboratory diagnosis and monitoring the viral shedding of 2019-nCoV infections","URL":"","author":[{"family":"Yang","given":"Yang"},{"family":"Yang","given":"Minghui"},{"family":"Shen","given":"Chenguang"},{"family":"Wang","given":"Fuxiang"},{"family":"Yuan","given":"Jing"},{"family":"Li","given":"Jinxiu"},{"family":"Zhang","given":"Mingxia"},{"family":"Wang","given":"Zhaoqin"},{"family":"Xing","given":"Li"},{"family":"Wei","given":"Jinli"},{"family":"Peng","given":"Ling"},{"family":"Wong","given":"Gary"},{"family":"Zheng","given":"Haixia"},{"family":"Liao","given":"Mingfeng"},{"family":"Feng","given":"Kai"},{"family":"Li","given":"Jianming"},{"family":"Yang","given":"Qianting"},{"family":"Zhao","given":"Juanjuan"},{"family":"Zhang","given":"Zheng"},{"family":"Liu","given":"Lei"},{"family":"Liu","given":"Yingxia"}],"accessed":{"date-parts":[["2020",3,27]]},"issued":{"date-parts":[["2020",2,12]]}}}],"schema":""} 2), and variation in the distribution of virus in the lower versus upper respiratory tract. Our understanding of clinical sensitivity of RT-PCR is based on a) prior studies using RT-PCR to detect respiratory viruses, and b) limited data on SARS-CoV-2 ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"giTi0VQ8","properties":{"formattedCitation":"\\super 2,3\\nosupersub{}","plainCitation":"2,3","noteIndex":0},"citationItems":[{"id":2051,"uris":[""],"uri":[""],"itemData":{"id":2051,"type":"report","abstract":"Background: The outbreak of novel coronavirus pneumonia (NCP) caused by 2019-nCoV spread rapidly, and elucidation the diagnostic accuracy of different respiratory specimens is crucial for the control and treatment of this diseases. \nMethods: Respiratory samples including nasal swabs, throat swabs, sputum and bronchoalveolar lavage fluid (BALF) were collected from Guangdong CDC confirmed NCP patients, and viral RNAs were detected using a CFDA approved detection kit. Results were analyzed in combination with sample collection date and clinical information. \nFinding: Except for BALF, the sputum possessed the highest positive rate (74.4%~88.9%), followed by nasal swabs (53.6%~73.3%) for both severe and mild cases during the first 14 days after illness onset (d.a.o). For samples collected ≥ 15 d.a.o, sputum and nasal swabs still possessed a high positive rate ranging from 42.9%~61.1%. The positive rate of throat swabs collected ≥ 8 d.a.o was low, especially in samples from mild cases. Viral RNAs could be detected in all the lower respiratory tract of severe cases, but not the mild cases. CT scan of cases 02, 07 and 13 showed typical viral pneumonia with ground glass opacity, while no viral RNAs were detected in first three or all the upper respiratory samples. \nInterpretation: Sputum is most accurate for laboratory diagnosis of NCP, followed by nasal swabs. Detection of viral RNAs in BLAF is necessary for diagnosis and monitoring of viruses in severe cases. CT scan could serve as an important make up for the diagnosis of NCP. \nFunding National Science and Technology Major Project, Sanming Project of Medicine and China Postdoctoral Science Foundation.","genre":"preprint","language":"en","note":"DOI: 10.1101/2020.02.11.20021493","publisher":"Infectious Diseases (except HIV/AIDS)","source":" (Crossref)","title":"Evaluating the accuracy of different respiratory specimens in the laboratory diagnosis and monitoring the viral shedding of 2019-nCoV