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1 INTRAOPERATIVE NEUROSURGICAL MAGNETIC RESONANCE IMAGING (iMRI) HSC iMRI PRACTICE STANDARD October 4, 2013
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INTRAOPERATIVE NEUROSURGICAL
MAGNETIC RESONANCE IMAGING (iMRI)
HSC iMRI
PRACTICE STANDARD
October 4, 2013
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TABLE OF CONTENTS
MRI Technology ………………………………………………………………Page 3 Hazards in the MRI Theatre …………………………………………………...Page 4 Safety Guidelines ………………………………………………………………Page 6 Emergency Situations ………………………………………………………….Page 10 The Surgical Procedure ………………………………………………………...Page 12 References …………………………………………………………………….. Page 17 Appendices:
IMRIS MRI-Safe Equipment ………………………………. Page 18
HSC Preoperative Patient Screening Checklist ……………. Page 24
HSC Patient Positioning Checklist …………………………. Page 25
HSC Pre-Magnet Entry ‘All Clear’ Checklist ………………. Page 26 Anesthesia Check List ………………………………………. Page 27 Positioning and Pre-Magnet Entry Checklists: Interventional Radiology ……………………………………. Page 28
Code Blue Posters ……………………………………..……. Page 29
Fire Orders Poster…..……………………………….……….. Page 31 MRI Department - MRI Contrast Patient Information Sheet... Page 32 MRI Department - Patient MRI Safety Checklist…………… Page 33 MRI Environment Screening Form for Staff and Visitors…… Page 34 Access to Kleysen Building Level 2 Request Form…………...Page 35 Kleysen Institute iMRI Operating Room Utilization Policy…..Page 36
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MRI TECHNOLOGY The mobile, intraoperative magnetic resonance imaging (iMRI) system in use at the HSC Kleyson Building was developed by Innovative Magnetic Resonance Imaging Systems Inc. (IMRIS). An ultra-powerful magnet is contained within the machine and is surrounded by the bore’s protective walls. The MRI machine is stored in a storage area between the two operating rooms and opens into each theatre through shielded metal double doors on the theatres’ wall. The magnet advances into each theatre and retracts back into its storage area using ceiling-mounted tracts. Even when not in use, THE MAGNET IS ALWAYS ON. When the shielded metal doors are securely closed, there are no risks from the magnet inside the theatre. The strengths of the magnetic fields are designated in units of telsa (T) for ultra-powerful magnetic fields, and units of gauss for less powerful magnetic fields. The strength of the magnetic field within the magnet’s bore is 3 T.
- 1 T = 10,000 gauss - The FDA limits the strength of a magnetic field accessible to the public to 5
gauss The coloured circles on the floor of the MRI theatre identify the following fields:
- The periphery of the beige circle is the 50 gauss line - The periphery of the green circle is the 5 gauss line
o The blue area of the floor is outside the 5 gauss line These gauss lines demonstrate that the magnetic intensity diminishes with greater distances from the magnet MRI Fields: In order to create diagnostic images, a MRI machine basically utilizes three fields:
1. An ultra-strong magnetic field: a. Created by super-conducting magnetic coils located within the
magnet’s bore. b. The magnet attracts any ferromagnetic objects with an enormous force c. This magnetic field designation in the MRI theatre is designated within
the periphery of the green circle on the floor.
2. Smaller gradient magnetic fields: a. Low magnetic fields surrounding the periphery or fringe of the bore b. The MRI theatre has coloured circles on the floor which identify these
areas when the garage doors are open in the theatre. c. These OR theatre floor coloured markings provide safety boundary
reminders for personnel and are used when positioning instruments and equipment in the OR that are MR conditional or unsafe
d. The blue-coloured floor space is located outside the 5 gauss line. e. Illuminated warning signs are posted outside theatre doors leading to
the theatre
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3. Small electromagnetic radio-frequency (RF) electromagnetic fields: a. Produced during the MRI and create a potential risk of heating b. The magnetic MRI field will tend to induce currents in any conductive
materials, including those that may be non-ferrous. c. The most common sources of thermal exposure tend to be looped
medical equipment leads. Conductive loops can also occur when touching the patient, crossing the extremities, clothing, and drug delivery patches containing metal.
d. Small RF fields will generate current that is absorbed by the body as heat. Heating is more prominent at the periphery of the body than at its core, and may result in surface burns.
HAZARDS IN THE MRI THEATRE
The majority of risks in the MRI theatre are from projectiles, burns and implants which either fail or become dislodged.
