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Intraoperative MRI Safety (6.12)

Intraoperative MRI Safety (6.12) - Policies, Clinical, UWHC Clinical, Department Specific, Surgical Services, Safety

6.12

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I. PURPOSE

A. To ensure the safety of patients, family members and health care professionals in the Intraoperative Magnetic Resonance
Imaging (IOMRI) suite.
B. To ensure the safety of patients and health care providers during the transfer from IOMRI OR to the IOMRI MRI suite.
C. This policy is an adjunct to the following policies and attachments:
1. Hospital Administrative Policy 12.11: Magnetic Resonance Imaging (MRI) Safety - Attachment 2
2. Surgical Services Policy 2.32: Assuring Compatible Aneurysm Clips
3. Environmental Services Policy 5.4: Cleaning of IOMRI Rooms
4. Environmental Services Policy 5.7: Post Op Cleaning of OR Rooms
5. r Services Policy 5.1: Terminal Cleaning of the OR Areas
6. Surgical Services Policy 3.01: Anesthesia Daily/Monthly OR Cleaning, Stocking and Assisting for All Procedures,
Including satellite Area Procedures
7. Surgical Services Policy 5.05: Guidelines for Handling Blood, Body Fluid and Contaminated Items in the OR
8. Appendix B: Guidelines for the Pregnant Anesthesia Provider- Attachment 1
9. Appendix C: Surgical Zone Red Line- Attachment 3

II. POLICY:
A. All patients, and patient family members, who are to enter the IOMRI suite, must go through a comprehensive screening
prior to entrance. (See Policy 12.11). The Comprehensive MRI Screening form will be filled out by the MRI nurse, tech or
physician prior to patient entry.
B. Medical personnel who anticipate entering the IOMRI MRI suite must be screened, and have documentation that they have
received MRI safety training.
C. The magnet is always on. There is a high potential for serious injury or death in the MR environment.
D. A transfer time-out (including verification of a full instrument count
and completion of a safety checklist) is required prior to the transfer of a patient and medical personnel from the IOMRI
OR (Zone III) to the IOMRI MRI suite (Zone IV), to ensure that the patient and staff traveling to the MRI suite (Zone IV)
are free of non MRI compatible equipment.
E. A white board with the time-out checklist will be posted on the wall of the IOMRI OR.
F. All objects that are not MRI safe are required to be removed prior to entering the MRI suite.
G. Appropriate signage will be clearly displayed on the entry and inner scanning room doors warning of danger of the
magnetic environment.
H. Daily cleaning and terminal cleaning of the IOMRI OR and IOMRI MRI suite will be in accordance with Policies 5.4, 5.7,
5.1, and 5.05 referenced above.
I. Daily /Monthly cleaning and restocking of anesthesia equipment and supplies in the IOMRI OR and IOMRI MRI suite will
be in accordance with Policy 3.01 referenced above.
1. Pregnant health care providers and patients: Follow the guidelines of Policies 12.11, related document, attachment
# 2, MRI in Pregnant Patients, and Guidelines for the Pregnant Anesthesia Provider, both referenced above.
J. Sterile draping procedures for patients in the IOMRI OR and MRI suite are to be in accordance with policy the principles of
asceptic technique.

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III. PROCEDURE:

IOMRI Transfer Time-Out
1. The following individuals are required to participate in IOMRI Transfer Time-Out:
Anesthesia Faculty
Surgeon MD (Resident or Attending)
Anesthesia Resident or Anesthetist
OR RN
OR Technician
MRI RN or Technician
Any other health care provider present in the room
Any other personnel who will enter MRI suite with patient
B. Time-Out Checklist will include: (See Appendix A)
C. Site Access Restriction: Zoning
1. Zone III –this area is the region of the IOMRI OR and existing MRI Control Room.
2. Zone IV – this area is the physical confines of the room within which the MRI scanner is located.
D. Entry Requirements into the MRI Suite
1. Pockets must be checked and emptied of all metallic objects with each entrance to MRI Suite. (Note: watches, credit
cards and electronic badges may be destroyed by the magnet and should also be removed) Lock drawers are available
outside the IOMRI MRI suite to hold items removed at the last minute.
2. Entry Requirements for Patients and Non-MR Personnel
a. All patients and non-MR personnel will be screened prior to entry into Zone III and Zone IV.
b. All patients undergoing an MR procedure must remove all readily removable metallic personal belongings and
devices on or in them including, but not limited to:
ξ Watches and Jewelry
ξ Pagers
ξ Cell Phones
ξ Body Piercings (Strongly recommend removable as anesthetized patients can not report heating or torque of
these)
ξ Contraceptive Diaphragms
ξ Metallic Drug Delivery Patches
ξ Cosmetics containing metallic particles (such as eye makeup)
ξ Clothing items that may contain metallic fasteners, hooks, zippers, loose metallic components, or metallic
threads.
c. It is extremely important to ensure all jewelry has been removed from patients preoperatively. The taping of rings
is not an acceptable practice, as there is a potential for an electrical burn, resulting from the radiofrequency
(energy) produced during imaging.
d. It is extremely important to ensure the removal of a temperature sensing foley catheter.
e. All non-MR personnel must be accompanied by, or in the immediate supervision of and in visual or verbal contact
with an identified MR person for the entirety of their duration within Zone III or Zone IV restricted regions.
f. Children should be gowned before entering Zone III to help ensure that no metallic objects, toys, etc. have been
inadvertently left with patient.
3. Entry Requirements for MR Personnel and Health Care Providers Entering the IOMRI (Zone IV)