infections","URL":"","author":[{"family":"Yang","given":"Yang"},{"family":"Yang","given":"Minghui"},{"family":"Shen","given":"Chenguang"},{"family":"Wang","given":"Fuxiang"},{"family":"Yuan","given":"Jing"},{"family":"Li","given":"Jinxiu"},{"family":"Zhang","given":"Mingxia"},{"family":"Wang","given":"Zhaoqin"},{"family":"Xing","given":"Li"},{"family":"Wei","given":"Jinli"},{"family":"Peng","given":"Ling"},{"family":"Wong","given":"Gary"},{"family":"Zheng","given":"Haixia"},{"family":"Liao","given":"Mingfeng"},{"family":"Feng","given":"Kai"},{"family":"Li","given":"Jianming"},{"family":"Yang","given":"Qianting"},{"family":"Zhao","given":"Juanjuan"},{"family":"Zhang","given":"Zheng"},{"family":"Liu","given":"Lei"},{"family":"Liu","given":"Yingxia"}],"accessed":{"date-parts":[["2020",3,27]]},"issued":{"date-parts":[["2020",2,12]]}}},{"id":2053,"uris":[""],"uri":[""],"itemData":{"id":2053,"type":"article-journal","container-title":"JAMA","DOI":"10.1001/jama.2020.3786","ISSN":"1538-3598","journalAbbreviation":"JAMA","language":"eng","note":"PMID: 32159775\nPMCID: PMC7066521","source":"PubMed","title":"Detection of SARS-CoV-2 in Different Types of Clinical Specimens","author":[{"family":"Wang","given":"Wenling"},{"family":"Xu","given":"Yanli"},{"family":"Gao","given":"Ruqin"},{"family":"Lu","given":"Roujian"},{"family":"Han","given":"Kai"},{"family":"Wu","given":"Guizhen"},{"family":"Tan","given":"Wenjie"}],"issued":{"date-parts":[["2020",3,11]]}}}],"schema":""} 2,3. Prior studies of respiratory viruses have found that sampling by nasopharyngeal (NP) swab may be more sensitive than oropharyngeal (OP) swab sampling, and that a combination of NP + OP may increase sensitivity, although variation by virus was observed ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"UCVi8DHI","properties":{"formattedCitation":"\\super 3\\uc0\\u8211{}5\\nosupersub{}","plainCitation":"3–5","noteIndex":0},"citationItems":[{"id":2053,"uris":[""],"uri":[""],"itemData":{"id":2053,"type":"article-journal","container-title":"JAMA","DOI":"10.1001/jama.2020.3786","ISSN":"1538-3598","journalAbbreviation":"JAMA","language":"eng","note":"PMID: 32159775\nPMCID: PMC7066521","source":"PubMed","title":"Detection of SARS-CoV-2 in Different Types of Clinical Specimens","author":[{"family":"Wang","given":"Wenling"},{"family":"Xu","given":"Yanli"},{"family":"Gao","given":"Ruqin"},{"family":"Lu","given":"Roujian"},{"family":"Han","given":"Kai"},{"family":"Wu","given":"Guizhen"},{"family":"Tan","given":"Wenjie"}],"issued":{"date-parts":[["2020",3,11]]}}},{"id":2049,"uris":[""],"uri":[""],"itemData":{"id":2049,"type":"article-journal","container-title":"Journal of Clinical Microbiology","DOI":"10.1128/JCM.00886-09","ISSN":"0095-1137","issue":"11","language":"en","page":"3439-3443","source":"Crossref","title":"Identification of Respiratory Viruses in Adults: Nasopharyngeal versus Oropharyngeal Sampling","title-short":"Identification of Respiratory Viruses in Adults","volume":"47","author":[{"family":"Lieberman","given":"D."},{"family":"Lieberman","given":"D."},{"family":"Shimoni","given":"A."},{"family":"Keren-Naus","given":"A."},{"family":"Steinberg","given":"R."},{"family":"Shemer-Avni","given":"Y."}],"issued":{"date-parts":[["2009",11,1]]}}},{"id":2081,"uris":[""],"uri":[""],"itemData":{"id":2081,"type":"article-journal","container-title":"Journal of Clinical Microbiology","DOI":"10.1128/JCM.00027-19","ISSN":"0095-1137, 1098-660X","issue":"9","language":"en","source":"Crossref","title":"Comparison of Respiratory Specimen Collection Methods for Detection of Influenza Virus Infection by Reverse Transcription-PCR: a Literature Review","title-short":"Comparison of Respiratory Specimen Collection Methods for Detection of Influenza Virus Infection by Reverse Transcription-PCR","URL":"","volume":"57","author":[{"family":"Spencer","given":"Sarah"},{"family":"Thompson","given":"Mark G."