1. Influence of magnetic field on ferromagnetic objects (projectile effect):
The main safety risk during an MRI results from the translation and torsion experienced by ferromagnetic objects within the magnetic field. This can lead to movement or malfunction of implanted medical devices and metal debris, and the acceleration into the bore of unsecured metal objects (projectiles). The best method to counter this risk is a comprehensive screening of all subjects and staff for ferromagnetic objects within their bodies or on their persons prior to entry into the magnet room. Constant vigilance and testing is required to keep the MRI suite free of unsecured ferromagnetic objects that may become dangerous missiles. A ferromagnetic object will experience a magnetic pull that increases greatly up to 40 mph as it approaches the magnet bore. A patient in the bore of the magnet could be seriously injured or killed by such a projectile. All ferromagnetic objects must be located outside the 5 gauss line or outside of the MRI theatre. a. It is essential for personnel to remove all ferromagnetic objects before
entering the magnet room including pagers, cell phones, stethescopes, pens, watches, paperclips and hairpins. Pockets shall be checked with each entrance to the OR.
b. Ferromagnetic vascular clamps including some aneurysm clips might rotate slightly and cause bleeding;
c. Tatoos and certain makeup (mascara and eyeliner) may contain iron oxide pigments. The irregular shapes of the iron oxide pigments try to align with the magnetic field and may cause swelling and irritation;
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d. Metal fragments embedded in a patient’s eye may move in the magnetic field and result in vision loss in that eye; and
e. Metal implants, including stainless steel sutures, cochlear implants, infusion pumps, neuro-stimulators, pacemakers, may become dislodged due to the effects of torque and pull from the magnet.
2. Influence of radio frequency electromagnetic fields: Brief applications/pulses of radio frequency (RF) electromagnetic fields are used during imaging. RF fields are restricted to the imaging room. The human body is electrically conductive by nature and small RF fields will generate current that is absorbed by the body core as heat. The heating will be more prominent at the periphery of the body. The main patient safety risks from the radio frequency field used in the MRI are peripheral tissue heating and burns. Metal devices absorb RF energy and become hotter than surrounding tissue. The best method to prevent this is a comprehensive screening to exclude all individuals with metal objects from the scanner room. This includes external metal objects such as jewelry, or internal devices such as implanted devices. Also ensure that conductive materials such as wire leads which might act as RF antenna do not come into contact with the patient’s skin. Ensure wire leads are not looped and that wires do not run over bare skin. Conductive loops can also be created with the patient’s limbs. Patients should not be positioned with their hands/legs/knees touching each other to create loops. Pacemakers and other implanted electrical devices may malfunction due to RF interference. Deaths have been reported during MRI procedures due to pacemaker malfunction. 3. Influence of acoustic noise:
The rapid changes of current with the gradient coils cause the coils to vibrate. Loud noised are created when these moving coils and their mountings vibrate.
Hearing protection earplugs or headphones must be worn by all patients, and by individuals who remain in the OR during scanning. Ensure the earplugs are properly inserted into the patient’s ears and are secured in place with tape.
4. Contrast agents: Contrast agents are occasionally injected into the patient as part of the MRI procedure. Risks associated with administration of these agents include reaction issues, contrast agent toxicity, allergy, and renal complication
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SAFETY GUIDELINES
MRI suite safety protocols include design of restricted areas, education and screening to all personnel who enter the theatre, and understanding how to react in emergency situations. The standard for safety access zoning is as follows: 1. Access zones: MRI suites are designed to restrict access and limit exposure to static magnetic fields. Access is restricted by zone. Zone 1 is open to the general public. It offers the least exposure to patients, visitors, attending physicians, hospital staff. This is often the reception and waiting area for the MRI suite. Its purpose is to channel patients and medical staff to the pre-screening area (zone 2) and to restrict further entry into the MRI suite. Zone 2 restricts public access and is the entry way into zone 3. Ferromagnetic objects are safe in this zone, but must be removed here. In zone 2, the patient is pre-screened and completes the documentation. The patient is gowned and personal items are removed and transferred to a family member. When entering zone 3, the patient’s gown must be MRI-safe and be free of metal snaps. If ambulatory, the patient may be screened through a ferrous metal detector. Hand-held ferromagnetic detectors are also available. Non-ambulatory patients in wheelchairs or stretchers must be transferred to MRI-safe equipment. Any indication of a metallic implant or foreign object must be investigated. A patient with a history of orbital trauma or removal of ferrous-based materials from an eye will require an x-ray or CT scan prior to the procedure. Zone 3 is the MRI OR theatre. Entrance to the MRI theatre is restricted and clearly posted with warning signage. Only personnel screened and orientated to this area can enter. As a designated OR theatre, it and must also meet the same standards as any OR theatre. The MRI machine and its immediate surrounding area within its 5 gauss line are classified as zone 4. The MRI area has swipe card access. Access cards are allotted by the MRI technologist to personnel who have had MRI education and screening. All theatre personnel must wear scrubs, MRI-safe shoes and undergarments and contraceptive diaphragms. Personnel must avoid all jewelry, watches, metallic pens and metal-frame glasses. Pockets shall be checked with each entrance to the OR. Eye glasses shall be checked by the MRI Technologist and, if deemed to be ferromagnetic, a strap shall be used to secure them Surgical count of all sharps and miscellaneous items shall be performed prior to each scan and as per policy. All ferromagnetic items shall be removed from the draped patient prior to each scan. Any ferromagnetic object dropped to the floor shall be picked up immediately. Nothing shall enter the MRI theatre without approval of the MRI technologist. Non-essential equipment shall not enter the MRI theatre.