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a. Entry through the controlled doors can be achieved by presenting a valid UWHC ID badge to the proximity card
reader located at the respective door.
b. All health care providers prior to entering Zone IV must remove all readily removable metallic personal
belongings and devices on or in them including, but not limited to:
ξ Watches and Jewelry
ξ Pagers
ξ Cell Phones
ξ Body Piercings (Strongly recommend removable as anesthetized patients can not report heating or torque of
these)
ξ Contraceptive Diaphragms
ξ Metallic Drug Delivery Patches
ξ Cosmetics containing metallic particles (such as eye makeup)
ξ Clothing items that may contain metallic fasteners, hooks, zippers, loose metallic components, or metallic
threads.
E. Education Requirements
1. All individuals working within Zone III and IV of the MR environment must watch the UW MRI instructional safety
video, read the Joint Commission Safety Alert on MRI Use
(www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_38.htm), and complete the Overview of
MRI safety annual review test.
F. Equipment Precautions
1. All equipment will be labeled with perspective MR safety status:
ξ MR safe –green “MR safe” label
ξ MR unsafe –red label worded “MR unsafe” with a slash through it
ξ MR conditional –yellow label.
a. MR safe: Equipment or devices that can be used in any area of the room, will not interfere with imaging, and will
not be affected by imaging; any item that poses no known hazards.
b. MR unsafe: Any item that is known to pose hazards in all MR environments. For example, this would include all
magnetic items.
c. MR conditional: Any item that has been demonstrated to pose no known hazards in a specified MR environment
with specified conditions of use (field strength, radiofrequency, spatial gradient).
2. Equipment in the IOMRI OR
a. Never assume MR compatibility or safety information about the equipment or device if it is not clearly
documented in writing or labeled.
b. All unknown external objects or devices being considered for introduction beyond Zone II must be tested with a
handheld magnet for ferromagnetic properties before entry into Zone IV.
c. All portable metallic or partially metallic devices that are on or external to the patient are to be positively
identified in writing as ferromagnetic or nonferromagnetic and safe in the MR environment prior to permitting into
Zone III.
d. Note: Patients may arrive with an MR unsafe oxygen tank on the bottom of the bed/stretcher. Only MR safe
oxygen tanks are permitted to stay in the IOMRI suite. MR unsafe oxygen tanks can become dangerous flying
projectiles, causing severe harm or death to both patient and staff if caught in the trajectory toward the magnet.
The impact of such objects would also cause serious damage to the magnet itself.
3. Room Equipment Check

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a. The IOMRI rooms will be checked before each case and at the end of the day for loose metal
objects and non-MRI equipment.
G. Items with Ferromagnetic Properties (non-instrument)
1. For IOMRI cases, needles and items with ferromagnetic properties will be counted:
a. Before the procedure to establish a pre-scan baseline
b. When additional items are added to the sterile field
.
c. At the time of permanent relief of either the scrub person and/or circulating nurse.
2. All counts will be done outside the 5-gauss line.
3. Any instrument or sharp dropped on the floor should be picked up immediately. Retain any dropped or contaminated
sharp off the sterile field and isolate in a sealed sharps container to be included in the final count. All dropped
instruments will be contained in a designated drop zone outside the 5-gauss line.
H. Thermal Injury Precautions – Preparation Prior to Draping
1. IOMRI patients will have additional safety requirements beyond the standard positioning guidelines for perioperative
patients. Electrical voltages and currents can be induced in electrically conductive materials that are within the bore of
the MR imager during the MR imaging process. This might result in the heating of this material by resistive losses.
This heat might be of a caliber sufficient to cause injury to human tissue.
a. Radio-frequency fields can cause skin burns if monitor cables or wires are permitted to form conductive loops with
themselves or with parts of the body. Radio-frequency (RF) magnetic field-related energy thermal injuries result
from wires such as, but not limited to, EKG leads, pulse oximeter probes, ESU grounding pads, when wires become
coiled or touch the skin in more than one location.
2. Position and secure all cables and wires to ensure that no electrically conducting loops (including patient tissue) are
formed within the MR scanner during imaging.
a. The larger the diameter of the conductive loop, the greater the potential of induced voltages or currents, and thus the
greater the potential for resultant thermal injury to adjacent or contiguous tissue.
3. Position and secure all cables and wires so there is no contact with the patient’s skin and all the cables/wires do not
cross any external metallic prosthesis or similar device on the patient.
4. Position all cables and wires to prevent “cross points.” A cross point is the point where a cable loops across itself, or
where a cable touches either the patient or sides of the transmit RF coil more than once.
a. Avoid the close proximity of conductive materials with each other. Cables and RF coils can capacitively-couple
(without any contact or crossover) when placed close together.
5. It is not sufficient to merely “unplug” or disconnect unused, unnecessary electrically conductive material and leave it
within the MR scanner with the patient during imaging.
6. All electrical connections, such as on surface coil leads or monitoring devices, must be visually checked by the
scanning MR Technologist prior to each use to ensure the integrity of the thermal and electrical insulation.
7. Apply insulation material between any cables/wires in contact with the patient’s skin to prevent any skin-to-skin
contact points and the formation of “closed-loops.”
a. Place insulating material between the patient’s skin and transmit RF coil that is used for the MR procedure.
b. When electrically conductive materials are required to be within the bore of the MR scanner with the patient
during scanning, care should be taken to place thermal insulation (including air, pads, etc.) between the patient and
the electrically conductive material, while simultaneously attempting (as much as feasible) to keep the electrical
conductor from directly contacting the patient during imaging.
8. The patient’s tissue is conductive and, therefore, may be involved in the formation of a conductive loop, which can be
circular, U-shaped, or S-shaped.
a. Ensure that skin folds contact, e.g. region of inner thighs, is minimized or eliminated in the region undergoing

