Chapter 30

Equipment for the Magnetic Resonance

Imaging Environment
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Magneti c resonance i magi ng1 (MRI) i s a noni nvasi ve di agnost ic procedure that can
produce superi or i mages wi t hout usi ng ioni zi ng radi at i on. MRI studi es are not
pai nf ul but do requi re pati ent immobi l i ty. Pati ents who are unable to hol d sti l l of ten
requi re sedati on or general anesthesi a. Medicall y unstabl e pati ents such as those
f rom intensive care may need scanning. A more recent devel opment is the use of
MRI t o gui de and moni t or i nterventi onal procedures (1,2,3,4, 5,6). MRI -guided
procedures may resul t in smal l er i ncisions as wel l as more accurate l ocal i zati on
and t i ssue ret ri eval .
Admi ni st eri ng anest hesi a i n the MRI uni t poses a number of techni cal di f f icul t i es.
Knowl edge of thi s envi ronment as wel l as i ts risks and probl ems are essenti al for
saf e anest hesi a pract ice. The practi ce gui del i nes f or anesthesi a care and
moni tori ng devel oped by the Ameri can Societ y of Anest hesiol ogists and the
American Associ at ion of Nurse Anestheti sts appl y to the MRI envi ronment j ust as i n
ot her part s of t he heal th care f aci l i ty (8). I n some stat es, t hese gui del i nes are
codif i ed i nto l aw (9).
Definitions
A devi ce i s consi dered to be MR saf e if i t presents no addi ti onal ri sk t o the pati ent
or operator. The presence of such a devi ce may af fect t he qual i ty of the di agnost i c
i nformati on when i t is placed i n the MR envi ronment (10, 11,12,13,14).
A devi ce i s MR compat i ble i f i t is MR saf e, i t s use i n the MR envi ronment does not
si gni f icant l y af f ect i magi ng qual i t y, and there is no signi f i cant eff ect on i ts
operati ons. A devi ce may be MR compati bl e or saf e for certai n MR envi ronments
but not others. Theref ore, usi ng the terms MR compat ible and MR safe wi thout
speci f i cati on of the MR envi ronment to whi ch the devi ce was t ested shoul d be
avoided. The term MR envi ronment i s used t o descri be the area wi thin t he 5-gauss
l i ne around the scanner (t he peri meter around an MR scanner wi t hi n whi ch t he
stat ic magnet f i el d i s hi gher t han 5 gauss).
Basic Principles
There i s a stat i c magneti c fi el d i nside the MRI scanner bore
(7,13,15,16,17,18, 19,20,21, 22,23). Once the magneti c f i el d i s establ ished, i t i s
usual l y not turned OFF. If the magnet i s deacti vated, i t can t ake up to 96 hours to
reestabl i sh the magneti c f i el d. The uni t of measurement of magnet i c f i el d strengt h
i s the Tesl a. A fi el d of 1 Tesl a i s roughl y 10, 000 ti mes t he magneti c fi el d at t he
earth' s surf ace. One Tesl a equal s 10,000 gauss. The st rengt h of a magnet is
quant if ied i n the mi ddle of t he magnet . However, t he f ield extends beyond the
margi ns of the magnet (t he f ri nge f i el d), decreasi ng in st rength wi t h di stance f rom
t he bore.
At omi c nucl ei wi t h an odd number of protons and/or neut rons have a spin t hat
produces a weak l ocal magneti c f i el d. I n the absence of a st rong magneti c f i el d,
t hese nucl ei are randoml y al i gned. A st rong magneti c f i el d causes approxi matel y
half of them t o rot ate and al ign parall el t o this appl ied f ield (the l ow-energy, or
ground, stat e). The remaining nucl ei al i gn agai nst the appl ied f i el d (the high-
energy, or exci ted, stat e).
Resonance descri bes the process of i nducing a change i n energy stat es of t he
nuclei caused by absorpt ion of a specif ic radi o f requency (RF) radi ati on. Addi ng
energy wi t h a short, cont rol l ed burst of RF energy causes some l ow-energy
(parall el ) spins to jump t o the exci ted (ant i -paral l el ) energy l evel . Immedi at el y af ter
t he RF pul se, t he nuclei rotate back i nto al ignment wi t h t he st atic magnet ic f i el d. As
t hey return to t hei r original ori entati on, energy i s rel eased. A recei ver coi l det ects
t his weak el ect ri cal si gnal and ampl i f i es i t for processi ng and eventual i mage
f ormati on. Relaxat ion rat es vary f or specif i c body t issues, al lowi ng dif ferenti at i on of
body structures.
Facility Design
A member of the anesthesia department shoul d be i nvol ved i n planni ng the MRI uni t
(24,25). An anesthesi a i nducti on room that adj oins t he scanni ng area is usef ul . The
anesthet ic can be ini t iated at thi s l ocat i on, where f erromagnet ic obj ects can be
saf el y used. The anesthet i zed pati ent can then be moved i nto t he scanni ng area.
Consi derati on shoul d be given to pl acing a postanesthesi a care room near the MRI
uni t .
Wave guides, speci al l y desi gned condui ts in t he wal ls, can be used t o pass pi pes,
cables, ducts, tubi ngs, and el ect ri cal wi res through the wal l whi l e mai nt ai ni ng RF
shiel di ng (26, 27) (Fi g. 30.1). They are commonly placed low i n the room at the
f art hest poi nt f rom the magnet and RF coi l s.
Fl uorescent l i ght ing emi ts RF energy that i nterf eres wi t h i maging (21). Therefore,
i ncandescent l i ght ing at a l ow wat t age i s used. Isolated electrical power i s used t o
reduce t he probl em of l eakage currents (10). I t i s i mportant t hat t here are an
adequate number of el ectrical pl ugs at conveni ent locat ions for portable moni tors
and other equi pment.
There are f our basic opti ons f or l ocati ng moni tori ng and ot her equi pment that is
used to admi ni ster anesthesia or sedati on and the person at tendi ng the moni t ors
and pati ent :
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View Figure

Figure 30.1 Wave guides are used to pass cables, tubings,
sires, and the like through the wall while maintaining radio
frequency shielding.