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Zone 4 is located within the 5 gauss lines surrounding the MRI machine. It exists in all dimensions. It has a floor marking which identifies its periphery in relation to whether the MRI machine is locked away behind storage doors, or advanced into the theatre. The area outside the periphery (zone 3) can only hold requires MRI-safe equipment. During the intraoperative MRI (iMRI), the patient remains in zone 4. The MRI technologist and theatre personnel also enter zone 4 to guide/position the anesthetized patent safely into the MRI machine. Once the patient is safely positioned, they do not remain in zone 4. The anesthetic machine will have long extensions so that the machine can be moved out of zone 4. The construction of the HSC MRI area is unique: the hallway outside the theatre is classified as zone 1. There is no zone 2. The theatre contains zone 3 and 4. The patient is interviewed, screened and prepared for entry into the MRI theatre while in the preoperative holding area. 2. Educational Requirements: All individuals working or observing within zones 3 and 4 must:
- Watch the MRI safety video - Level 1 Safety Training - Complete the MRI Environment Screening Form for Staff & Visitors
Questionnaire (see Appendix) - Level 2 Safety Training - Have had an orientation to the area provided by specialty champions - OR personnel shall review this MRI Orientation Manual
3. Screening Requirements: Staff: All personnel shall complete the MRI Environment Screening Form for Staff & Visitors, which will be reviewed by an MRI technologist to verify each individual is safe to work in an iMRI environment. These records are kept on file, and each person is responsible to update their information as needed. Any failures to meet this requirement shall be reported to the appropriate department Manager. Personnel who have not completed this requirement will not be allowed into Zone 3 or 4 during scanning. Although permitted to work in and around the MR environment, pregnant personnel are requested not to remain within zone 3 or 4 during scanning.
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Patients: Patients will be screened by the MRI technologist prior to their procedure:
- Patients with contraindicated metal implants may not enter zone 3; - Patients with a history of potential ferromagnetic foreign object
penetration including orbit trauma must undergo further investigation; - Some contrast agents cross the placenta readily and further assessment
is required for pregnant patients receiving IV contrast media. There is no evidence that MR imaging during pregnancy is harmful. However, a cautious approach should be taken;
- Patients who are to receive MRI contrast during the surgical procedure will also complete and sign a MRI Contrast Patient Information Sheet (see Appendix); and
- Patients undergoing surgical procedures will complete and sign a Patient MRI Safety Checklist (see Appendix).
