Magnetic Resonance Imaging for Critical Care Patients

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AUTHOR AUTHORS LINE MANAGER

Name: Dr Peter Frank Name: Dr Tom Owen

Title: CrCu Consultant Title: CrCU Clinical Director

INITIATING DIRECTORATE DATE AUTHORISED

Critical Care
IMPLEMENTATION REVIEW DATE
Critical Care

CLINICAL GUIDELINE
The governing principles outlined within this document are fully supported in every
respect by the Clinical Governance Sub-Committee.
All members of staff are required to adhere to the principles involved as outlined within
this document, together with any related procedures, which are enabled by this guideline.

This guideline was produced in consultation with:

DEFINITION OF CLINICAL GUIDELINES

Clinical Guidelines are evidence based systematic statements to assist practitioners and patients
in making decisions about appropriate health care for specific clinical circumstances.

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1. Full Guideline Title
Magnetic Resonance Imaging for Critical Care Patients

2. Adaptation
Adapted from LTHTr (2016) Anaesthesia for patients (adults and paediatric) at Magnetic Resonance
Imaging (MRI) scanners (Version 1), and RCOA (2002) Provision of Anaesthetic services in Magnetic
Resonance Units

3. Guideline aim
This guideline lays down recommendations that aim to make the preparation and transfer of critically ill
patients for MRI safe and efficient

4. Roles and responsibilities

The parent team requesting an MR scan is responsible for discussing the scan with the
department of radiology, and ordering the scan electronically.
The critical care team will assess the patient to ensure there are no contra-indications to MR
scanning, that the pre-MR checklist is completed, and that the patient is fit for the procedure
On the day of imaging, the critical care team will prepare and transfer the patient to the recovery
bay within the MR suite where they will handover to an anaesthetist appropriately trained to
provide general anaesthesia in the MR suite (see LTHTr (2016) Anaesthesia for patients (adults
and paediatric) at Magnetic Resonance Imaging (MRI) scanners for details)
On completion of the scan the anaesthetic team will contact critical care to request transfer back
to the unit, and return care of the patient to the critical care team
It is not the responsibility of the duty consultants covering critical care to provide anaesthesia for
patients having MR scanning, regardless as to whether they are trained to do so.
Consultant anaesthetists providing general anaesthesia in the MR suite will be expected to have
had appropriate training and experience.
The RCoA 2016 Guidelines for the Provision of Anaesthesia Services states It is not acceptable
for inexperienced staff unfamiliar with the MR environment to escort or manage a patient here,
particularly out of hours. It is expected that staff taking patients to MR scan will be performing
these duties on a regular basis to ensure competence and familiarity are maintained.
5. MRI anaesthesia availability
At present there is no out-of-hours service to provide emergency MRI anaesthesia. Patients must be
booked onto the existing GA lists to have MR performed. The lists are:

Week 1: Monday, Wednesday, Friday

Week 2: Monday, Wednesday, Thursday, Friday

Each list can accommodate 3-4 patients depending on scan time and patient complexity. Booking a
patient onto the list can be done by ringing the MRI coordinator on Ext. 2292 and discussing the case
with the duty radiologist.

If urgent MRI anaesthesia is requested by a parent team and there is no availability on the GA lists, then
it is the responsibility of the parent to team contact the department of anaesthesia (Ext. 2555) or the duty
anaesthetic consultant covering theatre 9. An assessment can then be made to see whether an
appropriately trained consultant anaesthetist can be made available to perform the scan outside of the
regular GA list times but during normal working hours. There is no obligation for an MR trained
anaesthetist to leave their list to perform this service.

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Current pathway for patients requiring urgent MR with general anaesthesia:

1. If urgent referral comes in and no availability on the next GA list then referring team to decide if
can wait until next available slot
2. If not soon enough, the referring team is required to find an anaesthetist to assist. If an available
MR trained anaesthetist found, the MR team will source an ODP and the scan can be performed
as soon as both parties and the patient is ready
3. If no anaesthetist to cover out of session or no in-patient slots available on GA session, the MR
team will prioritise the booked patients and/or do extra on the funded list after discussion with MR
anaesthetist, or cancel electives
4. If required on day due to clinical urgency and no GA session on that day or anaesthetists to assist
the last resort is to book on theatre 9 list, but this is rarely suitable due to the length of time an
MR scan takes

5. Preparing a critically ill patient for MRI anaesthesia

Before a patient can be added to a GA MR list a MR safety checklist (see appendix) must be completed.
It is the responsibility of the parent team to check this is done, however the critical care team will facilitate
the completion of the checklist if time available. In addition the incapacity form must be completed
(consent 4). Only once the radiology team have received these documents can the patient be considered
for MRI and added to a GA list.

Patients must be in a stable condition before they can be considered for MRI. Specifically they must:
Not be dependent on high doses of vasopressors, as transfer into the MRI scanner requires
disconnection from all infusions for a short period
Not be dependent on a high fraction of oxygen or high airway pressures, again due to the need to
transfer onto an MRI compatible ventilator
Have a maximum of two infusions. Patients requiring triple sedation to control their ICP, for
example, would not be appropriate
Not be dependent on a system which utilises very high flows of oxygen, such as high flow nasal
cannulae.
Be either calm and cooperative or anaesthetised. Restless and agitated patients will not tolerate
an MR scan

In addition to the above criteria, patient preparation requires the following:

Airway and Breathing circuit

Re-inforced endotracheal tubes are not compatible with the magnetic field and should be
changed
Ventilated patients should be established on a transport ventilator, and a blood gas should be
performed to ensure adequate support is being provided
Spontaneously breathing patients should have be able to lie supine for a minimum of 1 hour with
their oxygen needs met by a device which requires <15l/min.