},{"family":"Flannery","given":"Brendan"},{"family":"Fry","given":"Alicia"}],"editor":[{"family":"Kraft","given":"Colleen Suzanne"}],"accessed":{"date-parts":[["2020",4,16]]},"issued":{"date-parts":[["2019",6,19]]}}}],"schema":""} 3–5. Two limited studies of SARS-CoV-2 have compared percent test positivity based on sampling site but were not done in a way that allowed accurate calculation of sensitivity. The larger study (213 patients, not-yet peer reviewed) found that test positivity in the first 14 days of symptom onset was higher in NP swabs (72%) versus OP swabs (61%) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"k6pkjzo7","properties":{"formattedCitation":"\\super 2\\nosupersub{}","plainCitation":"2","noteIndex":0},"citationItems":[{"id":2051,"uris":[""],"uri":[""],"itemData":{"id":2051,"type":"report","abstract":"Background: The outbreak of novel coronavirus pneumonia (NCP) caused by 2019-nCoV spread rapidly, and elucidation the diagnostic accuracy of different respiratory specimens is crucial for the control and treatment of this diseases. \nMethods: Respiratory samples including nasal swabs, throat swabs, sputum and bronchoalveolar lavage fluid (BALF) were collected from Guangdong CDC confirmed NCP patients, and viral RNAs were detected using a CFDA approved detection kit. Results were analyzed in combination with sample collection date and clinical information. \nFinding: Except for BALF, the sputum possessed the highest positive rate (74.4%~88.9%), followed by nasal swabs (53.6%~73.3%) for both severe and mild cases during the first 14 days after illness onset (d.a.o). For samples collected ≥ 15 d.a.o, sputum and nasal swabs still possessed a high positive rate ranging from 42.9%~61.1%. The positive rate of throat swabs collected ≥ 8 d.a.o was low, especially in samples from mild cases. Viral RNAs could be detected in all the lower respiratory tract of severe cases, but not the mild cases. CT scan of cases 02, 07 and 13 showed typical viral pneumonia with ground glass opacity, while no viral RNAs were detected in first three or all the upper respiratory samples. \nInterpretation: Sputum is most accurate for laboratory diagnosis of NCP, followed by nasal swabs. Detection of viral RNAs in BLAF is necessary for diagnosis and monitoring of viruses in severe cases. CT scan could serve as an important make up for the diagnosis of NCP. \nFunding National Science and Technology Major Project, Sanming Project of Medicine and China Postdoctoral Science Foundation.","genre":"preprint","language":"en","note":"DOI: 10.1101/2020.02.11.20021493","publisher":"Infectious Diseases (except HIV/AIDS)","source":" (Crossref)","title":"Evaluating the accuracy of different respiratory specimens in the laboratory diagnosis and monitoring the viral shedding of 2019-nCoV infections","URL":"","author":[{"family":"Yang","given":"Yang"},{"family":"Yang","given":"Minghui"},{"family":"Shen","given":"Chenguang"},{"family":"Wang","given":"Fuxiang"},{"family":"Yuan","given":"Jing"},{"family":"Li","given":"Jinxiu"},{"family":"Zhang","given":"Mingxia"},{"family":"Wang","given":"Zhaoqin"},{"family":"Xing","given":"Li"},{"family":"Wei","given":"Jinli"},{"family":"Peng","given":"Ling"},{"family":"Wong","given":"Gary"},{"family":"Zheng","given":"Haixia"},{"family":"Liao","given":"Mingfeng"},{"family":"Feng","given":"Kai"},{"family":"Li","given":"Jianming"},{"family":"Yang","given":"Qianting"},{"family":"Zhao","given":"Juanjuan"},{"family":"Zhang","given":"Zheng"},{"family":"Liu","given":"Lei"},{"family":"Liu","given":"Yingxia"}],"accessed":{"date-parts":[["2020",3,27]]},"issued":{"date-parts":[["2020",2,12]]}}}],"schema":""} 2. The smaller study (9 patients) found 100% test positivity during the first five days of symptoms and 46% test positivity after the first five days, independent of swab type ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"rg4t8kl7","properties":{"formattedCitation":"\\super 6\\nosupersub{}","plainCitation":"6","noteIndex":0},"citationItems":[{"id":2083,"uris":[""],"uri":[""],"itemData":{"id":2083,"type":"article-journal","container-title":"Nature","DOI":"10.1038/s41586-020-2196-x","ISSN":"0028-0836, 1476-4687","language":"en","source":"Crossref","title":"Virological assessment of hospitalized patients with COVID-2019","URL":"","author":[{"family":"W?lfel","given":"Roman"},{"family":"Corman","given":"Victor M."