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4. Symbols:
MR safe symbol
- As defined by the ASTM International guidelines - A white square with green border and letters - Also may be a green square with white border and letters - Applied to an item that poses no known hazards in all MR
environments
MR unsafe symbol
- As defined by ASTM International guidelines - A white circle with red edge and red slash and black lettering - Is a known threat or poses a hazard in all MR environments
MR conditional symbol
- As defined by ASTM International guidelines - A yellow triangle with black border and lettering - Poses no known hazard in a specified MR environment with specified
conditions of use - Alerts the user that there are certain limitations to use - Conditions of use should also be included on the label
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EMERGENCY SITUATIONS
1. Cardiac arrest: If the patient undergoes a cardiac arrest during the MRI scan, unplug the coils from the MRI machine. The magnet shall be retracted from the procedure room and the shielded doors closed. Treatment including CPR can be initiated as the magnet is being docked. Once docking is complete, additional emergency equipment may be brought into the theatre. The Adult OR code blue cart is located outside the MRI theatre door. It may not be brought into the theatre until the magnet is completely retracted, the shielded metal doors are closed and the warning sign outside the door is no longer illuminated. Prior to CPR, the patient’s head must be released from the intraoperative head fixation device. The flat OR bed head rest is reattached the bed. If the patient is in prone position at the time of the arrest, CPR may be initiated in the prone position with a support under the sternum. The MRI-safe stretcher can be retrieved from the magnet storage room while the magnet doors are open. The patient can then be turned to supine position for compressions. The ZOLL R-Series Plus defibrillator may be operated as an automatic electronic defibrillator (AED), which is optimal. It may also be used in a manual mode. Code Blue Process – Interventional Radiology IMRIS Suite Code Blue emergencies occurring in the IMRIS Suite (second floor of the Kleysen Building) will be called as per the Code Blue Policy 110.050.010. To initiate a Code Blue: Dial 55 – state “Code Blue, Kleysen Building Level 2, OR1 or OR2 or MRI Clinic” If magnet is in the room, use visual Code Blue sign to signal to Control room personnel who will place the Code Blue call To prevent a hazardous situation, no one is allowed to enter or exit the procedure room when the magnet is in that procedure room. In the event that the MRI magnet is in use in the procedure room when the patient experiences a cardiac or respiratory arrest, the staff person designated by the Charge MRI technologist to unlock the IMRIS suite/SICU door will do so after the magnet has been returned to the Diagnostic Room. This will ensure safe environment when the Code Blue Response Team enters the procedure area. In the interval while the magnet is being housed, IR room personnel present in the IR room will provide CPR to the patient until the Code Blue Team is able to enter and take over resuscitation.
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Code Blue Process – Operating Room IMRIS Suite Code Blue emergencies occurring in the IMRIS Suite (second floor of the Kleysen Building) will be called as per HSC Adult Operating Room policy. When the magnet is in the OR: To initiate a Code Blue call, depress the blue code blue button on the wall and telephone the OR desk at 3524 to call the code. When the magnet is behind the shielded doors: To initiate a Code Blue call, depress the code blue button on the wall, and press ‘100’ on the Dukane intercom: state “Code Blue MRI Theatre” three times, as per standard OR Code Blue protocol. To prevent a hazardous situation, no one is allowed to enter or exit the operating room when the magnet is in that operating room. All OR Code Blue team personnel including the In-House Anesthetist (IHA), Perioperative Aide/Multiskilled worker, and High Risk Anesthesia nurse scheduled for work when an iMRI procedure is scheduled, must have had a safety assessment and received Level 1 safety training. Code Blue Process – Interventional radiology IMRIS Suite Code Blue emergencies occurring in the IMRIS Suite (second floor of the Kleysen Building) shall be called as per the HSC Code Blue Policy 110.050.010. To initiate a Code Blue: Dial 55 and state “Code Blue, Kleysen Building Level 2, OR1 or OR2 or MRI Clinic” When the magnet is in the room, use visual Code Blue sign to signal to control room personnel who will place the Code Blue Call. To prevent a hazardous situation, no one is allowed to enter or exit the procedure room when the magnet is in the room. In the event that the MRI magnet is in use in the procedure room when the patient experiences a cardiac or respiratory arrest, the Angio Technologist shall unlock the IMRIS suite/SICU door as the magnet is being retracted back to the Diagnostic Room. This shall ensure a safe environment when the Code Blue Response Team enters the procedure area. In the interval while the magnet is being housed, interventional radiology personnel present in the room shall provide CPR to the patient until the Code Blue Team is able to enter and lead the resuscitation treatments. 2. Quenching (rare): MRI machines are cooled by liquid helium. The release of this helium into the atmosphere is called quenching and is normally associated with de-energizing the MRI machine. However, it may be initiated in an emergency situation such as in the case of a
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patient who is suffering severe injuries as a result of being pinned against the magnet. The decision to quench is made by the MRI technologist or surgeon, and the quenching is performed by the MRI technologist. Once the quench process has been initiated, the helium is vented from the machine, and a loud rushing sound may be heard. The process takes about 20 seconds. The machine will now be subject to increased levels of oxygen surrounding it. The patient should be removed as quickly as possible and any sources of possible ignition near the machines should be minimized or removed. Non-essential staff should leave the room. Another risk is a quench pipe breech which could flood the room with cryogenic fluids. This creates an asphyxiation hazard for the patient and attending staff and the area should be evacuated immediately. 3. Electrical emergency: The MR technologist will activate an emergency electrical shut-down. This may be required for a fire, activation of the sprinkler system or malfunction of the MR machine. 4. Fire: In the event of a fire in the MRI theatre:
- Remove patient and personnel from immediate danger and evacuate the MRI theatre. If the magnet is in use at the time of the fire, personnel must manage the patient and the fire as per fire orders until the magnet is docked;
- Ensure the door is closed; - Call the code as per HSC Code Red Fire Emergency Policy 90.20.090; - Activate the fire alarm; - Activate a Code Red: Dial 55 – state “Code Red, Kleysen Building
SR2” - OR1 or OR2 or MRI Clinic”; - Try to extinguish the fire with a MRI-safe fire extinguisher located
near the theatre door; - Activate the emergency shut down procedure; - If it is evident that fire-fighting personnel will need to enter the room
quenching must also be activated to ensure safe entry for ferromagnetic objects;
- Heat from a near-by fire may increase the temperature of the helium and automatically quench the magnet;
- Fire department personnel may not enter the IR/OR until the magnet is retracted and the warning sign located outside the theatre door is no longer illuminated.
