Safety ScreeningPatient Prep

Patients

Non-Patients

“ The screening process and screening forms forpatients, non-MR personnel, and MR personnelshould be essentially identical. Specifically, oneshould assume that screened non-MR personnel,health care practitioners, or MR personnel mayenter the bore of the MR imager during the MRimaging process.”

ACR Guidance on MR Safe Practice, 2013 pg 5

Patient Support Personnel

Screening ProceduresIdentical to Patients (less clinical)

Document

Sample Screening Form

Courtesy Dr. Frank Shellock, mrisafety.com

Sample Screening Form

Courtesy Dr. Frank Shellock, mrisafety.com

The patient screening form should be thorough and comprehensive. “Simplifying” the form only increases the risk to the patient.

Sample Screening Form

Courtesy Dr. Frank Shellock, mrisafety.com

All Patients should be completely screened prior to each and every MR exam by

trained individuals (at least one screening should be by Level 2 personnel)

Having successfully undergone an MR procedure in the past, is not an indication that a

future procedure may be safely performed

Unresponsive Patient Screening

ACR Guidance on MR Safe Practice, 2013 pg 6

Verbal and Interactive ScreeningScreening should be performed by trained individuals

Screen non-emergent patients at least twice

The technologist who is performing the MR exam should interview / screen the patient verbally and interactively

Courtesy Chattanooga Imaging

FDA MAUDE Database

“The scanning technologist failed to follow safe procedures prior to scanning pt due to the assumption her fellow

co-workers already screening [sic] pt.”

Be aware of what can happen with a “hand-off”

Patient Dress

Remove all removable items

Dress all patients in MR-appropriate attire

http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=11359290

Importance of MR Appropriate Attire

A veteran was wounded Wednesday at Richard L. Roudebush Veterans Affairs Medical Center when a handgun he brought into the Indianapolis hospital accidentally discharged in his pocket while he was in a procedure room — possibly an MRI suite.Hospital officials confirmed the accidental shooting in a statement issued Thursday and reported the victim, whose name was not released, received immediate medical attention. The statement added the man's wound did not threaten his life.A hospital spokesman initially confirmed in a telephone call from The Indianapolis Star that the incident involved an MRI, but the subsequent statement said only that the incident occurred "in a procedure room." When asked for clarification about the involvement of the MRI, the spokesman said in an email that the statement "is our response at this time."The statement noted it is a violation of federal and state law to bring a firearm into the hospital and "notification of this law is posted at every entrance."

IndyStarDecember 31, 2015

Importance of MR Appropriate Attire

- FDA MAUDE database

Blouse catches fire during 1st sequence of a shoulder exam. 3rd degree burns to forearm.

Importance of MR Appropriate Attire

Sports attire11-year-old girl presented for outpatient MR

imaging of the spine for evaluation of scoliosis, wearing a gray undershirt under a long-sleeved

white tee shirt and gray sweat pants

Importance of MR Appropriate Attire

Importance of MR Appropriate Attire

Do not apply Pennsaid to an open skin wound, or on areas of infection, rash, or burn. Do not cover treated skin with a

bandage or expose it to heat from a hot tub, heating pad, or sauna. Heat or bandaging can increase the amount of diclofenac

you absorb through your skin.

Pennsaid: a nonsteroidal anti-inflammatory drug (NSAID) taken or applied to reduce inflammation and as an analgesic

reducing pain in certain conditions

Post MRI

Screening Orbits

243

Ferromagnetism of Intraocular Foreign Body Causes Unilateral Blindness after MR Study William M. Kelly,1 Patrick G. Paglen,2 Jack A. Pearson ,3 Armando G. San Diego,4 and Murray A. Soloman5