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radiofrequency energy irradiation.
b. Arms and fingers should not be positioned to form any type of conductive loop.
c. Legs should not be crossed.
9. Apply cold compresses to extensive or dark tattoos, including tattooed eyeliner, if these tattoos are in the volume in
which the body coil is being used for RF transmission.
I. Additional Patient Safety Precautions
1. Auditory Safety
a. Earplugs effective up to 25 decibels will be placed in both ears to prevent hearing damage during imaging.
b. Significant MRI-induced noise can produce hearing loss in patients who are susceptible to the damaging effects of
loud noises.
2. Contrast Agent Safety
a. All patients will be assessed for various allergies to include adverse reactions to contrast agents, pregnancy,
history of asthma and impaired renal function and/or disease.
ξ Nephrogenic Systemic Fibrosis (NSF) has been associated with patients with impaired and/or diminished
renal function and administration of Gadolinium contrast agents.
b. Risks and benefits of the use of any Gadolinium-based contrast agent will be discussed with pregnant patients and
patients with compromised renal function. Please refer to Appendix B: MRI in Pregnant Patients
J. Safety Guidelines for Emergency Situations
1. Cryogen Safety
a. Liquid helium is a cryogen that is stored in a reservoir around the MRI system to keep the magnet cold. The
physical properties of this cryogenic liquid can present significant potential safety hazards if the magnet is
quenched (turned off) and the cryogen venting system does not function properly. If exposed to room air, this
cryogenic liquid will rapidly boil and expand into a gaseous state. This produces several potential safety concerns,
including:
i. Asphyxiation is a possibility as cryogenic gas replaces oxygenated air.
ii. Frostbite may occur at the exceedingly low temperatures of this cryogenic gas.
iii. High pressures may build up, making it difficult to access the magnet room/Zone IV.
b. When the magnet quenches, a cryogen vent and duct system are supposed to vent the escaping gas outside the
building. However, there have been documented failures of the cryogen vent/quench pipe assemblies that have led
to considerable quantities of cryogenic gas being inadvertently discharged into the magnet room/Zone IV.
2. Quench Considerations
a. Because of the risks to personnel, equipment, and physical facilities, manual magnet quenches are to be initiated
only after careful consideration and preparation. A quench subjects a magnet to a change of 500°F (260°) thermal
shock within a few dozen seconds, which can cause major physical damage. Rarely, it is possible for the venting
cryogenic gas to breach the quench tube and cause significant damage to the magnet room and jeopardize the
safety of those in the vicinity.
b. All personnel assigned to the IOMRI should familiarize themselves with emergency procedures such as CPR,
should be aware of evacuation and quench procedures, and should understand the potential safety concerns
associated with a magnet quench.
c. Unless there is a life-threatening situation, quenching should be done only under the direction of the MR staff.
d. A quench should be initiated ONLY if a person is suffering from severe injuries due to being pinned against the
magnet AND it is impossible to remove the object safely.
e. Emergency deactivation of the magnetic field occurs in approximately 20 seconds after pushing the quench button.
3. Quenching Sequence of Events
a. Evacuate all non-essential personnel.