Circulation
Infusions must be delivered via a system which can be attached to the patient from the MR
control room. This is done by connecting two coiled extension lines end-to-end, plus one straight
extension set
As a maximum of two infusions can be given during the scan all non-essential infusions must be
disconnected prior to transfer

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Disability
Anaesthesia, if required, will usually be maintained with a propofol infusion plus any additional
boluses of opiates or benzodiazepines felt necessary by the consultant MR anaesthetist
Paralysis is not usually needed
Awake patients should be calm and cooperative.
Agitated or restless patients will require induction of anaesthesia on CrCU before transfer to the
MR scanner
The Codman microsensor and bolt are MR conditional. A patient can have an MR scan if certain
steps are performed first:
1. Disconnect all cables and patient monitoring devices attached to the microsensor
2. Coil the tubing of the microsensor near the base of the electrical connector into 5 or 6 loops
approximately 6cm in diameter and center on top of the patients head
3. Insert a dry gauze pad at least 1cm thick between the microsensor coil and the patients scalp
and secure with tape

Enteric
Patients should be fasted for 6h prior to scan
Disconnect feed and aspirate NG tube prior to transfer

It is the duty of the critical care team to ensure the patient is prepared for MR scanning. The steps
involved in the process are summarised in the flow chart.

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 Parent team decide MR scan needed
Parent team liaises with radiology to book scan on GA list if required. Parent team informs critical care

Step 1 of expected date and time of scan

The MR safety checklist is completed by either the parent team or the critical care team. It is the
responsibility of the parent team to ensure this is done

Step 2 An incapacity form (consent 4) is completed by either the parent team or critical care team

The critical care team will optimise the patient for MR scanning and decide whether they are stable
enough to proceed

AIRWAY Replace re-inforced tubes with standard endotracheal tube

Step 3 BREATHING Stable ventilation parameters, establish on Oxylog transport ventilator. If
spontaneously breathing capable of maintaining oxygenation in supine position for up to 1 hour
(tested before scanning)
CIRCULATION Not requiring high doses of vasopressors (eg <10ml/h of 4mg in 50ml solution).
Maximum 2 infusions
DISABILITY Capable of remaining calm and still for duration of procedure. Alfentanil usually stopped
in MR scan. Paralysis rarely needed
ENTERIC Fasted for 6h. NG tube aspirated

Final checks prior to transfer

Monitoring attached, working and batteries charged
Pumps charged and all infusions connected via 2 'curly wurlies' plus one single extension
Step 4 Sufficient supply of infused drugs and emergency drugs drawn up
Sufficient oxygen supply for transfers
All devices secure

Transfer to MR suite
The critical care team will transfer the patient when requested by the MR team
The transfer team should include an airway trained doctor, critical care nurse and a porter

Step 5 The patient will be taken to the MR holding bay, where care will be handed over to the Consultant
Anaesthetist running the MR list
The intensive care doctor will not be required to stay with the patient during the scan, the CrCU
nurse caring for the patient may stay with the patient or return to the unit depending on the
duration of the scan and workload on CrCU
Once the scan is complete the MR team will prepare the patient for transfer back to critical care,
and inform the ICU team that the patient is ready for collection
When the staff and bedspace are ready, the airway trained doctor and critical care nurse will
request a porter and head to the MR suite to retrieve the patient

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6. Disease/condition/target population
Patients admitted onto the critical care unit and subsequently undergoing diagnostics within the MRI
suite within the Lancashire teaching hospitals NHS foundation trust under general anaesthesia/ sedation.

7. Implementation strategy
Preparing a patient for MR scan will require some additional steps to be performed by the CrCU nursing
staff. This will require an educational package to be rolled out for all the nurses on CrCU by the practice
educators, with assistance from operating department practitioners and consultants who are familiar with
taking anaesthetised patients through the MR scanner.

The medical team will also require educating on their roles and responsibilities, identification of suitability
for MR scanning, and steps required in patient optimisation prior to scan.

A short educational guide will also be produced to help speed up the educational process.

9. Major Outcomes
This pathway aims to:
Minimise delay in ensuring patients are ready for MR scanning
Allow early identification of factors which may prevent a patient from being suitable for MR scan
Ensure patients are safe to go through the scanner
Improve the efficiency of GA MR lists and thereby reduce list overruns and cancellations

10. References

Farling P. Provision of Anaesthetic services in Magnetic Resonance Units. The Association of

Anaesthetists of Great Britain and Ireland. 2002

Krovvidi H. Guidance on the Provision of Services for Anaesthetic Care in the Non-theatre Environment.
2016

11. Guideline Availability

Intranet and Critical Care Unit

12. Companion Documents

LTHTR (2016) Anaesthesia for patients (adults and paediatric) at Magnetic Resonance Imaging (MRI)
scanners

13. Patient Resources

MRI Scan information available at www.nhs.uk/conditions/MRI-scan/Pages/introduction.aspx

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