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5. Emergency Evacuation: Follow evacuation plan policies for the building as directed by the MRI technologist.
THE SURGICAL PROCEDURE
Intraoperative MRI will be performed at this time mainly for patients booked for intracranial tumour removal procedures. A dedicated group of OR personnel including nurses, ORTs and perioperative aides shall be trained to work in the MRI theatre.
The designated OR space associated with the MRI theatre designated as “Operating Room # 2” includes:
- A scrub sink outside the theatre - An OR code blue cart stored in the hallway directly outside the theatre - A sterile core area which opens to the theatre and a second door to the
hallway - A utility room - A OR storage room similar to a sterile core which opens to the hallway
Patient Flow Prior to Surgery:
Clinic appointment with Neurosurgeon
Surgery date is booked with OR and MRI screening visit occurs (same day) The Surgical booking form will be completed and sent to OR scheduling a minimum of 3 working days prior to the date of the procedure.
Immediately following the appointment where the decision is made to perform an iMRI surgical procedure, the MRI department will be notified and the patients will be directed to the Green Owl Level 1, GC 191 MRI Reception Desk for MRI safety testing. Appointment for PAC visit
Surgical admission to MS3 on morning of surgery
Transported to OR preoperative holding area
Patient is assessed by nurse and screened by MRI technologist
Patient is assessed by anesthetist
Patient transported to MRI OR theatre
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Nursing Considerations on Day of Surgery:
- Pick up the keys to the MRI theatre and storage rooms from OR desk - The surgical case cart will be located in the SICU area beside the
secure door to MRI hallway. It will be placed there by Adult OR night personnel prior to the day staff arrival.
- Pick up case cart and use swipe access card to enter MRI area - Bring case cart and any required surgical supplies into the MRI theatre - Ensure that no magnetic items including chains, watches, keys,
lanyards, electronics, ferromagnetic pens and glasses, ear rings, etc. are on any theatre personnel prior to entry into the theatre
- Set up the theatre for the surgical procedure - The preoperative patient interviews and pre-procedure screening will
be conducted in the preoperative holding area. As well as standard anesthesia and nursing preoperative assessments, the following is completed:
i. MRI Preoperative Patient Safety Checklist together with MRI technologist (See Appendix)
ii. MRI Contrast Patient Information Sheet is completed by the MRI technologist if IV contrast media is to be administered (see Appendix)
- The patient is transported into the theatre and positioned on the MRI-safe OR bed. The bridge of the patient’s nose is positioned at the level of the red line on the OR bed head-board.
- Ask the perioperative aide to return the empty stretcher to the preoperative holding area
- The patient is anesthetized, and positioned with their head secured in the MRI-safe head fixation device
i. A torque screw force of 60 pounds (270 newtons) is applied for adults
ii. See Appendix for MRI Equipment including MRI-safe head- fixation device and special instructions
- MRI coils are positioned under the patient’s head by the MRI technologist and contained in a plastic bag
- A preoperative MRI is taken prior to prepping and draping - Counts are completed by nursing and anesthesia personnel
immediately prior to performing each Pre-Magnet Entry All Clear Safety Checklist and immediately following each MRI scan (See Appendices)
- If the patient is to be in prone position, ensure the MRI-safe stretcher is available inside the magnet storage room for easy access when the magnet doors are open. The stretcher is used to turn the patient to supine position for CPR during a code blue.
- Immediately prior to the magnet entry into the room, all power is shut off to the room. Equipment works from batteries. The analogue
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telephone and code blue button will remain operational - The patient is prepped and draped, and the surgical procedure begins
- Each time an iMRI scan is performed all ferromagnetic items are placed outside the 5 gauss line, counts are completed, and a Pre-Magnet Entry All Clear Checklist is performed immediately prior to magnet entry
- Team members should keep their distance from the magnet ant not put themselves between the magnet and he object they are holding. Whenever possible walk outside the 5 gauss line when carrying equipment or instruments.
