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History of MRI and ICDs | Demystifying (Cardiac) Device Monitoring for MRI Studies: The Expanded Role of Radiology Nursing
History of MRI and ICDs | Demystifying (Cardiac) Device Monitoring for MRI Studies: The Expanded Role of Radiology Nursing
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The Expanded Role for Radiology Nursing | Demystifying (Cardiac) Device Monitoring for MRI Studies: The Expanded Role of Radiology Nursing
The Expanded Role for Radiology Nursing | Demystifying (Cardiac) Device Monitoring for MRI Studies: The Expanded Role of Radiology Nursing
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Devices | Demystifying (Cardiac) Device Monitoring for MRI Studies: The Expanded Role of Radiology Nursing
Devices | Demystifying (Cardiac) Device Monitoring for MRI Studies: The Expanded Role of Radiology Nursing
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Pacing Indications | Demystifying (Cardiac) Device Monitoring for MRI Studies: The Expanded Role of Radiology Nursing
Pacing Indications | Demystifying (Cardiac) Device Monitoring for MRI Studies: The Expanded Role of Radiology Nursing
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CRT Therapy or Bi-Ventricular Devices | Demystifying (Cardiac) Device Monitoring for MRI Studies: The Expanded Role of Radiology Nursing
CRT Therapy or Bi-Ventricular Devices | Demystifying (Cardiac) Device Monitoring for MRI Studies: The Expanded Role of Radiology Nursing
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Programming for MRI  | Demystifying (Cardiac) Device Monitoring for MRI Studies: The Expanded Role of Radiology Nursing
Programming for MRI | Demystifying (Cardiac) Device Monitoring for MRI Studies: The Expanded Role of Radiology Nursing
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Device Worksheets  | Demystifying (Cardiac) Device Monitoring for MRI Studies: The Expanded Role of Radiology Nursing
Device Worksheets | Demystifying (Cardiac) Device Monitoring for MRI Studies: The Expanded Role of Radiology Nursing
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MRI Emergency | Demystifying (Cardiac) Device Monitoring for MRI Studies: The Expanded Role of Radiology Nursing
MRI Emergency | Demystifying (Cardiac) Device Monitoring for MRI Studies: The Expanded Role of Radiology Nursing
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Transcript

- Thank you. I'm glad to be here today. And as Michelle said, this is Demystifying Device Monitoring for MRI Studies: the Expanded Role of Radiology Nursing. And I'm Karen, and I do work at the University of Virginia. And I work in radiology.

However, this is not where my career started. I worked initially in the ICU and the CCU and the emergency department, and it was there that I learned about cardiac emergencies, including malfunctions of pacemakers and ICDs. After many years, I transferred to

the electrophysiology lab, which is that EP lab, and it was here that I learned about pacemakers and defibrillators literally from the inside out. In the EP lab, we also treat tachyarrhythmias and do ablations.

When I transferred to radiology, oops, little did I realize that my prior nursing experience would be of benefit as we were called on to monitor patients that had MRIs with devices. I have no disclosures.

Have you ever been pushed out of your comfort zone

to an unknown, fearful territory? Well, I propose that is exactly what happened to our nursing staff when, in the spring of 2017, one of our cardiologists came to radiology and he excitedly explained that radiology nurses were going to now be able

to monitor these MRI patients with devices. Well, he said that there was a new guideline that had come out and so we were going to be able to monitor these patients. This new guideline changed everything. There are actually or is actually a need for this study.

2,000,000 people have been, in 2016, the American College of Cardiology said that 2,000,000 people have pacemakers and ICDs. And half of these are going to need an MRI in their lifetime. So that prompted questions,

and we had a lot of questions. Who will be monitoring these patients? What are the guidelines? And how do we go about this?

Adapting this new role to radiology nursing monitoring device patients has been

quite a bit of a process. My objectives today are to have each participant gain an increased understanding of the history and the referral process related to this change and for you to have an increased understanding about pacemakers and ICDs.