Bot h the moni t ors and t he att endant are i nsi de the magnet room. Thi s al l ows
di rect observat ion of the pat i ent. The attendant can both see and hear t he
moni tors, but t he at tendant i s subj ect to possi bl e hazards (l oud sounds,
magneti c f orces, and possi bl y t race anestheti c gases or hypoxi a). I t may be
necessary f or t he at tendant to be i n t he room when there i s an i nabi l i t y to
see t he pat i ent , parti cul arl y if t he pat i ent has entered the scanner headfi rst
and/or the pati ent is a chi l d (28).
The moni tors are i nsi de t he room wi th t he at tendant outsi de. The pat ient and
moni tors can be vi ewed through a wi ndow or by using a tel evi si on camera.
Li ght -emi t ti ng di ode (LED) displays are usual l y easi er t o read f rom a
di stance than l i qui d crystal di spl ays (21). Remote auscul tati on usi ng
speci al ly desi gned equi pment can be used to moni tor heart and respi ratory
sounds (29). A drawback i s that moni t or sounds and alarm signal s may not
be heard wel l by the at tendant.
The t hi rd opti on is to have t he moni tors outside and the at t endant i nsi de the
room. Most equi pment can be kept outsi de the scanner room wi th cabl es and
such runni ng through wave gui des (30, 31). The attendant can observe t he
moni tor t hrough a wi ndow or a tel evision screen but cannot hear moni tor and
al arm sounds wel l .
The l ast opt ion i s to have both the moni tors and the att endant outside the
room. The att endant can see the moni tors and can hear t he al arms and
sounds but cannot observe t he pati ent wel l .
I f the att endant i s outsi de the room, he may f ai l to detect dangerous si t uat i ons i n a
t i mel y manner (32). There is a report of a pat i ent dying during an MRI procedure
when t he pneumat ical l y-driven venti lator ran out of oxygen (33). MRI audi t ory al arm
si gnals need to be much louder t han those used i n the operat i ng room due to the
si gni f icant scanner noi se.
Problems
I t i s i mportant to note t hat some devices that are stated to be MR compat ible have
l i mi tati ons or restricti ons t o thei r use in t he MR envi ronment , and i f t hey are not
used i n accordance wi t h these restri ct ions/ l i mi tat i ons, they can pose the same
t ypes of hazards as devi ces that are not MR compat ibl e (14,34).
Ferromagnetic Materials
Al l mat eri al s can be cl assi f i ed as ei ther paramagnet i c or di amagneti c
(7,15,16,17,18,21, 22,27,35, 36,37,38, 39,40,41,42). Paramagnet i c materi als are
weakl y att racted and di amagneti c materi al s are weakl y repel led by magnet i c f i el ds.
Ferromagneti sm is an extreme form of paramagnetism exhi bi ted by a smal l group of
materi al s that are powerf ul l y at tracted to magnet i c f i elds. Ferromagneti sm is shown
by devi ces containing i ron, i ron oxide, i ron-cont ai ni ng al l oys, ni ckel , and cobal t
(43).
Dependi ng on the conf i gurat ion of the magnet ic f ield and t he shape and mass of the
obj ect and i ts posi ti on wi thi n the magnet i c fi el d, t hese f orces can resul t i n
rotati onal (t orque) and/ or t ransl ati onal (att racti ve) moti on of the obj ect.
Ferromagnetic Materi als External to the Patient
The at t racti ve f orce exerted on a f erromagnet i c obj ect depends on the di stance
bet ween t he obj ect and t he center of the magnet , t he mass and geomet ry of the
obj ect, t he st rength of the magnet , and f actors that modi f y the f ield confi gurat i on
such as magneti c shi el di ng.
The at t racti ve f orce i ncreases rapi dl y as one nears the magnet and can be several
t i mes t hat of the eart h' s gravi tati onal f i el d by the t i me i t reaches the center of the
magnet. When f ree, f erromagnet i c obj ects can move toward the magnet center wi th
dangerous speed (mi ssi le or projecti l e ef fect). This can resul t i n equipment
damage as wel l as seri ous i nj ury t o pat ients and/or workers tryi ng to rest rai n the
equipment or trapped between the equi pment and the magnet (14,44,45). Si nce t he
magnet i s cont i nuousl y ON, i t can at tract f erromagnet i c devi ces even when no
i magi ng is occurri ng. In addi t i on,
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si gni f icant masses of f erromagneti c materi al i n proxi mi ty to the magnet can di sturb
t he homogenei ty of the stati c magneti c fi el d, resul t ing i n di st orted i mages.
Ferromagneti c parts may work l oose over t ime, so precauti ons shoul d be taken
duri ng product desi gn to prevent t he i ncl usi on of components that could be pul l ed
l oose and att racted to the magnet bore (10). Removabl e equipment covers shoul d
use capt ive hardware (e. g. , screws and f asteners).
There are hundreds of ferromagneti c obj ects that must be kept out of the MRI room.
These incl ude personal i tems (wat ches, scissors, keys, paper cl i ps, nai l cl i ppers,
hai rpi ns, calcul ators, ident if icat ion badges, ci garet te l ighters, steel -t ipped/heeled
shoes, pens, j ewel ry, cl i pboards, pagers, cel l phones, f i rearms, etc. ); pat i ent i tems
(strap buckl es, saf ety pi ns, j ewel ry, zi ppers, metal gown fasteners, cont racept ive
di aphragms, cosmet ics contai ni ng metal l i c part i cl es (such as eye makeup), skin
stapl es, superf icial metal l i c sut ures, RF taggi ng bracelets, metal l ic handcuff s or
ankle cuff s, etc.), and medi cal devices (standard gas cyl i nders, hemostats,
needl es, vials, stethoscopes, chest tube stands, i ntravenous poles, st retchers,
wheelchai rs, mobi l e stands, cart s, anesthesi a machi nes, vapori zers, moni t ors,
defi bri l lators, sandbags, tract ion wei ghts, etc. ) as wel l as mop buckets, vacuum
cl eaners, l aundry carts, chai rs, l adders, l ight f i xtures, f l oor buff ers, and part s of a
f orkl i f t (12,38,39,40,46,47,48,49, 50,51). Non-l i t hi um batteri es are st rongl y
magneti c.
