Anesthesia for CT

and MRI procedures

Objectives
Anesthetic Challenges in Remote Locations

Anesthetic Challenges in Magnetic Resonance Imaging

Anesthetic Challenges in Computed Tomography Imaging

Anesthetic Management for Adult Patients

Anesthetic Management for Pediatric Patients

Summary and Recommendations

Introduction
Anesthesia for MRI and CT procedures pose a unique risk:

- Scanning equipment
- Communication Difficulties
- Off-site location (distant from OR)
- CT: Radiation Exposure
- MRI: Strong magnetic field, radiofrequency energy, loud acoustic noise,
specialized equipment needed to deliver anesthesia safely
Anesthetic Challenges in A Remote Location
Preparation:

Set up includes:

- Transporting anesthetic monitors, equipment, anesthetic agents and other

drugs to a remote location.
- Establishing familiarity with equipment that differs from that typically used
in the main OR.
- Setting up specially designed lengths or extension of IV tubing, long circuit
tubing for the anesthesia circuit etc.
- Configuring the room setup to allow a visual of the patient and the
anesthesia machine/monitors by the anesthesiologist staff.
Anesthetic Challenges in A Remote Location
Sedation and anesthesia:

- Can exacerbate hemodynamic instability (especially in those receiving

vasoactive infusions)
- Adult patients: comorbidities causing increased risk of oversedation,
inadequate oxygenation and/or ventilation
- Pediatric patients: High incidence of oxygen desaturation
Anesthetic Challenges in a Remote Location
Communication:

- Darkened room
- Distance to the patient
- Obstructed line of sight to the patient and monitors
- Large acoustic noise generated during fast pulse MRI scanning can obscure
alarms on monitors and other anesthesia equipment.
- Presence of multidisciplinary team members who may not work together
with regularity.
- Procedures for possible emergencies should be briefly reviewed.
- A brief review of arrangements for immediate communication with
anesthesiology and other personal outside the imaging suite.
Anesthetic Challenges in a Remote Location
Cardiopulmonary Resuscitation:

Delayed due to:

- Removal of patient from scanner, placement onto a stretcher, and relocation

to a nearby environment with fully stocked resuscitation equipment.

Safety precautions that address these challenges:

- Practiced multidisciplinary team responses to emergencies.

- Prearranged communication protocols to summon additional anesthesia
personnel in an emergency.
Anesthetic Challenges for MRI
Environmental risks and challenges:

- Strong magnetic field, radiofrequency pulses with associated electromagnetic

interference, and loud acoustic noise - potentially HAZARDOUS
- Magnetic Field:

- May cause heavy objects to become accidental projectiles into the bore of the scanner

- Note: The magnetic field is constantly present even when the patient is not in the scanner

- Outermost line on the floor of an MRI suite is the 5 Gauss line (Point at which pacemakers, implanted
defibrillators etc. may be affected by the magnetic field).

- Stretchers, ICU beds and crash carts used for ACLS are NOT MRI compatible.
Zone I- All areas freely accessible to the general
public. Magnetic fringe fields in this area are
less than 5 Gauss (0.5mT).

Zone II- Public area. Interface between Zone I

and III/IV.

Zone III- Magnetic fields are sufficiently strong

enough to present a physical hazard to
unscreened persons.

Zone IV- Highest magnetic field and area from

which all ferromagnetic objects must be
excluded.
- 5 Gauss Field: Magnetic fields less than the 5 Gauss zone are inconsequential
to MRI safety. (0.5mT)
-
- 30 Gauss Field: Point where projectile hazards become significant and only
MRI compatible equipment can safely enter this region. (3mT)
Anesthetic Challenges for MRI
Magentic Field ct’d:

- Some anesthesiologist cannot safely enter the MRI suite (e.g. those with a
pacemaker, ICD or implanted insulin pump).
- Anesthesiologist should remain 0.5 to 1m from the bore of the scanner.
- Rapid patient motion produces an electrical current within the body →
nausea, vertigo, headache, light flashes, loss of proprioception or a metallic
taste.
- Anesthesiologist may experience the above symptoms with rapid head
movement in or near the magnet bore.
Anesthetic Challenges for MRI
Radiofrequency energy:

- Can cause tissue or device heating and can also induce current in conductors
(ECG leads, equipment cables, fluid-filled tubing)
- Result: Tissue burns or a fire on the patient.
Anesthetic Challenges for MRI
Electromagnetic interference:

- Strong magnetic field and radiofrequency energy may cause artifacts that
limit clinical interpretation of the ECG or pressure waveforms.
- ECG:
- MR-safe monitors use wireless transmitters or fiberoptic cables for the ECG and pulse
oximeter
- Clinical interpretation of the ECG may be difficult while patient is in scanner.
Anesthetic Challenges for MRI
Loud acoustic noise:

- Generated during pulses of energy required for imaging because the

gradient coils vibrate loudly in the strong magnetic field.
- Sound level of 40 dB is an acceptable limit in an operating room
- MRI scanner can generate noise levels as high as 125 dB → hearing damage
(patients and medical personnel)
Anesthetic Challenges for MRI
Emergency quench:

- Defined as loss of magnet superconductivity with sudden boil-off of

cryogenic [-260 C]liquid helium
- Magnet is only deliberately quenched in the event of a life-threatening
emergency
- If quench occurs, the quench duct should vent atop the building in which the
MRI is installed.
- If not properly vented, a quench can result in complete displacement of
oxygen inside the MRI suite by the large quantity of helium released →
hypoxia
Anesthetic Challenges for MRI
Preanesthesia consultation:

Reasons for consultation:

- Severe anxiety or claustrophobia, inability to lie supine, inability to

cooperate, morbid obesity, difficult airway, obtunded or comatose state,
hemodynamic instability.
- Involves reviewing the pathology for which the procedure is being performed
- Understanding the specific requirements for completion of the scan that may
affect anesthetic care
Anesthetic Challenges for MRI
Preanesethesia consultation ct’d:

- MRI Safety- Newer permanent PMs and ICDs may be MRI-conditional but
many patients are still using older devices
- If an MRI is necessary in a patient with a non-compatible MRI device,
scanning should be done at a center with equipment and experience
performing those procedures.
- Transdermal patches may contain aluminium and should not be worn during
the exam.
- Women who are or might be pregnant are informed that fetal safety remains
unproven
Anesthetic Challenges for MRI
Risks of gadolinium:

- Should not administer linear gadolinium contrast agent to patient with acute
or severe renal insufficiency
- All gadolinium agents are avoided in pregnant patients as they cross the
placenta and health consequences to the fetus are unknown,
Anesthetic Challenges for MRI
Preparation:

Equipment:

- Monitoring equipment is classified as MR safe, MR unsafe, MR conditional.

- MR Safe: Poses no known hazards in any MRI environment.
- MR Conditional: Poses no known hazard in a specified MR imaging
environment with specified conditions of use
- MR Unsafe: Pose hazards in all MR environments.
Anesthetic Challenges for MRI
Positioning:

- Strong, static magnetic fields is generated by a superconducting

electromagnet and is present at all times.
- Positioning of the anesthesia machine, monitors, and other equipment
within the MRI suite is carefully planned before, during, and after an
imaging study.
- Patient’s position in the scanner depends upon the specific imaging
requirements.
Anesthetic Challenges for CT
Radiation Risks:

- Pregnant Patients - affected by several variables → number, location, and

thickness of scanning slices

Fetal radiation exposure during CT scans not involving the abdomen or

pelvis is minimal if the abdomen is shielded.

- Anesthesiologists - exposed to ionizing radiation if present in the scanner

room.

Radiation dose is determined by: time, distance, shielding

Anesthetic Challenges for CT - Pregnancy

Examination Type Estimated Fetal Dose per Number of Examinations

Examination (RAD) Required for a Cumulative
5-Rad dose

Head (10slices) <0.050 >100

Chest (10slices) <0.100 >50

Abdomen (10slices) 2.600 1

Lumbar Spine (5slices) 3.500 1

Pelvimetry (1 slice with 0.250 20

scout film)
Anesthetic Challenges for CT
Preanesthesia consultation:

- Patients with severe anxiety or claustrophobia, inability to lie supine,

inability to cooperate, morbid obesity, a difficult airway, obtunded or
comatose state, or hemodynamic instability

Positioning:

- Configure the room setup to maintain an unobstructed view of the patient,

anesthesia machine, and monitors.
Anesthetic Management of the Adult
Monitoring and equipment:

- Standard ASA monitors (ECG, pulse oximetry, NIBP, capnography)

- All equipment and monitors must be MRI safe/compatible in the MRI suite
Anesthetic Management of the Adult
Anesthetic techniques:

Monitored anesthesia care (MAC):

- IV agents used to provide sedation; a natural airway and spontaneous

ventilation are maintained if possible
- Provided with incremental doses of a midazolam and fentanyl, a propofol
infusion, or dexmedetomidine infusion
- Goal: Patient remains immobile during the procedure
- Concerns: Oversedation - hypoxemia, hypercarbia, or airway compromise
(obese and OSA patients)
Anesthetic Management of the Adult
General Anesthesia:

Induction:

CT - inside the CT suite

MRI - usually done in a holding area near the MRI suite

Maintenance:

Standard ASA monitors, continuous ETCO2 and intermittent airway pressures

and volumes are monitored throughout maintenance of general anesthesia

Light anesthetic required as there is no painful stimuli applied.

Anesthetic Management of the Adult
General Anesthesia →Maintenance:

- Inhalational technique:

Ensure the use of MRI safe/conditional anesthesia machines

Sevoflurane selected as there are no MRI safe/conditional desflurane

vaporizers.

MRI compatible scavenging system

If MRI safe machine not available use an elongated breathing circuit through
a wave guide. Ensure the machine is in the safe zone.
Anesthetic Management of the Adult
General Anesthesia →Maintenance

TIVA Technique:

- Use MRI safe/conditional infusion pumps to administer IV agents

- OR use multiple lengths of IV tubing to connect the patient to MRI unsafe
infusion pump in a secure location.
Anesthetic Management of the Pediatric Patient
- Generally uncooperative and intolerant of relatively long periods of
immobility required for MRI or CT scanning.
- Require deep sedation or general anesthesia.

Location of the induction and recovery site:

- Central location specialized in pediatric anesthesia services → transport to

imaging suite
- OR the remote physical location of the scanning suite.
Anesthetic Management of the Pediatric Patient
Induction and recovery at a central location:

Advantage:

- Immediate availability of other subspecialized staff and equipment

Disadvantage:

- Need to transport patient to the imaging suite

Transport is accomplished with the following portable monitors, equipment and

essential drugs (SOAPME):

- Standard monitors, emergency airway equipment, anesthetic and other emergency drugs,
sufficient oxygen to ventilate for a long period of time.
Anesthesia Management of the Pediatric Patient
Induction and Recovery near the MRI or CT scanner:

Advantage:

- Avoidance of the need to transport the patient after induction or for recovery
(time and cost savings)
- Facilitation of parental presence

Disadvantages:

- Cost and availability of experienced pediatric nursing staff to manage care

before and after the procedure
- Need for institutional build-out of space for both the preoperative and
Anesthetic Management of the Pediatric Patient
Anesthetic techniques for infants younger than six months:

- General anesthesia or propofol sedation is commonly used.

- Feed and swaddle protocol:

- Feeding with breast milk

-Laying the infant face-up with the head at the edge of a blanket over a folded corner

- The infant is then tucked in with the remainder of the blanket (ensure the feet, legs, and
hips can move freely)

- Soothe the infant to sleep and secure the infant with a specialized safety strap.
Anesthetic Management for the Pediatric Patient
Anesthetic techniques for older infants and children:

- Children >5 yrs may be able to complete the imaging procedure with no
anesthesia
- Techniques: parental presence, distractions with goggles projecting a movie,
simple reassurance

Sedation:

- Standard ASA monitors required

- MRI safe/compatible equipment within the MRI suite
- Natural airway and spontaneous ventilation maintained if possible
- Use of incremental doses of Midazolam and Fentanyl
Anesthetic Management for the Pediatric Patient
General Anesthesia:

- Used in: ex-premature infants who are more sensitive to the respiratory
depressant effects of sedative medications
- OSA
- Symptomatic gastroesophageal reflux
- Adolescents with developmental delay
Anesthetic Management for the Pediatric Patient
Airway Management:

- Oxygen administered via nasal cannula

- Oxygen administered via oral airway or nasal trumpet
- Laryngeal mask airway (supraglottic airway)
- Endotracheal intubation → abnormal airway or risk for aspiration
Anesthetic Management for the Pediatric Patient
Ventilation management:

- Most patients allowed to breathe spontaneously if the imaging procedure is

brief.
- Small patients or those with NM weakness may require controlled
mechanical ventilation.