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b. The decision is made to quench the magnet by the MR staff (EXCEPT: in a life-threatening situation. In that
case, MR staff does not have to participate in the decision to quench.)
c. Remove the object from magnet (if possible). Ensure you have adequate support if there is an injured person.
d. Protect the patient from injury.
e. Transfer the patient to PACU when appropriate.
f. Open the doors to the hallway to displace the amount of helium in the MRI and OR rooms. This will help ensure
adequate oxygenation for the team.
g. The helium should escape through the quench pipe to the outside. The excess will escape in the room and rise to
the ceiling. Stay away from this area as contact with these very cold vapors could cause frostbite.
h. Notify the Environmental Health and Safety officer on call.
4. Failure of Cryogen Vent System
a. This process is necessary only if the cryogen vent system fails and the cryogenic helium gas from the magnet
escapes into the room with the patient.
b. Evacuate all excess personnel.
c. Open all doors to the external hallway. The remaining staff needs an oxygen mask to stay in the room.
d. The patient is protected as they are typically intubated and have sufficient oxygen.
e. Quickly work to safely remove the patient from the MRI.
5. Cardiac Arrest During MR Scan
a. Anesthesia will signal for help by either speaking over the room speaker to the control desk.
b. The OR team in the control room can enter the MRI through the magnet bay door. Everyone must empty all
pockets before safely entering the MRI suite.
c. Patient MUST be removed from IOMRI MRI suite to IOMRI OR suite or hallway for resuscitation.
d. Do not hit the quench button for a code during the scan.




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Emergency Procedures / Staff Roles in MRI Suite



ROLE


Quench / Evacuation of Patient / Team

Code - Evacuation



Anesthesia

ξ Direct Team
ξ Protect Airway
ξ Untether Patient
ξ Remove Patient from MRI
ξ Resuscitate Patient


ξ Direct Code
ξ Protect Airway
ξ Unstrap Patient
ξ Remove Patient from MRI
ξ Direct Care Based on Surgery/Symptoms
ξ Resuscitate Patient





Surgeon

ξ Direct Patient Safety
ξ Remove Cover from Patient
ξ Prepare Surgical Site for Transporting
ξ Begin Removing Drapes
ξ Assemble Head of Bed
ξ Remove Skull Clamp
ξ Assist with Transport
ξ Move Patient Out of Room


ξ Direct Patient Safety
ξ Prepare/Protect Surgical Site
ξ Remove Equipment from Surgical Field
ξ Chest Compressions
ξ Assemble Head of Bed
ξ Remove Skull Clamp



MR Tech /
Team Leader

ξ Assist with Patient Transport
ξ Move Patient Out of Room
ξ Notify MR Safety Officer


ξ Assist Anesthesia and Circulator
ξ Notify MR Safety Officer




Circulator

ξ O2, Ambu, Monitor
ξ Reassemble Head of Bed
ξ Direct Assistive Personnel
ξ Help with Patient removal from Room


ξ Prepare Emergency Cart
ξ Defibrillator (outside MRI)
ξ Assist with Removal of Skull Clamp
ξ Patient in Supine Position
ξ Direct Assistive Personnel



Scrub

ξ Remain Sterile
ξ Guard Magnet from Assistive Personnel
Entering MR/OR


ξ Clear Tables/Mayo Away
ξ Remain Sterile
ξ Guard Magnet from Assistive Personnel
Entering MR/OR


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Emergency Procedures / Staff Roles in MRI Suite, continued

ROLE


Fire / Evacuation of Patient / Team



Anesthesia

ξ Shut Off Anesthesia Gas Supply to Patient
ξ Protect/Maintain Airway
ξ Unstrap Patient
ξ Assist with Moving Patient
ξ Resuscitate Patient



Surgeon

ξ Determine if Patient can be Moved
ξ Prepare Surgical Site
ξ Assist with Patient Transfer to Stretcher and Remove from Room


MR Tech /
Team Leader

ξ Guard Magnet from Assistive Personnel Entering MR/OR
ξ Notify MR Safety Officer







Circulator

ξ Keep Doors Closed
ξ Notify Front Desk to Activate Fire Alarm System
ξ Call IP OR Control Station for Assistance
ξ RACE / PASS
ξ Get Stretcher
ξ After Instructed, Turn Off O2 Supply
ξ Delegate Tasks in the OR
ξ Assess Patient Before Transport
ξ Identify Potential Problems
ξ Provide Appropriate Interventions
ξ Assemble Head of Bed
ξ Remove Skull Clamp




Scrub

ξ Protect Surgical Site
ξ If Drapes are Burning, Attempt to Dowse Fire with Saline
ξ Remove Burning Material
ξ Assist with Moving Patient/Stretcher
ξ Bring Necessary Instruments



