Rethinking Sedation During Prolonged Mechanical Ventilation for COVID-19 Respiratory Failure.

We thank Drs Rah and Platovsky[1] for bringing attention to special considerations for gastrointestinal (GI) endoscopic procedures in an ambulatory care setting during the coronavirus disease of 2019 (COVID-19) pandemic. As institutions endeavor to ensure safe endoscopic practices for emergent, urgent, and elective cases, distribution of personal protective equipment (PPE) and access to reliable SARS-CoV-2 (COVID-19) testing remain key issues.

We would join Drs Rah and Platovsky[1] in arguing that endoscopy is especially high risk for several reasons: (1) upper and lower endoscopies are aerosol-generating procedures (AGPs)[2]; (2) these procedures involve bodily fluids that are known to carry the virus[3,4]; (3) the procedure requires the gastroenterologist, technologist, and, at times, anesthesia provider to stand in close proximity to the site of aerosolization,[5] and, in the case of upper endoscopy, this places all 3 providers well within the 2-mzone for aerosolization; (4) many therapeutic procedures last ≥2 hours, with COVID-19 well-documented in upper airway secretions and feces[3,4]; and (5) increased infectious risk to faculty and staff in the GI suite due to the higher case volumes and prolonged AGPs in these areas. Endoscopy procedures with anesthesia pose additional risk for transmission of COVID-19 infection to providers in the room due to intubation and extubation, which are aerosolizing procedures. Even moderate sedation with total intravenous anesthesia (TIVA) has added risks as patients without a secured airway tend to cough, aerosolizesecretions, and/or require manual airway support (including intubation) in the midst of the procedure.

Therefore, we strongly recommend PPE use per Center for Disease Control (CDC) guidelines for AGPs[6] andfor all procedures in the GI endoscopy suite during the COVID-19 pandemic. It is prudent that, at a minimum, all patients with risk factors (travel within 14 days, exposure to a positive patient, fever with or without respiratory symptoms) be tested the day before their procedure. Furthermore, as highly sensitive diagnostic tests (RT-PCR) for COVID-19 become widely available for routine use, we urge institutions to be cognizant of the risks associated with GI procedures and endeavor to institute testing of asymptomatic patients in these areas. We must remember that procedural areas such as endoscopy are not only associated withhigh patient volumes areas but also associated with prolonged AGP interventions.