Utility of a barrier enclosure in the management of a patient with coronavirus disease for endoscopic retrograde cholangiopancreatography under sedation

Abstract

Transmission of severe acute respiratory syndrome coronavirus 2, leading to coronavirus disease (COVID-19) is thought to occur primarily through respiratory droplets, while airborne transmission may occur with the generation of aerosols. Upper gastrointestinal endoscopy is deemed a potentially infectious aerosol-generating procedure; consequently, healthcare workers present at the premises are at a high risk, particularly because of the physical proximity to the patients.Various professional guidelines [1] recommend multi-pronged strategies for the use of endoscopes in the management of patients with COVID-19. This include deferring non-essential endoscopy, appropriate use of personal protective equipment (PPE), standard infection control practices, strict isolation precautions in negative-pressure rooms, and adequate disinfection protocols.After obtaining written informed consent, we describe the management of a 30-yearold man who had a history of thalassemia intermedia and presented with a 1-day history of fever, sore throat, and myalgia. A positive nasopharyngeal swab test confirmed COVID-19.On day 3, the patient developed productive cough. On day 7, he developed acute cholangitis. Imaging showed choledocholithiasis, likely a pigment stone secondary to chronic hemolysis. On day 18, in view of recurrent abdominal pain and worsening derangement of liver enzymes despite antibiotics, endoscopic retrograde cholangiopancreatography (ERCP) was performed instead of waiting for COVID-19 clearance, as was initially planned. As the patient was clinically stable with adequate oxygen saturation on room air, the procedure was performed under sedation.To reduce the risk of contamination, we used a barrier enclosure during the procedure. The barrier enclosure was a transparent acrylic trapezoidal box placed over the patient's head and upper torso during ERCP (Fig. 1A). It measured 60 × 55 × 61 cm (Fig. 1B).The patient was initially placed in a supine position in the box, and lignocaine was sprayed to anesthetize the pharynx. The patient was then turned to a prone position in the box, and a nasal cannula was applied. Sedation was induced with titrated boluses of midazolam, fentanyl, and propofol.Similar boxes, conceptualized for use with intubation, have garnered much interest in recent months. Kearsley [2] highlighted concerns regarding the use, while others speculated on the physics and virulence of droplets and aerosols in infection transmission [3], thus questioning the utility of such an enclosure.The patient coughed when lignocaine was sprayed into the pharynx and gagged slight-