The rapid ascent of magnetic resonance (MR) imaging as an important tool in neurodiagnosis has been fueled primarily by its unparalleled sensitivity for lesion detection, even when compared with its predecessor, computed tomography (CT). The absence of ionizing radiation is another attractive feature of MR that has provided additional momentum for its rapid development. However, only recently , and on the eve of widespread distribution of this new technology, has significant attention been focused on the potential biologic hazards of MR. Among the risks to which MR patients may be exposed are included ferromagnetic forces that may be exerted on certain internal metal objects. Most patients harboring various types of surgically implanted aneurysm and hemostatic clips as well as other types of metallic hardware can be readily identified by history. Exclusion of individuals with a history of cerebral aneurysm treated by aneurysm clips from consider-ation for MR eliminates the fearsome risk of a hemorrhagic event or other injury as a result of ferromagnetically induced motion of the metal clip. However, accurate recognition of the presence of small metallic foreign bodies such as an iron filing or shrapnel fragment, prior to consideration for MR , can be more problematic, even with preliminary CT, as we discov-ered. A former sheet metal worker with a clinically occult intraocular metal fragment experienced a vitreous hemor-rhage with resulting blindness during an MR examination. According to the Food and Drug Administration, this case represents the first reported instance of a serious complica-tion related to induced ferromagnetism. Attention to the oc-cupational history and a high index of suspicion may help avert this type of calamity in other patients similar to ours. The demonstrated ability of MR to cause serious injury as a result of ferromagnetism has important implications for a much larger group of potential MR candidates with surgically implanted metallic devices.

Case Report A 63-year-old man with recently diagnosed adenocarcinoma out-

side the central nervous system developed headaches and worsening

Received March 28, 1985; accepted after revision October 8, 1985.

lethargy during the course of an inpatient evaluation. A contrast-enhanced CT scan of the brain revealed hyperdense lesions in the right temporal lobe and anterior left parietal lobe. Mild dilatation of the lateral and third ventricles was noted. In addition, a probable tecta I lesion was seen adjacent to the aqueduct of Sylvius (fig. 1 A). A small , rounded density adjacent to the posterior scleral margin of the left globe was initially thought to represent a postinflammatory calcification . (While serving in the Armed Forces during World War II , the patient had been taken prisoner by the Japanese Army at Bataan. He had survived the Bataan death march. While prisoner, he had been exposed to parasites. Examination by an ophthalmologist in 1972 revealed abnormalities of the left retina, including a glial band extending supratemporally from the disk margin and ending at an elevated pigmented mass. This was believed to be secondary to an old parasitic [Toxocara] granuloma. A cataract extraction with im-plantation of a polymethylmethacrylate lens implant was performed on the left eye in 1982.)

After consultation with oncology and radiation therapy depart-ments and before initiation of whole-brain radiation , it was decided to perform a head MR study to confirm the suspected midbrain lesion (and thereby corroborate the diagnosis of obstructive hydrocephalus) and more accurately establish the extent of metastatic involvement. The patient denied knowledge of any metal implants.

The patient underwent an MR examination in a Diasonics 0.35 T system. Three multislice spin-echo pulse sequences were performed . Transaxial images were obtained using 500 and 2000 msec repetition times (TRs) and 28 and 56 msec echo times (TEs); sagittal images were obtained using 500 msec TRs and 28 and 56 msec TEs. At the completion of all data acquisition and at the moment the patient table was being pulled out of the magnet bore, the patient described a sudden tugging sensation at the left eye, a flash of light, then a dramatic decrease in vision. Examination revealed a gross vitreous hemorrhage on the left. MR showed extensive ferromagnetic artifact obscuring the left orbit (fig . 1 B). A repeat CT study with thin orbital sections (1.5 mm) displayed at bone window settings showed a 2-3 mm metallic density adjacent to the left disk margin (fig. 1 C).

Subsequent review of the patient's work history disclosed employ-ment as a sheet metal worker and lathe operator after military service. He admitted to working habitually without protective eyewear and on several occasions felt iron filings strike his face , but denied any specific recollection of an eye injury or consultation with a physician for such. It was concluded that in the remote past the patient had

'Department of Radiology, David Grant USAF Medical Center. Travis AFB , CA 94535. Address reprint requests to W. M. Kelly. 2Department of Ophthalmology. David Grant USAF Medical Center, Travis AFB, CA 94535. 3Department of Internal Medicine, David Grant USAF Medical Center, Travis AFB , CA 94535. ' Department of Pathology, David Grant USAF Medical Center, Travis AFB, CA 94535. 5 San Jose Magnetic Resonance Imaging Center, San Jose, CA xxxxx.