The presence or absence of f erromagnet i sm i n a given obj ect depends on a number
of f actors, i ncl udi ng i ts composi t i on and manufacture. Some obj ects that are
f erromagnet ic may sti l l be saf e because thei r mass i s too smal l f or t he f orces
i nvol ved t o be si gni f icant and/or because they are fi rml y anchored in posi ti on at a
saf e di stance f rom the scanner. One met hod i s to anchor al l devi ces that have
f errous materi al to a movabl e cei l i ng pendant system wi t h a predetermi ned l i mi ted
range of moti on (24). Even wi th a reduced ferrous load, some del icate i nst ruments
are sti l l f erromagneti c and subj ect to torque t hat can cause seri ous damage.
Theref ore, al l equi pment t hat is not requi red shoul d be removed f rom the si te.
Equi pment may be posi ti oned away f rom the magnet , i n a room adj acent t o the MRI
room wi t h tubings and wi res used to connect t o t he pati ent . The saf e di stance f rom
t he cent er of the magnet depends on fi el d st rength and shi el ding. I t is usual l y
consi dered to be greater t han t he 5-gauss l i ne (12). Equi pment contai ni ng
f erromagnet ic components shoul d not be al l owed past t he 5-gauss l i ne unl ess i t has
been label ed MR saf e f or t hat speci f ic MR envi ronment .
Al l persons enteri ng the scan room must be ri gorousl y screened f or i nternal and
external ferromagneti c materi al . Prominent warni ng si gns shoul d be posted. MRI
centers shoul d keep regi sters of commonl y used devi ces and whether they are saf e
t o bri ng i nto t he magnet room. The use of met al detectors i n MR envi ronments may
hel p, but i s not recommended by t he American Col lege of Radiology (49).
Nonambul at ory pati ents shoul d be brought i nt o the MR uni t by using a nonmagnetic
wheelchai r or wheel ed st retcher and t ransport equi pment checked for magneti c
obj ects (12).
Mat eri al s consi dered saf e in t he MRI scanner sui te i ncl ude al umi num, brass, ni ckel ,
pl ast i c, t i tani um, copper, beryl l i um, si lver, and gol d (43,52). Cert ai n types of
stai nl ess steel s are considered saf e, but others are st rongl y att racted i n t he
magneti c f iel d (11,38).
Bat t ery-powered equi pment should be tested at i ts i ntended locat ion and maxi mum
f iel d st rengt h to ensure that there is no si gni f i cant att ract ion. A magnet can be used
t o t est equi pment goi ng i nto t he MRI room (53). Most inst i tut ions have a cardi ac
pacemaker ri ng magnet , and this can be used.
Ferromagneti c screeni ng does not eval uat e the pot ent ial for RF-rel ated pat ient
i nj ury (53). Nonf erromagneti c metal s (e.g. , al umi num or copper) t hat would yiel d a
negat ive magnetic screen can absorb RF energy, resul t ing i n MR i mage art if act or
t hermal i nj ury to t he pati ent .
Implanted or Inserted Ferromagnetic Objects
Ferromagneti c obj ects wi thi n the pati ent are subj ect t o forces that try to bri ng them
i nto al i gnment wi th the magnet i c fi el d. The extent of i nj ury wi l l be af f ected by the
magneti c f iel d st rength, f erromagnetism of the obj ect, t he obj ect' s geometry and
ori entati on, the l ocati on of the obj ect in si tu, and t he l ength of t i me t he obj ect has
been indwel l i ng (f i brosi s or granul at i on t i ssue can serve to stabil i ze the obj ect ).
There are documented cases of death and bl i ndness resul t ing f rom MR i maging of
pati ents wi t h ferromagneti c i ntracerebral aneurysm cl i ps, cardi ac pacemakers, and
cl i nical ly occul t met al l i c i ntraocular (39,54,55,56). MRI i s cont rai ndicated f or a
pati ent wi t h shrapnel located in a bi ol ogi cal l y sensi t ive area. I t could move and
i nj ure the pat ient (10). Peopl e i n certai n occupati ons, such as sheet metal workers,
are at ri sk of havi ng magnet ic f ragments in t hei r bodies and i n many cases are not
aware of t hei r presence (39). Now that MR i magi ng i s a f i rml y establ ished
di agnost ic modal i t y, ef f ort s are bei ng made to use magneti cal l y compat i ble
subst i tut es for previ ousl y uti l i zed f erromagnet ic i mpl ants (39). For example, most
new cerebral aneurysm cl i ps are made of nonferrous mat erial (52).
The Food and Drug Admi nistrat ion (FDA) requi res that MR imagers be l abel ed to
i ndi cate that the devi ce i s cont raindi cated for pat i ents who have el ect rical ,
magneti c, or mechani cal impl ants because the energi es produced by MRI syst ems
may i nterf ere wi t h t he operati on of these devi ces (57). The composi t ion of the
device and i ts magni tude of magnet i c def lecti on shoul d be det ermi ned before these
pati ents are scanned. These
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devices i ncl ude pacemakers, cardi overt er-def i bri l lat ors, el ectromechani cal inf usion
pumps, cochl ear i mpl ants, neurosti mulators, bone-growth st i mulators, dent al
i mplants, bul l ets, magneti c sphi ncters, magneti c st oma pl ugs, magnet i c ocul ar
i mplants, t issue expanders wi th magnet ic posts, and magnet ic prostheti c appl i ances
(57). Problems may also occur wi t h magneti c obj ects t hat are at tached to t he
pati ent 's body (e.g., body pi ercing) (12).
Equipment Malfunction
Magneti c i nterf erence can cause computer or osci l lometri c i mages to be di storted
(7,21,27,58,59). Devi ces wi t h rechargeabl e bat teri es may swi t ch of f and bl ank thei r
screens. MRI i nt erf erence also causes transformers to become saturated and burn
out . RF pulses are al so capabl e of i nduci ng el ect ri cal eddy currents and short
ci rcui ti ng el ect ri cal equipment. The magneti c f i el d may cause damage or erase data
on magnet ic medi a such as di gi tal tapes or f loppy di sks.
Equi pment may contain pumps, electric motors, el ectroni c ci rcui t ry, or anal og
gauges t hat are af fected by the magnet ic f ield (10). The magnets i n motors may
become saturated. This can resul t i n l ack or slowi ng of motor operati on or
i ncreased operat ing current , whi ch coul d ul ti matel y burn the motor out .