Temperature management:

- MRI safe/compatible temperature probe is necessary for all infants and children.
- Interference of normal thermal regulations during GA → hypothermia
- Radiofrequency radiation emitted by the MRI machine generates heat →hyperthermia
Anesthetic Management for the Pediatric Patient
Anesthetic Agents:

Induction:

- Intravenous propofol or inhaled sevoflurane

Maintenance:

- Inhalation Anesthetic , TIVA or a combination

Anesthetic Management for the Pediatric Patient
Anesthetic Agents:

Volatile anesthetics:

- Use of potent volatile anesthetic agents allows rapid recovery and eliminated
the need for MRI safe/compatible infusion pumps
- Sevoflurane is the only potent volatile anesthetic agent used for induction
- Induction via sevoflurane outside the MRI suite → immediate placement of
an IV catheter → patient moved to the MRI suite for maintenance of GA and
imaging
Anesthetic Management for the Pediatric Patient
Intravenous anesthetic agents:

- Requires MRI safe/compatible infusion pumps are preferred

- Propofol: rapid onset and recovery, beneficial antiemetic and relatively
benign side effects
- Considered superior to dexmedetomidine due to: more satisfactory
emergence, better parental satisfaction

- Dexmedetomidine: Typically used in combination with other IVA (propofol,

ketamine, fentanyl, midazolam)
- Fewer sedation-related adverse events (e.g. Upper airway obstruction)
Anesthetic Management for the Pediatric Patient
Intravenous Anesthetic Agents:

Ketamine: Rarely selected for induction since large doses may cause
hallucinations and increased secretions (midazolam and glycopyrrolate can
decrease these effects)

- Can be used as maintenance in combination with other agents.

- Has a good safety profile for patients undergoing MRI, CT and other
procedures outside the main OR.
Anesthetic Management for the Pediatric Patient
Intravenous Anesthetic Agents:

- Remifentanil: Rapid recovery time → increased parent satisfaction

- Avoid chloral hydrate: Can be fatal due to resedation at home after discharge

Resedation is due to long elimination half-life of the active metabolite (8-12

hours at recommended doses)

Emergency Management:

- Responding personnel should be subspecialized in pediatric resuscitation

- Cognitive aids may be particularly useful in off-site locations since radiology
personnel may be unfamiliar with anesthesia-related emergencies
Summary and Recommendation
These imaging procedures pose unique risks due to:

- Scanning equipment, a setting remote from the OR, communication

challenges, risk for oversedation and inadequate oxygenation and/or
ventilation.

Specific risks in these settings include:

- MRI: strong magnetic field, radiofrequency energy, electromagnetic

interference may cause artifacts in monitoring equipment, loud acoustic
noise
- CT: exposure to ionizing radiation
Summary and Recommendations
Preanesthesia consultation:

- Assessing the pathology for which the procedure is being performed and
specific requirements for completion of the scan
- Assess for comorbidities, hemodynamic instability, factors that may cause
complications due to MRI equipment or radiation exposure during CT

Ensure MRI safe/compatible monitors and equipment for MRI procedures.

Plan positioning of the anesthesia machine, monitors and other equipment w/in
the MRI suite.
Summary and Recommendations
For adults undergoing MRI or CT scanning, minimal IV sedation with monitored
anesthesia care.

General anesthesia is not indicated for a nonpainful MRI or CT procedure in an

infant less than 6 months old (“feed and swaddle” technique preferred).

For older pediatric patients undergoing longer scans small boluses of IV

midazolam and fentanyl used.
References
● Ruskin, Keith, and Anne Clebone. “Anesthesia for Magnetic Resonance Imaging and Computed Tomography Procedures.” UpToDate, 7 Aug.
2018,
www.uptodate.com/contents/anesthesia-for-magnetic-resonance-imaging-and-computed-tomography-procedures?csi=9a5cbcfa-31e4-42
74-b63a-def8226c771a&source=contentShare#H1388376312.
● https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6761775/
● https://radiology.ucsf.edu/patient-care/patient-safety/mri/access-restrict
● https://www.aafp.org/afp/1999/0401/p1813.html