- Sterile drapes including a C-arm drape are applied to protect the sterile field during the scan
- Following the scan, the C-arm drape is cut open on top with MRI-safe scissors, and the sterile field protective cover drapes are removed
- Immediately following each magnet exit, a count is performed by nursing personnel for items on the surgical field and by anesthesia personnel for items on the anesthetic cart
- If a sterile item is requested from MDR, it shall be delivered to the OR desk, a perioperative aide will the transport the item to the MRI theatre.
- If an item is requested from the Adult OR core, it shall be transported to the MRI theatre by a perioperative aide
- Call for the postoperative bed prior to the end of the procedure - The patient is transported to PACU postoperatively as per standard
practice - At the end of the case, the covered soiled case-cart is transported to the
Adult OR and is sent to MDR as per routine processes - At the end of the case a perioperative aide will clean the theatre and
scrub sinks as per routine OR terminal cleaning processes. A housekeeping cart is stored in the OR utility room located next to the MRI theatre
- See Appendices for Code Blue Poster and Fire Orders Poster
Considerations for Perioperative Aides:
- Telephone numbers for the iMRI OR are as follows: i. Nurses telephone beside computer is 75656
ii. Analog telephone on service arm is 75667 iii. MRI control room is 75659/75662;
- Patients going to the MRI theatre will be taken to induction room # 2
in the preoperative waiting area;
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- Ensure patients from MS3 have a gown with no metal snaps, and their identification tag is taped to the gown and NOT secured with a metal safety pin. If this is not done on MS3 a supply of blue patient gowns with no snaps is located in preoperative holding room #2;
- Always use MRI-safe oxygen tank if oxygen is required preoperatively
or postoperatively. Return to MRI department immediately or as soon as possible. The perioperative aide shall follow the patient to PACU and retrieve the tank;
- Armboards are not MRI safe and must be removed from the OR bed;
- If patient is not going onto a stretcher postoperatively, remove
stretcher immediately after patient is transferred to OR bed, and return stretcher to preoperative waiting area. Otherwise a bed will be provided as per the OR slating clerks. The patient transfer board is located on the wall beside the MRI theatre door;
- During a code blue the MRI-safe stretcher shall be used when flipping
a prone patient. It is located in the magnet storage room and can be accessed when the magnet doors are open.
- Ensure the OR bed is in the locked position after the 180 degree turn; - Ensure all clamps and bed attachments are tightened/secured to the OR
bed;
- A baby flannel lifting sheet shall be placed at the shoulder level of the OR bed for positioning;
- All gel positioning devices must be covered with pillow cases or arm-
board covers. Please ensure gel positioners are not sent to laundry. Clean the gel positioners and re-cover before leaving the IMRI OR so they will be ready for subsequent cases;
- The Neptune is to be kept outside the MRI OR as it interferes with the
magnet. The nurse or aide will bring the Neptune into the theatre at the end of the case to suction any fluids;
- An empty case cart is brought to the MRI theatre at the end of the case
to transport any garbage or linen which is taken to the Adult OR for routine transfer to MDR; and
- The MRI OR housekeeping room shall remain unlocked at all times.
Please inform the OR manager if any suspicious activity is observed in this area, as it is unattended over the night shift.
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Note to All Personnel: - Never lose awareness of the magnet - Any incidents shall be reported to the area managers/supervisors and
the Workplace Safety and Health Committee - Personnel who violate safety rules will be banned from the area and
will require additional education prior to being allowed back into the iMRI theatre.
REFERENCES
1. Vandenhoven, H. and Wozniak, L. (date unknown). Intraoperative magnetic resonance imaging theatre: MR personnel orientation manual. University of Alberta Hospital: Edmonton Alberta.
2. Vandenhoven, H and Wozniak, L (date unknown). Intraoperative magnetic resonance imaging theatre: Standards of practice. University of Alberta Hospital: Edmonton, Alberta.
3. MRI safety intro. Retrieved from http://www.mr-tip.com/serv1.php?type=mri_safety&p=intro March 7, 2013.
4. MRI safety tutorial. Retrieved from http://www.biac.duke.edu/research/safe/tutorial.asp March 11, 2013.
5. Willis HRH Strategic Outcomes Practice Technical Advisory Bulletin (2009). Magnetic resonance imaging hazards and safety guidelines. Retrieved from http://www.willis.com/Documents/Publications/Services/Claims_Management/MRI_Safety_August_2009_v6.pdf March 15, 2013.