There are two general methods to sol ve t his problem: locat e the equipment out of
t he magneti c f i el d or make the equi pment compati bl e wi th the magnet i c f i el ds.
One way t o make equi pment MRI compat ible i s to shi el d moni tors and cabl es f rom
RF currents. Cabl es can be wrapped wi th a thin l ayer of al umi num foi l , and smal l
copper boxes can be used t o house el ect ri cal equi pment. Usi ng appropriat e RF
f il ters i n the magnet shieldi ng and isolated f i l t ered al ternat ing-current power
ci rcui ts may permi t ef f ecti ve moni t ori ng (58).
Moni tors speci al l y desi gned f or use in the MRI uni t combi ne l ow f erromagnetic
content, shi el di ng, and f i l t ers to minimi ze magnet ic f iel d i nterf erence. These
devices may have some l i mi tat i ons to thei r use in t he uni t. It i s important that pri or
t o use, manuf acturer declarati on and/or cl earance by a recogni zed body such as
t he FDA demonstrates MR compat i bil i ty.
Image Degradation
Equi pment can degrade the qual i ty of i maging i n two ways (7, 10,17,27,30,58,60).
Fi rst, f errous metal in moni tors and other equi pment can cause di sturbances i n the
magneti c f iel d. Second, the equi pment may generate si gnals t hat i nt erf ere wi t h the
MRI si gnals.
Any RF energy wi t hi n the bandwi dt h of the receiver, i ncl uding stray radi ati on f rom
outsi de RF sources, i s ampl if i ed. Sources of RF noi se i ncl ude el ectri cal machi nery,
motors, computer hardware, di splays, tel evi si on t ransmi t t ers, beeper-pagi ng
systems, t wo- way radi os, commerci al radio stat ions, and other el ect rical equipment .
I t i s common practice, therefore, t o enclose the scanning area i n an RF shi el d.
Nonconduct ive devi ces can saf el y be passed through the shi eld, but wi res that
t ransgress the shi el d can act as aeri als and f eed noi se f rom the external
envi ronment i nto the examinati on area. Thi s can be overcome by f i l teri ng wi res that
run in and out of t he shiel d. Care must be taken to match f i l ters to specif i c
moni tors.
To prevent RF interf erence f rom degradi ng t he MR i mage, appropri ate measures to
provi de shiel di ng, such as housi ng t he di spl ay i n a RF-t i ght enclosure or locat ing
t he uni t outsi de t he room, should be used. In ei ther case, t he connect i ons bet ween
t he di spl ay uni t and t he pati ent shoul d pass through f i l ters t hat attenuat e
f requencies around the i magi ng f requency. Al l el ect ricall y conducti ve materi al t hat
i s not requi red should be removed f rom t he MRI system bore.
The dist ance f rom t he magnet ic core necessary t o prevent RF i nterference varies
wi th t he st rength of the magnet . Several met ers between the scanner and other
equipment are usuall y necessary. Thi s di stance can make i t dif f icul t to read and
i nteract wi th t he equi pment. Long spl i ced l ines and t ubi ngs may di sconnect , impose
hi gh resi stance, or become obstruct ed.
Another sol ut ion i s t o adj ust t he f requency of the noise source so t hat i t i s outsi de
t he MRI-recei ver syst em bandwi dt h. This can of ten be accompl i shed by adj ust ing
t he bl ock that cont rol s the operati on of the mi croprocessor i n the moni tor.
Once t he examinati on has started, the posi ti on of the moni tori ng equi pment shoul d
not be changed, because reposi t ioni ng of a l arge metal l ic mass may degrade
magneti c f iel d homogenei t y.
Burns
Appl ying i ntermi t tent RF f i el ds to metal li c obj ects wi thi n the i maging area can
cause heati ng and resul t i n burns (7,10,16,26,48,57,59,61, 62,63,64, 65,66).
Equi pment of pri mary concern i s that whi ch may be posi t i oned di rect l y i n the RF
t ransmissi on f i el d. This i ncl udes el ect rocardiogram (ECG) el ect rodes and l eads,
pulse pickup and pulse oxi metry sensors and cabl es, hal o devices, and surf ace
coil s as wel l as metal li c components, connectors, and surf ace coi ls. These can
provi de a pat h for current f l ow through the pati ent or al ong the cable shield t o
ground. If thi s current i s not l i mi t ed, pati ent burns can resul t at the l ocati on of
equipment or at body parts l ocat ed next to an i nsuff i ci ent ly i nsulat ed RF shi el d.
Ot her devi ces t hat uti l i ze a wi re such as thermodi l ut ion Swan-Ganz catheters or
epi dural cathet ers can al so subject the patient to el ectri c shocks or dangerous
heati ng (43).
Burns may al so occur f rom contact wi th t he scanner bore. Hi gh duty cycle
sequences cause heat to buil d up
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on the insi de of t he bore. Burns can be mi ni mi zed by usi ng t he fol l owi ng measures:
El ect ri cal l y-conduct ive leads shoul d be repl aced wi t h nonconduct ing paths
(e.g., f i beropt ic cabl e or pl ast ic tubi ng) or hi gh-resistance pat hs (e.g., carbon
ECG l eads).
El ect ri cal l y-conduct ive materi al (ECG l eads, cabl es, etc.) t hat must remai n
wi thi n t he MR system bore shoul d be posi t ioned t o prevent cross points. A
cross point is where a cabl e crosses another cable, loops across i tsel f , or
t ouches ei ther the pati ent or si des of the magnet i c bore more than once.
When t he pati ent i s moved, wi res may coi l and form a l oop, so i t is i mportant
t o check all wi res each t i me the pat i ent i s moved.
Cables and sensors shoul d be kept away f rom the bore (e.g. , by pl aci ng a
pulse oxi meter sensor on the pat ient' s toe when t he head i s bei ng
exami ned).
Al l sensors, wi res, and cabl es shoul d be checked to ensure that t he el ect ri cal
i nsul at i on around them i s i ntact . A smal l towel shoul d be placed between the
pati ent and the wi res or cable t o avoi d contact wi th t he ski n.