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Appendix A

IOMRI PATIENT TIME-OUT SAFETY CHECKLIST


ACTION
1. Surgical instruments visually checked. All ferrous instruments removed from patient and transfer cart.
2. Cautery pad removed.
3. Oral and visual check for needles and stylets.
4. Anesthesia Equipment review. All ferrous instruments/monitors removed. Wireless monitor battery time checked
prior to transfer.
5. Sequential Compression device unplugged and pump away from table.
6. Bear hugger unplugged and pump away from table.
7. Check to ensure reinforced ET tube is NOT used.
8. MR-safe esophageal tube only.
9. Avoid skin-to-skin contact – place sheets between the arms and trunk and between each leg as needed.
10. No loops of wires, leads, cords – double check the EKG leads; place bovie pad where you can reach it easily at time
of scan to remove the pad or cord. These should run in parallel as close to the center of the bore as practical.
11. Place earplugs in both ears at positioning that provide safety coverage to 25 decibels. Surgeons may want to cover
with a tegaderm to prep into the field.
Remove at end of case. Earplugs available for medical personnel accompanying the patient in the MRI.
12. Ensure the patient position will allow entry into the magnet, 70 cm.
13. Use ferrous free skull pins and radiolucent head holder.
14. MR-safe foley only (temperature sensing foley NOT used).
15. Ensure adequate padding at the patient’s shoulders as the bottom coil can butt up against the patient at this location
and cause injury.
16. Safety strap is secured around patient’s trunk and ferrous free.
17. Posterior coil on.
18. * Anterior coil draped and ready for placement. *
19. Assure sterile draping of surgical site is maintained and adheres to policy.
19. Questions and visual for removal of unsafe MRI equipment (pager, watch, keys, wallet, etc.) of Anesthesia,
Radiology, Nursing and other medical personnel entering the MRI. Any personal ferrous objects may be stored in
lock boxes available near entry to MRI suite.
20. Before double doors open, safety czar verbally screens and receives acknowledgement from those persons who will
travel with patient into the IOMRI suite. (zone IV)


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Appendix B
MRI in Pregnant Patients
The following memo provides an update on the UW-Madison Department of Radiology policy for scanning pregnant patients,
including the use of Gadolinium contrast agents.

Non-contrast MRI in Pregnant Patients:
Our policy on MRI in pregnant patients without the use of Gadolinium based contrast remains unchanged. There are no known
deleterious effects of MR imaging on the fetus. As part of the screening process, patients are screened for pregnancy, and if a patient is
found to be pregnant, according to the ACR Safety Guidelines (Kanal, AJR 188:1-27, 2007), “consideration should be given to
reassessing the potential risks versus benefits of the pending study in determining whether performance of the requested MR
examination could safely wait until the end of pregnancy”. We share this philosophy. As such, when an MRI is ordered on a pregnant
patient, a discussion between the attending radiologist, patient’s attending physician and the patient should take place. If it is
determined that the MRI should proceed, it should be documented in the medical record that:

1. The information needed cannot be obtained from ultrasound or other diagnostic test that does not require ionizing radiation.
2. The information that is needed affects the care of the patient and/or the fetus during pregnancy.
3. The attending referring physician feels that the scan cannot wait until after the pregnancy and is needed to obtain the necessary
information.
In addition, informed consent must be obtained from the patient and signed by both the attending radiologist and the attending referring
physician. There are no data to suggest any differences in risk from MRI exposure at different trimesters, and therefore all safety
considerations for non-contrast MRI in pregnancy apply equally at all stages of pregnancy. Other standard MRI screening continues to
apply for pregnant patients.

Gadolinium Based Contrast Agents in Pregnant Patients:
Historically, Gadolinium based contrast agents have been absolutely contraindicated in pregnant patients at UW Madison. It is well
known that free Gadolinium (which is highly toxic) accumulates in the amniotic fluid in low concentrations of uncertain significance,
after intravenous injection of Gadolinium based contrast agents. There are also animal data that demonstrate teratogenic effects of
Gadolinium in the developing animal fetus. There is a paucity of safety data in humans; with no large-scale safety studies and only a
few studies with small numbers of patients that demonstrated no deleterious effects of Gadolinium based contrast agent exposure in
pregnancy. Given the lack of human safety data and the theoretical risks of teratogenicity, Gadolinium has historically been an absolute
contraindication. However, unusual and extenuating circumstances may arise where the care of the mother and/or fetus would be
significantly compromised without a contrast enhanced MRI during pregnancy, and no other diagnostic test would answer the clinical
question. In these rare situations, the UW-Madison Department of Radiology policy allows for the use of Gadolinium based contrast
agents, but only with a well documented risk benefit analysis demonstrating the need for an MRI with Gadolinium. This analysis must
involve the attending radiologist and attending referring physician. In addition to the same documentation required for non-contrast
MRI, it should be documented that:
1. Alternative imaging tests, including ultrasound and those using ionizing radiation (CT with or without iodinated contrast, nuclear
scintigraphy, fluoroscopy, etc) could not provide the necessary information. Only if such tests will not provide the needed information
should MRI with a Gadolinium based contrast agent be considered.
2. If an MRI is needed, consideration to non-contrast techniques should be strongly considered. Reasons why a non-contrast MRI could
not provide the necessary information must be provided.
Informed consent from the patient must be obtained and should document that the patient is
aware of the potential risks. The consent form must be signed by the attending radiologist and attending referring physician.

Questions can be directed to Scott Reeder, Liz Sadowski, Fred Kelcz, Howard Rowley, Mike Tuite or Tom Grist.

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Appendix C: Guidelines for the Pregnant Anesthesia Provider

Guidelines for the Pregnant Anesthesia Provider

I. PURPOSE
A. To insure that pregnant anesthesia providers receive education concerning the risks of prenatal exposures in
their work environment.
B. To insure that pregnant anesthesia providers are assigned to cases in such a way that their risk is minimized
throughout the pregnancy.