},{"family":"Guggemos","given":"Wolfgang"},{"family":"Seilmaier","given":"Michael"},{"family":"Zange","given":"Sabine"},{"family":"Müller","given":"Marcel A."},{"family":"Niemeyer","given":"Daniela"},{"family":"Jones","given":"Terry C."},{"family":"Vollmar","given":"Patrick"},{"family":"Rothe","given":"Camilla"},{"family":"Hoelscher","given":"Michael"},{"family":"Bleicker","given":"Tobias"},{"family":"Brünink","given":"Sebastian"},{"family":"Schneider","given":"Julia"},{"family":"Ehmann","given":"Rosina"},{"family":"Zwirglmaier","given":"Katrin"},{"family":"Drosten","given":"Christian"},{"family":"Wendtner","given":"Clemens"}],"accessed":{"date-parts":[["2020",4,17]]},"issued":{"date-parts":[["2020",4,1]]}}}],"schema":""} 6. Additional studies suggest that sputum and lower respiratory specimens (endotracheal aspirate) may have higher viral loads and thus possibly higher sensitivity when tested compared to the nasopharynx or oropharynx, especially earlier during disease course ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"xn0F6Pxb","properties":{"formattedCitation":"\\super 2,7,8\\nosupersub{}","plainCitation":"2,7,8","noteIndex":0},"citationItems":[{"id":2051,"uris":[""],"uri":[""],"itemData":{"id":2051,"type":"report","abstract":"Background: The outbreak of novel coronavirus pneumonia (NCP) caused by 2019-nCoV spread rapidly, and elucidation the diagnostic accuracy of different respiratory specimens is crucial for the control and treatment of this diseases. \nMethods: Respiratory samples including nasal swabs, throat swabs, sputum and bronchoalveolar lavage fluid (BALF) were collected from Guangdong CDC confirmed NCP patients, and viral RNAs were detected using a CFDA approved detection kit. Results were analyzed in combination with sample collection date and clinical information. \nFinding: Except for BALF, the sputum possessed the highest positive rate (74.4%~88.9%), followed by nasal swabs (53.6%~73.3%) for both severe and mild cases during the first 14 days after illness onset (d.a.o). For samples collected ≥ 15 d.a.o, sputum and nasal swabs still possessed a high positive rate ranging from 42.9%~61.1%. The positive rate of throat swabs collected ≥ 8 d.a.o was low, especially in samples from mild cases. Viral RNAs could be detected in all the lower respiratory tract of severe cases, but not the mild cases. CT scan of cases 02, 07 and 13 showed typical viral pneumonia with ground glass opacity, while no viral RNAs were detected in first three or all the upper respiratory samples. \nInterpretation: Sputum is most accurate for laboratory diagnosis of NCP, followed by nasal swabs. Detection of viral RNAs in BLAF is necessary for diagnosis and monitoring of viruses in severe cases. CT scan could serve as an important make up for the diagnosis of NCP. \nFunding National Science and Technology Major Project, Sanming Project of Medicine and China Postdoctoral Science Foundation.","genre":"preprint","language":"en","note":"DOI: 10.1101/2020.02.11.20021493","publisher":"Infectious Diseases (except HIV/AIDS)","source":" (Crossref)","title":"Evaluating the accuracy of different respiratory specimens in the laboratory diagnosis and monitoring the viral shedding of 2019-nCoV infections","URL":"","author":[{"family":"Yang","given":"Yang"},{"family":"Yang","given":"Minghui"},{"family":"Shen","given":"Chenguang"},{"family":"Wang","given":"Fuxiang"},{"family":"Yuan","given":"Jing"},{"family":"Li","given":"Jinxiu"},{"family":"Zhang","given":"Mingxia"},{"family":"Wang","given":"Zhaoqin"},{"family":"Xing","given":"Li"},{"family":"Wei","given":"Jinli"},{"family":"Peng","given":"Ling"},{"family":"Wong","given":"Gary"},{"family":"Zheng","given":"Haixia"},{"family":"Liao","given":"Mingfeng"},{"family":"Feng","given":"Kai"},{"family":"Li","given":"Jianming"},{"family":"Yang","given":"Qianting"},{"family":"Zhao","given":"Juanjuan"},{"family":"Zhang","given":"Zheng"},{"family":"Liu","given":"Lei"},{"family":"Liu","given":"Yingxia"}],"accessed":{"date-parts":[["2020",3,27]]},"issued":{"date-parts":[["2020",2,12]]}}},{"id":2056,"uris":[""],"uri":[""],"itemData":{"id":2056,"type":"article-journal","container-title":"The