MRI Safety Symposium. ACR Safe Practice Guidelines. An Overview of the ACR Guidance Document on MR Safe Practices. Zachary W. Friis, Ph.D.

Transcription

1 MRI Safety Symposium An Overview of the ACR Guidance Document on MR Safe Practices Zachary W. Friis, Ph.D.,DABR IT HAS BEEN RECOGNIZED THAT THERE ARE MANY POTENTIAL RISK IN THE MR ENVIRONMENT. NOT TO JUST PATIENTS BUT TO ANYONE THAT MAY INTERACT WITH THE MAGNETIC FIELD

2 IN 2001 THE ACR FORMED A BLUE RIBBON PANAL OF EXPERTS TO ADDRESS MRI SAFETY IN 2002, THE PANAL PUBLISHED THE FIRST MR SAFE PRACTICES GUIDELINES THE 2002 PUBLICATIONS WAS SUBSEQUENTLY REVIEWED AND UPDATED IN IT WAS AGAIN UPDATED IN 2007, WHICH IS THE DOCUMENT MOST OF YOU MIGHT BE FAMILIAR WITH.

3 ACR MR Test Manual 2015 ACR MR Test Manual 2015

4 Joint Commission Updates IT IS IMPORTANT TO THINK OF THESE GUIDELINES AS A TEMPLATE FOR MR FACILITIES TO FOLLOW IN THE DEVELOPMENT OF AN MR SAFETY PROGRAM. THE ACR SAFE PRACTICE GUIDELINE SHOULD BE USED TO ESTABLISH YOUR SITE S POLICY AND PROCEDURES MANUAL THESE POLICIES AND PROCEDURES SHOULD BE REVIEWED AND UPDATED PERIODICALLY THE PRINCIPLES BEHIND THE MR SAFE PRACTICES GUIDELINES ARE INTENDED TO BE APPLICABLE TO ALL MRI SETTINGS THIS INCLUDES: DIAGNOSTIC IMAGING, RESEARCH, INTERVENTIONAL, AND INTRAOPERATIONAL MR APPLICATIONS ONE OF THE MOST IMPORTANT THINGS TO TAKE AWAY FROM THE MR SAFE PRACTICES GUIDELINES IS: NEVER ASSUME

5 OVERVIEW THE GUIDELINE IS COMPRISED OF 14 CHAPTERS AND 4 APPENDICES DURING THIS TALK, WE WILL REVIEW THIS DOCUMENT SECTION BY SECTION A. ESTABLISH, IMPLEMENT, AND MAINTAIN CURRENT MR SAFETY POLICIES AND PROCEDURES. 1) ALL MR SITE SHOULD MAINTAIN MR SAFETY POLICIES 2) THESE POLICIES SHOULD BE REVIEWED PERIODICALLY 3) EACH SITE SHOULD NAME A MR MEDICAL DIRECTOR 4) PROCEDURES SHOULD BE IN PLACE TO ENSURE THAT ANY AND ALL ADVERSE EVENTS OR NEAR INCIDENTS SHOULD BE REPORTED IN A TIMELY MANNER (LESS THAN 24 HOURS!!!) An MRI Suite should be divided into four Zones Zone I is freely accessible to the general public. Zone II can be thought of as the interface between Zone I and the controlled access zones. In Zone II, there should be a gate keeper preventing access to Zone III and IV. The gate keeper should screen any non-mr people prior to entering Zone III.

6 An MRI Suite should be divided into four Zones Zone III is the region in which free access by unscreened non-mr personnel or ferromagnetic objects can result in serious injury or death. Zone III should be PHYSICALLY restrictive. For example: key locks, passkey-locking doors, or other reliable barriers. Combination locks are often discouraged, since the combinations never seem to remain secret. ONLY MR personnel should be allowed FREE ACCESS. An MRI Suite should be divided into four Zones Zone III extends to any area that potentially hazardous magnetic fields may be. Remember, magnetic fields are 3D! Inadequate magnetic shielding may mean magnetic field lines extend beyond what is not immediately thought of as a Zone III area. Such as: roofs, computer rooms, and storage areas. It is important that these areas be controlled and labeled as well. An MRI Suite should be divided into four Zones Zone IV is synonymous with the MR scan room itself. As part of the Zone IV site restriction, all MR installations should provide for direct visual observation by level 2 personnel to access pathways into Zone IV.

7 An MRI Suite should be divided into four Zones Zone IV should be clearly marked with a lighted sign stating, The Magnet is On. An MRI Suite should be divided into four Zones In the case of cardiac or other medical emergencies, MR personal should immediately remove the patient from Zone IV (preferably even out of Zone III) and begin basic life saving procedures. Quenching the magnet during these emergencies is not advisable.