Al l unnecessary conduct i ve materi al s such as unused wi res, l eads, sensors,
cables, and surface coi ls shoul d be removed f rom the MRI envi ronment .
Al l el ect ri call y-conducti ve materi al that must remai n i n the MR syst em bore
shoul d be kept f rom di rect l y cont acti ng the pati ent by pl aci ng thermal and/ or
el ect rical i nsul at ion (i ncl udi ng ai r) bet ween t he conductive materi al and the
pati ent . Wi res shoul d not cross metal l ic prostheses.
Cables shoul d be posi ti oned so that t hey exi t as cl ose as possi bl e to t he
center of the pat ient tabl e of t he MR system (63). I t i s also i mportant t o avoi d
cable contact wi t h t he skin or t he MRI scanner.
Consci ous pati ents shoul d be i nstructed to call out i f t hey experience
uncomf ort abl e heat level s so that t he procedure can be i mmedi atel y
di scont inued.
Any moni tor t hat does not appear t o be operati ng properl y during t he MR
procedure shoul d be removed.
A col d compress/i ce pack shoul d be pl aced al ong ski n staples, superf i ci al
metal l i c sut ures, and lead att achment si tes, i f thi s can be saf el y
accompl i shed (49).
Hypothermia
Hypothermi a can be a probl em, especi al l y wi t h smal l chi l dren (27). Ai r i s of ten
ci rcul ated over the pati ent duri ng t he imaging sequence. Coveri ng the pati ent,
warmi ng f l ui ds, and usi ng non-el ect rical heati ng pads and humi di f i ed i nspi red gases
can hel p t o prevent hypothermi a (52). Heati ng bl ankets and radiant l i ghts cannot be
used because they i nterf ere wi t h i magi ng.
Other Patient Problems
Loud sounds in t he MR envi ronment may obscure cri es f or hel p f rom a pati ent i n
di st ress (9). The pati ent should be gi ven a squeeze bal l t o sound a di st ress si gnal ,
but thi s i s of l i mi ted usef ul ness i n the sedated pati ent .
A maj or probl em f or anesthesi a personnel is the rel ati ve inaccessi bi l i t y of the
pati ent . Thi s creates probl ems wi t h moni tori ng, ai rway management, i nt ravenous
access, pati ent visual izati on, and moni tor appl i cat i on. Pati ents can onl y be di rectl y
observed f rom ei ther end of the tunnel and can onl y be ext ri cated by sl i di ng them
out .
Specific Equipment
A number of devi ces speci al ly desi gned to be used i n the MRI uni t are avai lable. It
i s i mport ant t o demonstrat e MR compat ibi l i ty by preuse testi ng, manuf acturer
declarat i on, and/or cl earance by a recogni zed body such as the FDA. For devi ces
t hat do not carry such credenti al s, i t i s advi sabl e t o consul t the manuf acturer or
bi omedical personnel wi t h expert ise i n MRI bef ore int roducing t hem i nto t he MRI
room. I t i s i mportant to read al l of the i nstruct ions accompanyi ng a piece of
equipment , because some equi pment may be MR safe or compati bl e onl y i f
i nstal led a cert ai n distance f rom the magnet (67).
MR i s an evol vi ng technol ogy, and speci f icati ons and perf ormance characteristi cs
of speci f ic MR systems cont inual l y change. Products shoul d be tested under
si mul at ed or actual use condi ti ons. Because upgrades to the MR system t o achi eve
hi gher performance l evel s may aff ect the characteri st i cs of t he equipment,
yesterday' s devi ce tests may not be suf fi ci ent t o ensure the saf et y and
ef fectiveness of a devi ce wi th t oday' s MR system (10). Si nce new equi pment i s
conti nuall y bei ng i nt roduced, i t is onl y possi bl e t o make general i zati ons about
whi ch equi pment i s MRI compati bl e. I t i s recommended t hat equi pment i ntended f or
use wi t hi n t he magnet room be cl earl y l abel ed wi th t he maxi mum fi el d l evel wi thin
whi ch i t can operate ef fect ively (10).
Moni tors wi t h mul ti pl e f unct i ons decrease the amount of equipment t hat must be
t ransported, decreasi ng the ri sk of equi pment damage and i nj ury to t he personnel
responsi bl e f or t ransport .
Any equi pment t hat has an al arm shoul d have a vi sual al arm signal , because
audi tory si gnal s may not be heard (5).
Anesthesia Machines
St andard anesthetic machi nes contain varyi ng amounts of ferromagneti c
subst ances and el ect roni cal l y cont rol l ed components, maki ng them unsui tabl e f or
use i n
P. 877

proxi mi t y to an MRI magnet (68,69). Non-MRI compat i bl e anesthesia machi nes
have been used wi thout probl ems by keepi ng them 20 t o 30 feet away f rom the core
of t he magnet (26). Some anesthesi a pract i ti oners have used l ong tubings fed i nto
t he scanni ng room f rom an anesthesi a machine placed outsi de t he scanni ng room
or a st andard anesthesia machi ne bol ted to the wal l (31,52). Repl aci ng
f erromagnet ic components (e.g., support struct ures, cast ors, cyli nders, and part s of
cyl i nder supports) wi t h nonf erromagnet ic mat erials and aluminum cyl i nders can
make an anest hesi a machi ne MRI compati bl e. A few ounces of magneti c mat eri al
may prove negl igi bl e. MRI -compat i ble anesthesia machi nes are avai l abl e (Fi g.
30.2). Al umi num cyl inders have been avai l abl e f or some ti me. Unfort unatel y,
confusi on about cyl i nder composi t i on can ari se (70).
Vaporizers
Most standard vapori zers perf orm accuratel y when used i n t he scanni ng room
(36,68,69, 71). However, a port abl e vapori zer may be dangerous due to
f erromagnet ism (51).
Anesthesia Breathing Systems
A number of breat hi ng systems have been used successf ul l y i n the MRI
envi ronment. These i ncl ude the ci rcl e and Mapl eson systems (20,35, 52, 58,72, 73).
Long corrugated or f resh gas tubing wi l l be requi red i f t he anesthesi a machi ne i s
remot e f rom t he pat ient . Fortunatel y, most components of ci rcle breathi ng systems
used today are nonmet al l i c.