Lancet Infectious Diseases","DOI":"10.1016/S1473-3099(20)30196-1","ISSN":"14733099","language":"en","source":"Crossref","title":"Temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by SARS-CoV-2: an observational cohort study","title-short":"Temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by SARS-CoV-2","URL":"","author":[{"family":"To","given":"Kelvin Kai-Wang"},{"family":"Tsang","given":"Owen Tak-Yin"},{"family":"Leung","given":"Wai-Shing"},{"family":"Tam","given":"Anthony Raymond"},{"family":"Wu","given":"Tak-Chiu"},{"family":"Lung","given":"David Christopher"},{"family":"Yip","given":"Cyril Chik-Yan"},{"family":"Cai","given":"Jian-Piao"},{"family":"Chan","given":"Jacky Man-Chun"},{"family":"Chik","given":"Thomas Shiu-Hong"},{"family":"Lau","given":"Daphne Pui-Ling"},{"family":"Choi","given":"Chris Yau-Chung"},{"family":"Chen","given":"Lin-Lei"},{"family":"Chan","given":"Wan-Mui"},{"family":"Chan","given":"Kwok-Hung"},{"family":"Ip","given":"Jonathan Daniel"},{"family":"Ng","given":"Anthony Chin-Ki"},{"family":"Poon","given":"Rosana Wing-Shan"},{"family":"Luo","given":"Cui-Ting"},{"family":"Cheng","given":"Vincent Chi-Chung"},{"family":"Chan","given":"Jasper Fuk-Woo"},{"family":"Hung","given":"Ivan Fan-Ngai"},{"family":"Chen","given":"Zhiwei"},{"family":"Chen","given":"Honglin"},{"family":"Yuen","given":"Kwok-Yung"}],"accessed":{"date-parts":[["2020",3,27]]},"issued":{"date-parts":[["2020",3]]}}},{"id":2084,"uris":[""],"uri":[""],"itemData":{"id":2084,"type":"article-journal","abstract":"BACKGROUND: Coronavirus disease 2019 (COVID-19) has become a public health emergency. The widely used reverse transcription PCR (RT-PCR) method has limitations for clinical diagnosis and treatment.\nMETHODS: A total of 323 samples from 76 COVID-19 confirmed patients were analyzed by droplet digital PCR (ddPCR) and RT-PCR based two target genes (ORF1ab and N). Nasal swabs, throat swabs, sputum, blood, and urine were collected. Clinical and imaging data were obtained for clinical staging.\nRESULTS: In 95 samples tested positive by both methods, the cycle threshold (Ct) of RT-PCR was highly correlated with the copy numbed of ddPCR (ORF1ab gene, R2 = 0.83; N gene, R2 = 0.87). 4 (4/161) negative and 41 (41/67) single-gene positive samples tested by RT-PCR were positive according to ddPCR with viral load ranging from 11.1 to 123.2 copies/test. Then the viral load of respiratory samples was compared and the average viral load in sputum (17429 ± 6920 copies/test) was found to be significantly higher than in throat swabs (2552 ± 1965 copies/test, p < 0.001) and nasal swabs (651 ± 501 copies/test, p < 0.001). Furthermore, the viral load in the early and progressive stages were significantly higher than that in the recovery stage (46800 ± 17272 vs 1252 ± 1027, p < 0.001) analyzed by sputum samples.\nCONCLUSIONS: Quantitative monitoring of viral load in lower respiratory tract samples helps to evaluate disease progression, especially in cases of low viral load.","container-title":"Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America","DOI":"10.1093/cid/ciaa345","ISSN":"1537-6591","journalAbbreviation":"Clin. Infect. Dis.","language":"eng","note":"PMID: 32221523","source":"PubMed","title":"Quantitative Detection and Viral Load Analysis of SARS-CoV-2 in Infected Patients","author":[{"family":"Yu","given":"Fengting"},{"family":"Yan","given":"Liting"},{"family":"Wang","given":"Nan"},{"family":"Yang","given":"Siyuan"},{"family":"Wang","given":"Linghang"},{"family":"Tang","given":"Yunxia"},{"family":"Gao","given":"Guiju"},{"family":"Wang","given":"Sa"},{"family":"Ma","given":"Chengjie"},{"family":"Xie","given":"Ruming"},{"family":"Wang","given":"Fang"},{"family":"Tan","given":"Chianru"},{"family":"Zhu","given":"Lingxiang"},{"family":"Guo","given":"Yong"},{"family":"Zhang","given":"Fujie"}],"issued":{"date-parts":[["2020",3,28]]}}}],"schema":""} 