II. FUNDAMENTALS
A. For many of the occupational exposures included, there is limited human evidence of direct harm to
developing fetuses. However, there are often animal studies that demonstrate risk, and/or a lack of human
studies that demonstrate safety in pregnancy. In these cases, risk to the pregnant anesthesia provider is
assumed to be possible, and the provider will not be assigned to such cases.

III. POLICY
A. All anesthesia providers who are pregnant, or considering pregnancy, will be provided with a copy of this
policy. A list of references will be available so individuals can review the literature if they so choose.
B. Magnetic Resonance Imaging (MRI)
1. As per the UWHC Policy 12.11 Magnetic Resonance Imaging (MRI) Safety section on Pregnancy and
Breastfeeding, “pregnant visitors or non-MRI personnel will not be allowed in the MRI room during
actual data acquisition.” Pregnant anesthesia providers will not be allowed to stay in the MRI room
during scanning.
2. Pregnant anesthesia providers may go in and out of the MRI room when the scanner is not actively
scanning.
3. Any questions regarding the risks to a pregnant woman in contact with the MRI system can be
directed to the MRI section chief.
4. Note: There are no known biologic effects to a developing fetus from non-ionizing radiation
exposure, however, no long-term studies have been documented.
C. Radiation
1. In-utero radiation exposure has the potential to cause miscarriage, intrauterine growth restriction,
microcephaly, mental retardation, organ malformation, and childhood cancers such as leukemia.
These risks are most significant during weeks 8-25 of gestation, and when high doses of radiation are
absorbed.
2. Radiation-induced noncancer health effects are not detectable for fetal doses below 50mGy. Fetal
doses above 100mGy can cause fetal health effects.

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3. Pregnant providers should keep their total fetal dose of radiation below 1mGy throughout the
pregnancy. (Wisconsin Dept. of Health and Family Services, HFS 157-Radiation Protection
Regulatory Guide; International Commission on Radiological Protection)
a. Examples of fetal radiation doses when pregnant women undergo the following radiologic
procedures:
i. Chest x-ray <0.01 mGy; Abdominal x-ray 1-4 mGy
ii. Head CT <0.5 mGy; Abdominal CT 8-49 mGy; Pelvis CT 25-79 mGy
4. Lead aprons protect against 80-90% of incident radiation. Aprons at UW have a lead equivalence of
0.4mm and 0.5mm; and transmission of radiation through the apron from a primary beam 40 inches
away is 8% and 3.2% respectively.
5. The UW Radiation Safety Officer is available to talk with anyone regarding radiation exposure
concerns.
6. Anyone can request and wear a radiation dosimetry badge to monitor their exposure.
7. The pregnant anesthesia provider will not be assigned to cases involving high dose radiation,
radiotherapy, neuro-interventional radiology, or the cardiac cath lab.
8. The pregnant anesthesia provider will not be allowed to remain in the CT scanner while it is scanning.
9. Every attempt will be made to keep pregnant anesthesia providers out of cases involving fluoroscopy.
10. Pregnant anesthesia providers will not be excluded from cases that involve taking limited plain x-rays.
11. Pregnant anesthesia providers will protect themselves by maximizing their distance from the source (6
feet or greater), maximizing their shielding with lead aprons +/- lead shields, and monitoring their
exposure with a radiation badge (if they so choose).
D. Waste Anesthetic Gases
1. The Task Force on Trace Anesthetic Gases of the ASA Committee on Occupational Health has
written “Waste Anesthetic Gases: Information for Management in Anesthetizing Areas and the
Postanesthesia Care Unit”
a. Conclusion: There is no evidence of risk to pregnant anesthesia providers who work in areas that
have proper scavenging of waste anesthetic gases.
2. Animal Studies
a. Nitrous oxide has been shown to be teratogenic in experimental animals at concentrations of 50-
75%, when given for 24 hours during the period of organogenesis. When given at low
concentration throughout the entire pregnancy, rats have an increase in fetal resorptions and
visceral and skeletal abnormalities.
b. Potent volatile anesthetics are not teratogenic in rodents except when given at anesthetizing
concentrations for many hours on several days during pregnancy.
c. These experimental outcomes are not relevant to occupational exposure to trace levels of waste
anesthetic gases.
3. Epidemiological Studies
a. Studies in the 1960s and 1970s were inconsistent, but some suggested an increased risk of
spontaneous abortion in those exposed to waste anesthetic gases, particularly nitrous oxide.