View Figure

Figure 30.2 MRI-compatible anesthesia machine. (Picture
courtesy of Ohmeda.)

P. 878


Anesthesia Ventilators
St andard anesthesi a venti l ators usual ly cont ain f erromagnet ic mat erials, pumps,
el ect ric motors, and anal og gauges that can be aff ected by t he magneti c fi el d
unl ess specif i cal l y adapted f or the MRI . These may not functi on properl y in a
magneti c f iel d or may degrade the i mage. A remote venti l ator in t he control room
wi th ci rcui t tubi ng fed i nto the scanning room can be used, or an incompati bl e
venti l ator can be at tached to the wal l (31,52).
Speci al l y engi neered MRI-compati bl e venti lat ors (both anesthesi a and cri ti cal care)
t hat have no el ect roni c components are avai l able (27,35,74, 75, 76,77). Fl ui di c
venti l ators work wel l i n the MRI envi ronment (75). Cur-rent l y avai lable MRI -
compat ibl e anesthesi a machi nes are equipped wi th venti l ators. An MR-compati bl e
posi t i ve end-expi rat ory pressure (PEEP) devi ce i s avai l abl e (78).
Pulse Oximetry
Most of t he earl y pulse oxi meters were both suscept i ble t o i nterference f rom t he RF
pulses and a source of int erf erence to t he MRI si gnal (10,15,17,21,79, 80). Burns
have been report ed at both the sensor si te and along the cabl e
(17,22,61, 62, 81,82). Heavy insul at ion and shi el di ng can be used to i sol ate the
moni tor si gnal (17,21). The moni tor should be placed as f ar f rom the magnet as
possi bl e.
Components, i ncl uding t he probe, wi t h a low f erromagnet ic content are useful , as i s
mi nimi zi ng t he number of el ect rical connecti ons and computer chi ps wi t hi n the
moni tor. Most consol es have f i l ters i n t he ci rcui try and some model s have f i l ters i n
t he cabl e to help el i minate extraneous si gnals. These hel p t o separate the si gnal
f rom background noise (21).
A conveni ent method to el i mi nate f erromagnetic wi re i s to use a f i ber-opt i c cabl e
(79,83). If a standard f erromagneti c cabl e is used, i t shoul d be wrapped wi th
al umi num or copper f oi l to shi el d t he metal and decrease RF i nterf erence
(22,80,84).
A variety of MRI -compat i bl e sensors, cabl es, and consol es are avai l abl e. The
sensor can be shi el ded to prevent noi se f rom reachi ng the MR system. The di gi ts
can be prot ected wi t h clear pl ast ic coveri ngs (27).
The sensor should be pl aced as far f rom the scan si te as possi bl e. This may
requi re that i t be pl aced on the f oot or head, depending on the area to be i maged.
The cabl e should be extended i n a strai ght l i ne away f rom the pati ent. The length of
t he cabl e shoul d al l ow the oxi meter to be f ar enough f rom the magnet to prevent
i mage degradati on.
Respiratory Gas Monitoring
There are a number of di ff erent t echnol ogi es to measure respi ratory gases. They
are discussed i n Chapter 22. Mai nst ream capnometry systems cause i mage
i nterf erence. The sensor requi res shi el di ng f rom RF radiat i on. Si destream moni tors
may be used during i magi ng as l ong as the moni tori ng devi ce is outside the
magneti c f iel d (19,58, 85). Mul t i pl e l engths of tubi ng may be connected t o al l ow the
moni tor t o be outside the magnet ic f ield. The ext ra l ength of tubi ng between the
pati ent and the moni tor may degrade the capnogram and decrease t he accuracy of
t he end-ti dal readi ng, especi al l y wi t h smal l pati ents (22). However, even if end-ti dal
measurements are not accurate, the t rends and respi rat ory pattern may sti l l gi ve
useful i nformat ion. If enough tubi ngs are connected toget her, the resi stance can
become so hi gh that t he al arm f or bl ocked tubi ng i s acti vated (83).
MRI -compati bl e mul ti gas moni tors are avai labl e. Thi s technology can be combi ned
wi th ot her modal i t i es such as pul se oxi met ry, el ect rocardiography, and noninvasi ve
bl ood pressure moni toring (52). Such equi pment can be posi ti oned ei t her i nsi de or
outsi de the magnet room.
Chemi cal detectors (Chapter 22) t hat change col or i n the presence of carbon
di oxi de are made of pl asti c and contain no metal part s. They must be pl aced close
t o t he pati ent and may be di ff icul t to see. They are qual i tat ive devi ces and are onl y
generall y quanti t ati ve. Thi s makes them more sui ted f or checki ng t racheal tube
pl acement t han f or l ong cases. El ectrochemi cal oxygen anal yzers are usual l y saf e
f or use i n the MRI sui te as l ong as they are outsi de the magnet i c f i el d (20, 22).
Noninvasive Blood Pressure Monitors
Aut omat ed bl ood pressure moni tors are di scussed in Chapter 27. The MRI does not
af fect moni t ors t hat use the osci l lometri c method as l ong as the el ectroni c uni t i s
ei ther shiel ded or wel l away f rom the magnet core (18,19,20,26,27,36,85,86, 87,88).
I t may be necessary t o use extended tubi ngs. Ferrous connecti ons on the cuff
shoul d be replaced wi th pl ast i c ones (83).
Manual sphygmomanomet ers have been adapted f or use duri ng MRI by replaci ng al l
f erromagnet ic components wi t h brass, al umi num, or pl ast ic pi eces (36). A pl ast i c
stet hoscope can be used t o moni tor Korotkoff sounds. The magnet i c f i el d may
af fect the accuracy of anal og gauges si nce t he movement mechani sm in some
gauges uses a smal l magnet and a coi l for operati on. Blood pressure can be
moni tored outsi de the scanner by l engthening the t ubi ng connect ed t o the cuff (89).
Ul trasonic Doppl er uni ts have been used t o moni tor systol i c bl ood pressure (89,90).
Invasive Blood Pressure Monitors
Most i nt ravascul ar l ines are nonmagnet ic and are not aff ected by t he magneti c f iel d
(36). Di rect pressure readi ngs can be obtained if the l ead f rom the pressure
P. 879

t ransducer i s passed through a RF f il t er or posi ti oned away f rom the magnet
(30,58). Fi ber-opti c MRI-compati bl e transducers are avai l abl e (18, 91).