AJNR 7:243-245, March/ April 1986 0195-6108/86/0702-0243 © American Society of Neuroradiology

AJNR 7:243-245, March/ April 1986 0195-6108/86/0702-0243

2 x 3.5 mm rusted iron filing

AJNR 7:243-245, March/ April 1986 0195-6108/86/0702-0243

ACR Guidelines

“All patients who have a history of orbit trauma bya potential ferromagnetic foreign body for whichthey sought medical attention are to have theirorbits cleared by either plain X-ray orbit films(2 views) or by a radiologist’s review andassessment of contiguous cut prior CT or MRimages (obtained since the suspected traumaticevent) if available.”

ACR Guidance on MR Safe Practice Pg 6

Pregnancy: Patients

FDA -The safety of MR imaging during pregnancy has not been proved.

Pregnancy: Patients

ISMRM-"MR Imaging may be used in pregnant women if other nonionizing forms of diagnostic imaging are inadequate or if the examination provides important information that would otherwise require exposure to ionizing radiation."

Pregnancy: Patients

Can be accepted at any stage of pregnancy

Level 2-designated attending radiologist to confer with ordering physician and determine that the risk-vs-benefit ratio to the patient warrants the study

ACR

Pregnancy: PatientsACR

Document in the report or patient’s medical record:

Pregnancy: PatientsACR

Guidelines no longer specify informed consent

Pregnancy: Patients

Should not be routinely used in pregnant patients

Case-by-case decision made by level 2 MR personnel-designated attending radiologist who will assess the risk-benefit ratio for the particular patient

Decision to administer a GBCA should be accompanied by a well-documented and thoughtful risk-benefit analysis

Risk to the fetus of a GBCA remains unknown and may be harmful

ACR Gadolinium

Pregnancy: Staff

Permitted to work in and around the MR environment throughout all stages of their pregnancy

May perform all job-related duties

Requested not to remain with the scanner bore or Zone IV during active scanning

ACR Ferromagnetic Detection

“…the use of ferromagnetic detection systems isrecommended as an adjunct to thorough and conscientious screening of persons and devices approaching Zone IV.”

ACR Guidance on MR Safe Practice, 2013 pg 5

Metal DetectorsAC current in coils produces alternating magnetic field

Eddy currents are produced in Any conductive metal passing through resulting in an oscillating magnetic field from the conductor

Additional coils in the detector detect that field

No distinction betweenconductive metal and ferromagnetic

The use of metal detectors in MRIis discouraged

Ferromagnetic DetectionFerromagnetic detectors “monitor” the surrounding magnetic field

When something ferromagnetic moves it distorts the surrounding magnetic field

Ferromagnetic detectors sense that change

Images courtesy of Metrasens

Single Pillar Systems“Screener”

mednovus.com koppdevelopment.com ferroguard.com

Single Pillar Systems

Between Zone II and III

“Screener”

Hand-Held

Uses magnets to augmentsensitivity

Target suspected areas - not intended for whole-body screening

Zone IV

Designed to detect larger ferromagnetic items

Remove all removable items

Dress all patients in MR-appropriate attire

AJR:188, June 2007; pg 5

MR Staff attire

Ferromagnetic free?

Claustrophobia / Anxiety

Not a safety issue

Do not use the terms “open” or “closed” MRI

Do not ask prior to the study “are you claustrophobic?”

The tech who scans the patient should be the one to safety screen the patient

Claustrophobia / Anxiety

Do not rush the patient - allow them time to ask questions

Stay in contact with the patient until they are positioned in the magnet are state they are comfortable

Cool wash cloth for the eyes

Aromatherapy

Claustrophobia / Anxiety Claustrophobia / Anxiety

www.comforttalk.com