8 MR personnel and non-mr personnel All individuals working within Zone III or Zone IV of the MR environment should be documented as having successfully completed MR safety training approved by the MR medical director. Personnel should have an annual refresher in MR Safety. MR personnel and non-mr personnel There are two levels of MR personnel Level 1: Those who have passed minimal safety educational efforts to ensure their own safety as they work within Zone III. Level 2: Those who are more extensively trained and educated in the broader aspects of MR safety issues MR personnel and non-mr personnel Examples Level 1: Nurses, Janitorial Staff, Emergency Responders Level 2: MR Technologist The MR Safety Director is responsible for determining who qualifies to be which level, and the MR Safety Director is responsible for their training.

9 Patient and non-mr personnel screening Your site should have a comprehensive policy regarding Patient and non-mr personnel as well as a policy in place for devices and object screening. Devices or Objects going into Zone III and IV should be properly labelled. MR SAFE MR CONDITIONAL MR UNSAFE C. MR Technologist 1. MR technologists should be in compliance with the technologist qualifications listed in the MR Accreditation Program Requirements. 2. Except for emergent coverage, there will be a minimum of 2 MR technologists or one MR technologist and one other individual with the designation of MR personnel in the immediate Zone II through Zone IV MR environment.

10 D. Pregnancy Related Issues Health Care Practitioner Pregnancies Pregnant health care practitioners are permitted to work in and around the MR environment throughout all stages of their pregnancy Pregnant health care practitioners are requested not to remain within the MR scanner bore or Zone IV during actual data acquisition or scanning. D. Pregnancy Related Issues Patient Pregnancies Currently no special consideration is recommended for the first, versus any other, trimester in pregnancy. Pregnant patients can be accepted to undergo MR scans at any stage of pregnancy if, in the determination of a level 2 MR personnel-designated attending radiologist, the risk benefit ratio to the patient warrants that the study be performed. D. Pregnancy Related Issues Patient Pregnancies The radiologist should confer with the referring physician and document the following: 1:The information requested from the MR study cannot be acquired by means of nonionizing means (e.g., ultrasonography). 2:The data is needed to potentially affect the care of the patient or fetus during the pregnancy. 3: The referring physician believes that it is not prudent to wait until the patient is no longer pregnant to obtain this data.

11 D. Pregnancy Related Issues Patient Pregnancies MR Contrast should NOT routinely be used on pregnant patients. Several studies have shown that MR contrast can pass through the placental barrier and be filtered by the fetal kidneys. Risk to the fetus is still unclear and a topic of current research. Therefore, a well-documented and thoughtful risk benefit analysis should be performed prior to prescribing contrast to pregnant patients. E. Pediatric MR Safety Concerns Sedation and Monitoring Issues Children make up the largest group of people undergoing MRI that require sedation. Adherence to standards of care mandates following the sedation guidelines have been developed by the American Academy of Pediatrics, the American Society of Anesthesiologists, and the Joint Commission on Accreditation of Healthcare Organizations. E. Pediatric MR Safety Concerns Sedation and Monitoring Issues Sedation providers most also adhere to protocols outlined by their individual state and their institution.

12 E. Pediatric MR Safety Concerns Sedation and Monitoring Issues Young pediatrics and neonatal patients present require constant temperature monitoring. The small body size means there can be wide variances in internal body temperatures. E. Pediatric MR Safety Concerns Pediatric Screening Issues Children are NOT reliable historians Screening should be done in the presence of a guardian or parent. Like adults, the ACR makes a case for gowning pediatric patients too. E. Pediatric MR Safety Concerns Pediatric Screening Issues Stuffed animals, pillows, blankets, and other comfort aids should be discouraged from use in the MRI Scan room. If unavoidable, these items must be thoroughly checked.

13 E. Pediatric MR Safety Concerns MR Safety of Accompanying Family or Personnel Those accompanying or remaining with the patient should be screened using the same criteria as anyone else entering Zone IV. Hearing protection and MR safe/mr conditional seating are recommended for accompanying family members within the MR scan room. E. Time Varying Gradient Magnetic Field Related Issues: Induced Voltages We will be discussing this in depth in our physics discussion later during the course. G. Time Varying Gradient Magnetic Field Related Issues: Auditory Considerations We will be discussing this in depth in our physics discussion later during the course.

14 H. Time Varying Radiofrequency Magnetic Field Related Issues: Thermal We will be discussing this in depth in our physics discussion later during the course. I. Drug Delivery Patches and Pads Bill will be discussing the reasons for this later in his talks. J. Cryogen-Related Issues We will discuss Cryogen-Related Issues later during this talk.

15 K. Claustrophobia, Anxiety, Sedation, Analgesia and Anesthesia Adult and pediatric patient anxiolysis, sedation, analgesia, and anesthesia for any reason should follow established ACR, American Society of Anesthesiologists (ASA), and TJC standards. L. Contrast Agent Safety Contrast agent administration issues: Bill will be discussing at length Contrast Safety M. Patients in Whom There Are or May Be Intracranial Aneurysm Clips We will discuss this at length later in later presentations.

16 N. Patients in Whom There are or May Be Cardiac Pacemakers or Implantable Cardioverter Defibrillators We will discuss this at length later in later presentations. SO WHAT S THE MOST IMPORTANT THING TO REMEMBER WHEN IT COMES TO MR SAFETY?! NEVER ASSUME