Electrocardiographic Monitors
The ECG can cause pati ent burns and i mage degradati on as wel l as funct ion
i naccuratel y i n the MRI envi ronment (15, 17,21,27, 35,52,58). ST-segment
moni tori ng i s i mpossi bl e in the presence of t he magneti c f i el d usi ng current
t echnol ogy (92).
The amount of RF i nterference that is coupl ed i nto t he l eads can be cont roll ed by
appropri at e desi gn measures (e. g. , by selecti ng appropri ate materi al s f or t he ECG
l eads and by fi l teri ng the ampl i fi er ci rcui t ry i nput ) (10). Speci al MRI-compati bl e
el ect rocardi ographi c l eads may be const ruct ed by usi ng hi gh-resi stance conductors
t hat mi ni mi ze i nduced RF currents (23).
A number of measures wi l l mi ni mize eff ects (7, 21,27,35,58,93). Non-f erromagnet i c
f ast eners, electrodes, l eads, and cabl es are avai labl e. A f i l t er can reduce arti f acts
i n most l eads (68, 94). Good ski n preparati on i s i mport ant to opt imi ze t he ECG
si gnal . The ski n should be shaved and cl eansed wi th al cohol before the electrodes
are placed (15). For best resul ts, the ski n shoul d be dri ed or l ightl y abraded (27).
El ect rodes shoul d be placed as cl ose to the center of the magnet as possibl e
because t he RF power i s changing l east at thi s poi nt. The l i mb el ect rodes shoul d
be as cl ose together as possi bl e and i n the same pl ane. Usi ng chest l eads, V
5
and
V
6
mi ni mizes art i f acts (95). Li qui d crystal screens do not undergo di storti on as do
cathode ray t ubes (58). The rel at ive l ength of ECG l eads may be cri t ical i n
preventi ng gradi ent -induced art if act ; t herefore, many manufacturers advi se agai nst
modi f yi ng ECG l eads suppli ed wi th MR systems (58).
Tel emet ry may sound appeal i ng because i t reduces the wi ri ng and cabl es needed,
but i t may i nt erf ere wi th the RF used f or imagi ng. This i nterf erence i s not seen wi th
ul trahi gh f requency uni ts. These tel emet ry uni ts are l i mi ted to QRS compl ex
detecti on (27,88).
Temperature Monitors
St andard t hermi stor t emperature probes can di st ort the magneti c f i el d, causi ng
l ocal i zed i mage di stort i on if placed near the area of interest (96). They coul d al so
cause a local i zed concent rati on of RF power t hat woul d resul t i n i ncreased heat ing.
Smal l wi re probes have been used i n the MRI wi t hout excessi ve heati ng (96).
Al though t emperature probes wi t h f i l tered cabl es are avai l able, they carry t he same
ri sks of si gnal i nterf erence and burns as other el ect roni c moni tors (97,98). A burn
associ ated wi th t emperature moni tori ng using a probe speci al l y desi gned f or use
duri ng MRI has been report ed (98). A burn may be caused by inadvertent f ormati on
of a cabl e l oop duri ng pati ent movement.
Fl uoropt i c temperature probes that contai n materi al that has temperature-
dependent opti cal properti es are not af f ected by hi gh magneti c fi el d st rength and
RF pul ses and are theref ore more sui tabl e f or use in t he MRI envi ronment (96).
These probes are more expensi ve and more f ragi le than wi re t hermi stors.
Li qui d crystal temperature stri ps work wel l i n the MRI room but may not be easy t o
observe (15).
Laryngoscopes
The standard l aryngoscope (Chapter 18) is not ferromagneti c but can undergo a
degree of torque i n a magneti c f i el d (58). Pl ast i c l aryngoscopes are avail abl e, but
most bat teri es are magnet ic. One sol uti on is to modi f y t he handle t o operat e f rom a
non-battery-based power source (36,52). A remote f i beropt ic l ight source can be
used. MRI -compati bl e l aryngoscopes are avai labl e. Most are powered by l i thium
bat teri es. A paper- or plasti c-covered l i thium bat t ery can be used wi th a pl asti c
l aryngoscope (17,18,19, 58,99).
I f an MRI-compati bl e l aryngoscope i s not avai lable, anesthesi a can be i nduced and
t he ai rway i ntubated outsi de the magnet room usi ng a convent ional l aryngoscope
before the pati ent is moved i nto the scanner (19). If i nadvertent extubat ion occurs
whi l e t he pati ent i s i n t he scanner, an MRI -saf e l aryngoscope wi l l be needed.
Tracheal Tubes
Tracheal tubes (Chapter 19) are most commonl y made of pol yvi nyl chl ori de and are
saf e to use i n the MRI envi ronment. There are reports of si gnal i nterference f rom
t he spring i n the cuf f inf l at ion check valve (60,100,101). A tracheal tube wi th a wi re
spi ral cannot be used i n the MRI room (35,102). Connectors should be pl ast i c.
Supraglottic Airway Devices
The l aryngeal mask (Chapter 17) i s sui tabl e f or t he MRI envi ronment . It al l ows t he
l i ght l evel of anest hesi a that i s possible, as there are no pai nf ul st i mul i invol ved i n
t he MRI process. Because some laryngeal inf l ati on valves masks cont ai n metal l ic
materi al , i t may be necessary t o remove the val ve and knot t he pi l ot tube (103).
Speci al l aryngeal mask ai rways (LMAs) wi t h val ves that do not contain f errous
materi al are avai l able (104). I f the LMA-Fl exibl e or LMA-ProSeal is used, the metal
coil produces a l arge black hol e i n t he i mage in t he area surroundi ng t he ai rway as
wel l as deteri orati on of the i mage furt her out (105).
P. 880


The LMA may not be sui t abl e if magnet ic resonance spectroscopy i s perf ormed
because t he resonance of some si l icone-cont ai ni ng materi al s compromi ses
i nterpretat ion of the scans (106).
Ot her supragl ott i c devi ces are f or the most part made of pol yvinyl chl ori de or
si l icone, which does not cause probl ems wi t h the MRI . There are no reports of
probl ems at t he t ime of thi s wri ti ng.