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b. Since scavenging has become routine, there is no evidence of increased risk to pregnant anesthesia
providers.
4. Occupational Safety and Health Administration (OSHA), the National Institute for Occupational
Safety and Health (NIOSH), the Food and Drug Administration (FDA), the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO), and the ASA are all concerned with the possible
hazards of waste anesthetic gases.
5. Current standards of waste anesthetic gas scavenging will be maintained. Levels of halogenated
agents will be < 2ppm (parts per million) when used alone. Halogenated agents will be < 0.5ppm and
nitrous oxide will be <25ppm when these agents are used together.
6. Anyone can request a halogenated agent or nitrous oxide badge to measure her exposure level.
7. The anesthesia provider is responsible for completing the appropriate anesthesia machine check to
ensure that there are no leaks, and that the scavenging system is functioning properly.
8. All anesthesia providers in the room will limit excess contamination by maintaining a good mask seal
during inhalational inductions and during mask anesthesia. They will also insure that the vaporizers
and nitrous oxide are off during intubation and at the end of the case.
E. Chemicals and Medications
1. Methylmethacrylate (MMA)
a. Used for cementing total joint replacements.
b. Clear liquid with a distinctive, sharp, fruity odor. Most people can smell it when the level in the
air is considerably below the level, which is hazardous to health.
c. OSHA Permissible Exposure Limit is 100 parts per million for all workers.
d. Animal studies have shown that inhalation of MMA can cause an increase in early resorptions,
birth defects, decreases in fetal weight, and delayed ossification when pregnant rats are exposed to
high levels.
e. The US Environmental Protection Agency reported in 1985 that chronically exposed pregnant
women experienced “complications during pregnancy” although doses and duration of exposures
were not reported.
f. Occupational exposure to MMA is classified as Pregnancy Risk Category C: “Either studies in
animals have revealed adverse effects in the fetus but no controlled studies have been reported, or
studies in women and animals are not available. Drugs should be given only if potential benefit
justifies the potential risk to the fetus.
g. Since there is no evidence of safety, and there is animal evidence of risk, pregnant anesthesia
providers should not be assigned to cases that involve exposure to methylmethacrylate.
2. Collodion
a. Used by some surgeons (urologists) to help achieve a watertight closure.
b. Consists of 60-70% diethyl ether and 20-25% ethyl alcohol 200 proof.
c. Teratogenic and mutagenic effects exist for ether and ethyl alcohol.
d. Direct inhalation of collodion vapors has anesthetic properties. It can cause dizziness, drowsiness,
unconsciousness, respiratory failure, and death.

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e. OSHA Permissible Exposure Limits: 400 parts per million (ppm) for ethyl ether, and 1000 ppm
for ethyl alcohol.
f. Pregnant anesthesia providers may be in rooms where collodion is used, but should avoid direct,
prolonged exposures in confined poorly ventilated spaces.
3. Medication exposures to be avoided
a. Pentamidine: Used for treatment of PCP pneumonia. Pregnant providers should not care for
patients during the administration of aerosolized pentamidine as it can be teratogenic and
embryolethal.
b. Ribavirin: Used for treatment of RSV. Pregnant providers should not care for patients during the
administration of aerosolized ribavirin as it can be teratogenic.
i. As per UWHC Policy 2.29 Ribavirin Delivery via Small Particle Aerosol Generator, no
pregnant women should be exposed during drug administration.
4. Medications that require care in handling
a. Mycophenolate (Cellcept): Mycophenolate is teratogenic, so proper handling to avoid self-
contamination is important. Pregnant providers may administer this, but should be sure to wear
gloves and use caution when doing so. Empty infusion bags and tubing should be disposed of
properly in biohazard containers.
b. Antineoplastic medications (cyclophosphamide, methotrexate): These medications are mutagenic,
so proper handling to avoid self-contamination is important. Pregnant providers should wear
gloves and use caution when preparing and administering these medications. Empty infusion bags
and tubing should be disposed of in biohazard containers.
c. Ganciclovir (Cytovene): Mutagenic and teratogenic. Wear gloves and use caution when handling
to avoid self contamination.
d. Flourouracil (Efudex): Mutagenic. Wear gloves and use caution to avoid self contamination.
e. 5-alpha reductase inhibitors (Avodart, Propecia, Proscar): These are antiandrogens and can cause
feminization of a male fetus. Wear gloves and use caution if handling of these medications is
necessary.
f. Testosterone (Androgel, Androderm): These medications may affect fetal sexual development.
Wear gloves and use caution if contact with these medications is necessary.
5. Organic solvents
a. Exposure during pregnancy has been shown to cause an increase in the risk of major
malformations, spontaneous abortions, and visual deficits in humans. Children whose mothers
were exposed during pregnancy have also been shown to have poorer performance with regard to
neurocognitive function, language, and behavior measures.
b. Examples include: floor & tile cleaners, glues, lab reagents, paint thinners, paint removers, dry-
cleaning chemicals, aerosol sprays, spot removers, gasoline.
c. Ethylene oxide: chemical used in sterilization of surgical instruments. Exposure during early
pregnancy may cause birth defects and miscarriage.