2,7,8. What does a negative RT-PCR test mean? The negative predictive value [(true negatives)/(true negatives + false negatives)] allows us to understand the significance of a negative test, which depends on the prevalence of disease in the population being tested. In asymptomatic patients, the prevalence of SARS-CoV-2 in the Bay Area and in the U.S. is not yet known, but based on data in other countries ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"R3t6KhLI","properties":{"formattedCitation":"\\super 9\\nosupersub{}","plainCitation":"9","noteIndex":0},"citationItems":[{"id":2088,"uris":[""],"uri":[""],"itemData":{"id":2088,"type":"article-journal","container-title":"New England Journal of Medicine","DOI":"10.1056/NEJMoa2006100","ISSN":"0028-4793, 1533-4406","language":"en","source":"Crossref","title":"Spread of SARS-CoV-2 in the Icelandic Population","URL":"","author":[{"family":"Gudbjartsson","given":"Daniel F."},{"family":"Helgason","given":"Agnar"},{"family":"Jonsson","given":"Hakon"},{"family":"Magnusson","given":"Olafur T."},{"family":"Melsted","given":"Pall"},{"family":"Norddahl","given":"Gudmundur L."},{"family":"Saemundsdottir","given":"Jona"},{"family":"Sigurdsson","given":"Asgeir"},{"family":"Sulem","given":"Patrick"},{"family":"Agustsdottir","given":"Arna B."},{"family":"Eiriksdottir","given":"Berglind"},{"family":"Fridriksdottir","given":"Run"},{"family":"Gardarsdottir","given":"Elisabet E."},{"family":"Georgsson","given":"Gudmundur"},{"family":"Gretarsdottir","given":"Olafia S."},{"family":"Gudmundsson","given":"Kjartan R."},{"family":"Gunnarsdottir","given":"Thora R."},{"family":"Gylfason","given":"Arnaldur"},{"family":"Holm","given":"Hilma"},{"family":"Jensson","given":"Brynjar O."},{"family":"Jonasdottir","given":"Aslaug"},{"family":"Jonsson","given":"Frosti"},{"family":"Josefsdottir","given":"Kamilla S."},{"family":"Kristjansson","given":"Thordur"},{"family":"Magnusdottir","given":"Droplaug N."},{"family":"Roux","given":"Louise","non-dropping-particle":"le"},{"family":"Sigmundsdottir","given":"Gudrun"},{"family":"Sveinbjornsson","given":"Gardar"},{"family":"Sveinsdottir","given":"Kristin E."},{"family":"Sveinsdottir","given":"Maney"},{"family":"Thorarensen","given":"Emil A."},{"family":"Thorbjornsson","given":"Bjarni"},{"family":"L?ve","given":"Arthur"},{"family":"Masson","given":"Gisli"},{"family":"Jonsdottir","given":"Ingileif"},{"family":"M?ller","given":"Alma D."},{"family":"Gudnason","given":"Thorolfur"},{"family":"Kristinsson","given":"Karl G."},{"family":"Thorsteinsdottir","given":"Unnur"},{"family":"Stefansson","given":"Kari"}],"accessed":{"date-parts":[["2020",4,17]]},"issued":{"date-parts":[["2020",4,14]]}}}],"schema":""} 9, is estimated to be approximately 1%. Given that the estimated prevalence of asymptomatic patients in the Bay Area is very low, the negative predictive value for a test in an asymptomatic patient prior to surgery is very high. For example, if the COVID-19 prevalence is assumed to be 1% and the sensitivity/specificity of a NP swab test is estimated at 75%/98%, then the negative predictive value of the test is 99.7%. References: ADDIN ZOTERO_BIBL {"uncited":[],"omitted":[],"custom":[]} CSL_BIBLIOGRAPHY 1.Mahony, J. B. Detection of Respiratory Viruses by Molecular Methods. Clinical Microbiology Reviews 21, 716–747 (2008).2.Yang, Y. et al. Evaluating the accuracy of different respiratory specimens in the laboratory diagnosis and monitoring the viral shedding of 2019-nCoV infections. (2020) doi:10.1101/2020.02.11.20021493.3.Wang, W. et al. Detection of SARS-CoV-2 in Different Types of Clinical Specimens. JAMA (2020) doi:10.1001/jama.2020.3786.4.Lieberman, D. et al. Identification of Respiratory Viruses in Adults: Nasopharyngeal versus Oropharyngeal Sampling. Journal of Clinical Microbiology 47, 3439–3443 (2009).5.Spencer, S., Thompson, M. G., Flannery, B. & Fry, A. Comparison of Respiratory Specimen Collection Methods for Detection of Influenza Virus Infection by Reverse Transcription-PCR: a Literature Review. Journal of Clinical Microbiology 57, (2019).6.W?lfel, R. et al. Virological assessment of hospitalized patients with COVID-2019. Nature (2020) doi:10.1038/s41586-020-2196-x.7.To, K. K.