Other
MRI -safe and -compati bl e sucti on regul ators and nonmet al l i c precordi al
stet hoscopes are avail able and shoul d be used.
Some i nf usi on pumps need to be l ocated away f rom the magnet or shi el ded or t hey
may perf orm i naccuratel y (17, 36). MRI-saf e i nfusion pumps are avai l abl e.
Extension tubing may be requi red. There i s a report of a pat i ent -control led
analgesi a devi ce t hat malf uncti oned af ter exposure t o the magneti c f iel d (107,108).
Some i nf usi on pumps f uncti on correct l y i n the MRI envi ronment (52, 109,110, 111).
I t i s possi bl e to moni t or i ntracranial pressure in t hi s set ti ng by using a
nonferromagneti c subdural bol t or pl ast ic catheter and a f i beropti c cabl e
(21,53,112,113).
El ect roencephal ography and evoked potenti al moni tori ng, both of which use long
conducti ng wi res, wi l l requi re technol ogi cal advances bef ore they can be used i n
magneti c f iel ds (92).
Personnel Hazards
I t i s not possi bl e at this ti me to determi ne wi thout questi on i f there are hazards to
personnel who work i n the MRI envi ronment. This i s largel y due to the rel ati vel y
short t i me f or whi ch t hi s method of i magi ng has been i n existence and t he f act t hat
t his work i s occasi onal f or most pract i ti oners. Future epidemi ol ogic evidence may
or may not demonst rate harmful ef f ects of long-term exposure. Femal e st af f shoul d
consi der avoi di ng this area duri ng the f i rst 3 months of a pregnancy.
Noise
Noi se i s due to vibrat ion of the swi tched gradi ent coi l s and i s enhanced wi t h higher
st rengt h gradient coi l s, shorter gradient duty cycl es, and faster pul se repeti t ion
f requencies i n the magnet (114). The trend t oward upgraded i magi ng syst ems and
st ronger magnets woul d suggest that noi se l evel s are li kel y to i ncrease (31). Noise
l evel s up t o 106 4 deci bels wi t h an average around 92 deci bel s have been
demonst rated (31). These are potenti al l y damagi ng l evel s, and care must be t aken
t o reduce these l evel s of exposure as much as possi ble. Ear pl ugs should be
consi dered, al though they may i nterfere wi th heari ng audi tory al arm si gnal s (43,52).
Exposure to the Magnetic Field
Wi th the i ncreased use of MRI and magnets of i ncreasi ng st rength, anest hesi a
provi ders are experi enci ng i ncreased exposure to stat ic magnet ic f ields wi t hi n MRI
uni ts. The stati c magneti c f i el d ext ends beyond the conf i nes of the magnet . The
st rengt h of this f ri nge f i el d depends on the magnet conf igurati on and shieldi ng. It
decreases rapi dl y as the distance f rom the magnet i ncreases. The bi ol ogi c eff ect of
stat ic magnet ic f ields i s a controversi al topi c (38). There are no demonst rated
oncogenic or terat ogenic eff ects (52). I t would seem prudent t o take reasonabl e
precauti ons agai nst repeti tive and avoi dable exposure t o i ntense magnet i c f i el ds.
Ri sks i ncl ude danger f rom unrest rai ned f erromagnet ic objects and f rom movement
or malf unct i on of MR-incompati bl e i mpl ants wi thi n thei r bodi es (31).
Trace Anesthetic Gases
Trace anesthet ic gases and thei r risks to anest hesi a personnel are di scussed in
Chapter 13. Scavengi ng systems and good venti l at ion wi t h f requent ai r exchanges
are not al ways avai l abl e in the MRI uni t (31). Some breat hi ng systems such as the
Mapl eson systems (Chapter 8) are of t en used f or pedi atri cs, and many of these are
not scavenged.
Hypoxia
I f l i qui d hel i um that surrounds t he superconducti ng solenoi d i n the magnet escapes,
i t is possi bl e that a hypoxi c envi ronment may be created (31). Oxygen sensors can
be pl aced in t he cei li ng t o warn of thi s probl em.
1
Most physi ci ans refer to t hi s t ype of imagi ng as MRI, whi l e most physici sts ref er t o
i t as nuclear magneti c resonance (NMR) (7). Both are accepted terms and refer to
t he same technol ogy.
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Questions
For the f ol lowing quest ion, sel ect the correct answer
1. The distance from the center of the magnet that is usually considered to be
safe for ferromagnetic obj ects is
A. The 2-gauss l ine
B. The 3-gauss l ine
C. The 4-gauss l ine
D. The 5-gauss l ine
E. Beyond t he 5-gauss l i ne
Vi ew AnswerFor the fol l owing quest i ons, answer
i f A, B, and C are correct
i f A and C are correct
i f B and D are correct
i f D i s correct
i f A, B, C, and D are correct .
2. Whi ch factors determi ne the attracti ve force on a ferromagnetic obj ect in
the MRI uni t?
A. The strength of the magnet
B. The mass and geomet ry of the object
C. Magnet ic shielding
D. The distance of t he obj ect f rom t he outer f i el d of the magnet
Vi ew Answer3. Which of the foll owing are considered to be safe i n the
MRI scanner?
A. Al umi num
B. Beryl l ium
C. Gol d and si l ver
D. Al l t ypes of st ai nless steel
Vi ew Answer4. Which metals can cause a negati ve magneti c screen and
absorb radio frequency energy that can result i n an MRI arti fact or thermal
i njury to the pati ent?
A. Al umi num
B. Gol d
C. Copper
D. Si l ver
Vi ew Answer5. Sources of radio frequency noise that can degrade the
MRI i mage include
A. Commerci al radio st at ions
B. Beepers
C. Mot ors
D. Li quid cryst al displ ays
Vi ew Answer6. Which i tems may cause a burn from radio frequency
fiel ds?
A. ECG el ect rodes
B. Epi dural cathet ers
C. Pulse oxi metry cabl es
D. Swan-Ganz cat heters
Vi ew Answer7. Methods to keep pediatric pati ents from developing
hypothermia i n the MRI unit i ncl ude
A. Warm f l uids
B. Radiant l i ghts
C. Covering t he pat i ent
D. El ect rical heati ng pads
Vi ew Answer