6. Allan, M., Feast, R., Gledhill, M., Hurrell, M., Oliver, J. & Tremewan, T. (2002). Magnetic resonance imaging safety guidelines. Publisher unknown.
7. HSC (2013). HSC Policy 110.050.010 Code blue paging & response (adult, child, newborn or NICU infant). HSC.
8. HSC (2009). HSC Policy 90.20.090 Code red fire emergency. HSC. 9. WRHA (2008). WRHA Policy # 110.050.010 Code Blue Team Resuscitation in
Acute Care. WRHA. 10. HSC (2013). Policy # 80.110.024. HSC Code Blue Paging and Response (Adult,
Child, Newborn or NICU Infant). HSC.
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IMIRIS MRI-SAFE EQUIPMENT
IMRIS MRI-safe OR bed secured to the floor – swings from side-side
IMRIS MRI-safe intraoperative headrest
IMRIS MRI-safe coils
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SPECIAL INSTRUCTIONS For the iMRI Suite Head Fixation Device
STERILIZATION: THIS ITEM IS NOT TO BE AUTOCLAVED
• iMRI Imris bed attachment to decontam/MDR for manual cleaning after a
case. • Included are photos of the components assembled/disassembled. The device is
disassembled in decontam for cleaning, and decontam will reassemble after drying the cleaned device.
• Depending on the case done, the attachments sent for cleaning may vary.
Included are photos of all components
Bed attachment --- neurosurgery iMRI suite --- assembled
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Bed attachment --- neurosurgery iMRI suite --- disassembled
Skull clamp --- neurosurgery iMRI suite --- assembled
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Skull clamp --- neurosurgery iMRI suite --- disassembled
Re-useable Skull Pin Disposable Skull Pin (All gold with single black band.) (All black plastic, with gold tip.)
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Holder for iMRI coil
Holder for cranial reference frame
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ONCE DEVICE IS RETURNED FROM MDR:
• Make sure the device components and hinges are inspected for cleanliness. The item shown in the picture below will be sterilized in the navigation cranial pan 001
Stealth Cranial reference frame holder: Catalogue # PN9733825
• The OR requires the device to be returned loosely assembled. Reference the photos for device configuration.
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iMRI Checklist – Interventional Radiology Patient positioning checklist "Pre drape" Pre Post QA
Non-MRI compatible stretcher, oxygen tanks and monitors removed Old leads removed Old linens removed and new linens on Angio table MRI safety questionnaire completed Visual check for non MRI compatible objects Patient head positioned in head coil No skin to skin contact Monitor wires and IV lines straight without loops and protected from pt's skin Foley bag taped and catheter protected from patient's skin
Pre Magnet Entry "All Clear" Pre Post QA Anesthesia counts correct Anesthesia machine brakes on and outside 50 Gauss line Anesthesia cart/blades/laryngoscope handle clear of 5 Gauss line Nerve stimulator off patient and outside 5 Gauss line Nursing counts are correct All instruments removed N/A N/A Vital signs monitor and infusion pumps outside 50 Gauss line The following items are outside the 5 Gauss line: Bear hugger Instrument tables Booms and lights Clipper & charger Unplug and move injector Portable lead shields Foot pedals Unplug and move coil/stent detachment devices Table controls are moved to end of table and lead is folded back Drapes are applied to operative field Pressure bags are secured with tourniquets Suction is Ready (at table side) Patient is wearing earplugs Nursing computer is powered down All unnessassary supply carts removed from room Pocket checks All clear declared MR technologist initials Circulating nurse initials Interventional technologist initials MR technologist signature: Circulating nurse signature: Interventional technologist signature:
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CODE BLUE: ADULT OR
DO NOT OPEN THE THEATRE DOOR IF THE MAGNET IS IN THE ROOM!!
In the event of a code blue:
1. MRI retraction process shall be initiated by MRI technologist
2. If magnet is out, push blue button and telephone 3524 to call the code. If the magnet is not out, use blue code button and intercom
3. Remove head fixation and replace bed head 4. Initiate CPR
a. CPR may be initiated in prone position until patient can be turned to supine
5. DO NOT OPEN THE THEATRE DOOR UNTIL THE MAGNET IS RETRACTED!
6. Assist anesthetist with medications and provide equipment to scrubbed team
7. When the magnet is retracted and the magnet door is closed:
a. Bring in code blue cart and plug in b. Turn on ZOLL defibrillator c. Connect ZOLL defibrillator pads to
patient’s chest to monitor and shock d. Assist as required
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CODE BLUE: INTERVENTIONAL RADIOLOGY
DO NOT OPEN THE THEATRE DOOR IF THE MAGNET IS IN THE ROOM!!