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d. Pregnant anesthesia providers are unlikely to be exposed to these chemicals in their workplace.
However, they should be aware of the risk, and that others may be working with such chemicals
(ie stripping the floors in the OR at night).
F. Infectious/Isolation Patients
1. H1N1 (swine flu)
a. This is a novel virus, so data and research are limited.
b. There is a higher fatality rate in pregnant women (versus non-pregnant women) who get H1N1
infection.
c. Pregnant anesthesia providers should not care for patients who have H1N1.
d. Pregnant providers should be immunized for H1N1 when the immunizations are available. (Each
woman should discuss this with her obstetrician.) They should also receive the injectable,
preservative-free influenza vaccine (the seasonal flu shot).
e. Pregnant providers who are exposed to a patient with H1N1 should contact their obstetrician to
discuss the recommended prophylaxis with Tamiflu.
2. 5th Disease (parvovirus B19)
a. Common in preschool age children and at day-care centers. “Slapped cheeks” appearance.
b. Many women of childbearing age have immunity.
c. Pregnant women who are not immune, and who contract 5th Disease have the risk of fetal hydrops,
fetal demise, and stillbirth.
d. Pregnant anesthesia providers will not be allowed to care for patients who have 5th Disease.
e. If a pregnant provider is exposed to 5th Disease, she should contact her obstetrician. It is
recommended that blood tests are then done for IgM and IgG antibodies to parvovirus B19, and
that an ultrasound is done 6-8 weeks after the exposure.
3. Varicella and herpes zoster
a. Pregnant women who are not immune, and who contract varicella or zoster are at risk of fetal
effects. Offspring can have limb hypoplasia, eye & brain damage, and skin lesions. The risk is
about 2%, and is highest in the first 20 weeks of pregnancy.
b. Pregnant anesthesia providers who are not immune, or who do not know if they are immune,
should not care for patients with active varicella or herpes zoster.
c. Pregnant anesthesia providers who are immune can safely care for patients with chicken pox or
shingles.
4. Tuberculosis
a. The pregnant anesthesia provider should continue with annual TB skin test screening.
b. The pregnant anesthesia provider may care for patients with TB as long as they use standard TB
isolation precautions.
5. HIV, Hepatitis
a. Immunization against hepatitis B is encouraged for everyone.
b. The pregnant anesthesia provider can care for patients with HIV and hepatitis as long as they use
standard universal precautions.

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REFERENCES

Hood J. (2008) The pregnant health care worker--an evidence-based approach to job assignment and reassignment.
AAOHN J; 56(8):329-33.

Wagner L, et al. (1991) Radiation bioeffects and management text and syllabus. Am College of Radiolog; 164.

Toppenberg, K et al. (1999) Safety of radiographic imaging during pregnancy. Am Family Physician; 59.

International Commission of Radiological Protection. (1991) Recommendations of the ICRP, Publication 60,
Pergamon Press, Oxford.

International Commission on Radiological Protection, Pregnancy and Medical Radiation. (2000) Annals of the ICRP;
Publication 84, Pergamon Press, Oxford.

McCollough C et al. (2007) Radiation exposure and pregnancy: when should we be concerned? Radiographics
27(4):909-17.

Health Physics Society: http://hps.org

http://www.osha.gov

Waste anesthetic gases: information for management in anesthetizing areas and the postanesthesia care unit. (1999,
2002) ASA Committee on Occupational Health: Task Force on Trace Anesthetic Gases.

Wrońska-Nofer T, et al. (2009) DNA damage induced by nitrous oxide: study in medical personnel of operating
rooms. Mutat Res; 666(1-2):39-43. Epub 2009 Apr 5.

McGregor DG. (2000) Occupational exposure to trace concentrations of waste anesthetic gases. Mayo Clin Proc;
75(3):273-7.

Boivin JF. (1997) Risk of spontaneous abortion in women occupationally exposed to anaesthetic gases: a meta-
analysis. Occup Environ Med; 54(8):541-8.

Laslo-Baker D, et al. (2004) Child neurodevelopmental outcome and maternal exposure to solvents. Arch Pediatr
Adolesc Med; 158(10): 956-61.

Collodion, U.S.P. Material Safety Data Sheet. Mallinckrodt Baker, Inc., 222 Red School Lane, Phillipsburg, NJ
08865.

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Reproductive hazards of handling medications. Pharmacist’s Letter/Prescriber’s Letter (2006) 22: 220339.

Timpe E, et al. (2004) Environmental exposure of health care workers to category D and X medications. Am J
Health-Sys Pharm; 61(15):1556-7.

Ito S, Koren G. (1994) Estimation of fetal risk from aerosolized pentamidine in pregnant healthcare workers. Chest;
106(5): 1460-2.

Pastuszak AL, et al. (1994) Outcome after maternal varicella infection in the first 20 weeks of pregnancy. N Engl J
Med; 331(7): 482.

http://www.motherisk.org The Hospital for Sick Children (SickKids), University of Toronto. (Resources and
references for professionals and for mothers; including occupational and environmental exposures, infectious diseases
in pregnancy, and drugs in pregnancy.)




SUBMITTED/REVIEWED BY:
Deborah Rusy M.D. 9/2015


REVIEWED BY:
Denise Dillon 9/2015
Surgical Services Policy & Procedure Committee 9/2015


SIGNED BY:

Jeff Fenne, MSN, RN
Director, Surgical Services Department