-W. et al. Temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by SARS-CoV-2: an observational cohort study. The Lancet Infectious Diseases (2020) doi:10.1016/S1473-3099(20)30196-1.8.Yu, F. et al. Quantitative Detection and Viral Load Analysis of SARS-CoV-2 in Infected Patients. Clin. Infect. Dis. (2020) doi:10.1093/cid/ciaa345.9.Gudbjartsson, D. F. et al. Spread of SARS-CoV-2 in the Icelandic Population. New England Journal of Medicine (2020) doi:10.1056/NEJMoa2006100. Appendix B: Imaging Suite DowntimesImaging suite downtimes are derived from airflow characteristics in each imaging suite to achieve a 99% air turnover. If anyone is present in the suite during or after an aerosol-generating procedure in this time period, airborne PPE should be utilized. The most efficient way to achieve the desired air exchange is to keep the doors closed. When caring for asymptomatic patients, providers and patients may exit the imaging suite. However care should be taken to minimize the time that the door(s) to the suite are open to minimize potential contamination of adjacent airspace and maximize air turnover.ParnassusMission BayRoom NumberRadiology NameRoom DowntimeRoom NumberRadiology NameRoom DowntimeM365IR Room 830 minutesC2675IR Hybrid/OR2315 minutesM375IR Room 945 minutesA2683IR/OR2430 minutesM337IR Room 415 minutesC1769MBCT130 minutesL367NIR Z30 minutesC1716MBCT230 minutesL382NIR S15 minutesC1714MBCT330 minutesL389NIR Q30 minutesC1755MRI Induction Room 15 minutesL361CT 215 minutesC1729Nuclear Medicine45 minutesL363CT 430 minutesC1721PET/CT45 minutesL300MRLP45 minutesC1778Fluoro 145 minutesL314MR430 minutesC1782Fluoro 245 minutesM345Room 530 minutesC1758ARN Holding 145 minutesM347Room 630 minutesC1758BRN Holding 245 minutesM337ERCP15 minutesC1758QUS145 minutesL376US Room 215 minutesC1758VUS460 minutesMt. ZionPCMBRoom NumberRadiology NameRoom DowntimeRoom NumberRadiology NameRoom DowntimeA237MZ IR 130 minutesL2141-APCMB130 minutesA239MZ IR 330 minutesL2141-BPCMB230 minutesA241MZ Holding Room45 minutesL2171PCCT115 minutesA134MZ CT30 minutesL2131Holding Room 345 minutesL2131Holding Room 445 minutesL3180EBreast Biopsy45 minutesL2128US Room 245 minutesAppendix C: Aerosol-Generating Procedures Performed by RadiologistsAny procedure involving a patient who:Aerosol-generating procedures performed by radiologistsrequires intubation/extubationis receiving a form of ventilatory support associated with the risk of mechanical dispersal of aerosols*requires active airway suctioning (i.e. tracheostomy patient)*Note: Any patient undergoing sedation may require airway rescue, which would require utilization of aerosol precautions.Lung biopsyLung ablationThoracentesisPleural drainsChest tube for pneumothoraxBronchial artery embolizationBronchial stentingNasogastric Tube (NG tube) or Orogastric tube (OG tube) placementAny procedure that requires NG tube placement:GastrostomyGastro-jejunostomy tube placementJejunostomyGI stent placementAdapted from D: Signs in Radiology Example of room-specific sign posted INSIDE room Example of sign to be posted OUTSIDE room during HIGH-RISK (aerosol-generating) procedure and to stay posted until room downtime is completeAPPENDIX E: Isolation Status LinksCONTACT ISOLATION: ISOLATION: ISOLATION: CONTACT ISOLATION: ................
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