In the event of a code blue:
1. The MRI retraction process shall be initiated by the MRI technologist;
2. If the magnet is out, push the code blue button and telephone 55 to call the code and state “Code blue Kleysen Building, Level 2, OR1”;
3. Initiate CPR; 4. DO NOT OPEN THE THEATRE DOOR
UNTIL THE MAGNET IS RETRACTED! 5. Assist anesthetist with medications and
provide equipment to scrubbed team; 6. When the magnet is retracted and the
magnet door is closed the code blue response team may enter; and
7. Assist as required.
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FIRE ORDERS
DO NOT OPEN THE THEATRE DOOR IF THE MAGNET IS IN THE ROOM
In the event of a fire:
1. MRI retraction process shall be initiated by the MRI technician
2. DO NOT OPEN THE THEATRE DOOR UNTIL THE MAGNET IS RETRACTED!
3. Remove any burning material on or near the patient, smother with water/saline or use MRI-safe fire extinguisher as appropriate
4. Ask the technologist in the control room to activate the building fire alarm a. If the magnet is in the room dial 55 b. If the magnet is not in the room, activate the fire alarm across the hall from the theatre door
5. When the magnet is retracted and the magnet door is closed: a. Bring a stretcher into theatre b. Relocate patient if required:
i. Adult OR: MRI or Adult OR theatre ii. IR: Level 2 corridor or into MS3
6. Shut off or remove medical gas sources
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Access to Kleysen Building Level 2 Request Form Reason for Access: ________________________________________________________ Dates for which Access Required: Ongoing: Yes _______ No ________ If not Ongoing: From __________________ To: ______________ I confirm that: (initial each statement) • I have completed Safety Training*: Level 1_____ Level 2 ____ • I have read and can operationalize the Code Red and Code Blue Policies for the KIAM building _____________
I understand that I may not use my access to allow any other individual access to the Kleysen Building. I agree to abide by the policies, procedures, guidelines, and standards of the Winnipeg Health Sciences Centre. Name: (Signature) ____________________________________________ (Print) _____________________________________________ Department: _____________________________________________ Approved: Director of Research: ____________________________________________ Director, Diagnostic Imaging: ______________________________________ Director, Surgical Processes: _______________________________________ *Note: Safety Training consists of: Level 1 Level 2
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Kleysen Institute iMRI Operating Room Utilization Policy
1. KIAM SR2 is only accessible by card access. Access is granted after the following conditions are met:
• Access has been approved for clinical/research purposes on humans; • MRI safety training/safe access has been approved by the MRI technologist;
• MRI training by the Champion responsible for the relevant professional group has been completed and sign‐off affirming same has been sent to the MRI Department.
2. Doors to the ORs are locked at all times when not in use. Arrangements for
unlocking/relocking must be made with the Manager, Adult OR to access the Neurosurgical OR and the Charge Technologist, MRI to access the Interventional Radiology OR.
3. All equipment/instruments purchased for the iMRI OR shall remain within the
iMRI OR. Some equipment is stored in the attached sterile storage room. 4. Traffic in the OR corridors shall be kept to a minimum. Quiet entry and egress is
required.
5. There is a three (3) business day booking rule for all iMRI OR surgical procedures.
6. An MRI technologist shall be present when the MRI is in use.
7. All personnel shall: • Comply with the HSC MRI Standards of Practice protocols including abiding by the safety procedures for placement of equipment prior to allowing the MRI magnet into the OR. The standards are available in the suite and on request from the Adult OR.
• Complete a count of all instruments/equipment brought into the OR for clinical and research activity (both MRI and non‐MRI procedures). Complete the count on arrival into the OR and at the end of the procedure. All equipment brought into the OR shall be removed at the end of the procedure. Counts shall be maintained and available for review.
• Familiarize themselves with the iMRI Code Blue and Code Red procedures. • Wear freshly laundered hospital issued surgical greens and bouffant hair coverings. Cost recovery will apply.
• Have eyeglass frames tested for magnetic properties. Use an approved strap if required.
• Not bring food or drink into the OR or the control room.
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• Not bring electronic devices into the OR unless approved by the MRI technologist.
• Not bring potential magnetic items into the iMRI OR such as chains, watches, keys, lanyards, pens, jewelery including all earrings, rings, piercings, necklaces, bracelets.
Note: Non‐compliance with the above policies will result in revocation of iMRI OR access. Anyone failing to comply with the policies will be responsible for damages caused by that non‐compliance.