I'd also like to give you a working tool that provides a consistent way to prepare for MRI patients. And of course, this presentation would not be complete if we don't discuss what potential issues to anticipate and how to care for an emergency. Understanding where we're going is always important

to have an understanding of where things have come from. The development of pacemakers and ICDs and even MRI are all relatively new. The first pacemaker was implanted in 1958. The first ICD was implanted in 1980. And in the late 70s and early 80s,

MRI came on the market as a very good diagnostic tool. That wasn't that long ago. Following that, it wasn't until 2002 that clinical studies began to study MRIs for patients that had cardiac devices. And in 2007, or excuse me, in 2008,

the first MR conditional pacemaker came on the market. And that was a major event. In 2015, like eight, about seven years later, the first and MR conditional ICD came on the market. In 2017, in response to a number of factors, an expert consensus statement was written

that guided practitioners and gave some guidelines for the care of these patients. Following that, even in 2018, just a year ago, Medicare and Medicaid began to reimburse for device patients an MRI.

So the full title of this statement

that changes everything is the 2018 HRS, that's the Heart Rhythm Society, Expert Consensus Statement on MRI Imaging and Radiation Exposure in Patients with CIEDs. Those are cardiovascular implantable electronic devices. And this guideline is intended to provide

useful and practical recommendations for patients so that they can safely undergo imaging and treatment. It's not intended to dictate management of details that they state are best left to the individual institutions to develop.

The Heart Rhythm Society and 11 other national and international colleges collaborated to write this statement. They included experts from the American College of Cardiology, the American College of Radiology,

the American Heart Association, people from Europe and Peru. And these were experts that were saying, "Okay, we've got these patients that need MRIs. "What are we going to do about it?" And one of their statements,

and the one that actually changed everything for us, was, "It is recommended that personnel "with the skill to perform advanced cardiac life support, "including the expertise in arrhythmia recognition, "defibrillation and transcutaneous pacing "accompany that patient."

So this means that qualified radiology nurses can monitor device patients. So what's the big deal? Radiology nurses have extensive training in the care and safety of patients in radiology and in MRI.

However, understanding of pacemakers and defibrillators and the potential issues that can occur are not necessarily a part of the radiology nurse background. In caring for these patients that are having their MRI device studies,

nurses need to be prepared. Radiology nurses need to be prepared.

This change was significant for our hospital as I believe it is for most. And I want to share with you how we at UVA have adapted our institutional protocol

into this new role of monitoring MRI device patients. Prior to this statement, at our hospital, device nurses had been monitoring all of these device cases. And collaboration occurred between physicians, between nurses and managers from cardiology,

radiology, the device clinic, MRI, and even we had someone from IT that worked to coordinate this change. These meetings occurred both formally and informally, and education was and continues to be a major part of this process.

Before I go any further, I want to make sure that everybody has a handout. If you didn't pick one up the door, let it be known, we'll make sure that you have one. It just has a few terms that I think would be beneficial. So as each institution develops their own protocol,

it is important that every time an MRI is requested for a device patient, that there is a clear process scrupulously done with each case. And this needs to be reflected in the institutional protocol. So the primary care physician or the LIP

will request an MRI study. The radiology physician does an evaluation determining the strength of the study and if there are other options available. The cardiologist or EP physician will also do a very thorough evaluation

and they will be checking for abandoned leads. That means they physically need to look at a chest x-ray to see if there's anything present. They want to know the type of device the patient has. What is the underlying rhythm? Is this device MR conditional or MR nonconditional?

Another device evaluation actually occurs on the day of the study. It's recommended that this evaluation is done to evaluate the function of the generator and the lead, both before and after the MRI study. So it was comforting to me to know

that this comprehensive evaluation had occurred before we were even asked to see a patient and monitor them for their study.

So what is a device? A device includes pacemakers and defibrillators, and that's what I'm speaking about today.

Another name for a device is the CIED. That's the cardiovascular implantable electronic device. A pacemaker is also called the pacer. A defibrillator may be called an ICD, which is an implanted cardiac defibrillator, or some people call it an AICD,

which is an automatic implanted cardiac defibrillator. Now you don't have to be an expert with devices, but having a general understanding is important. So MR conditional is a device that has been approved by the FDA with conditions. That means that there is a designated generator

and lead that are combined to make this system. It's been implanted as a unit, and it's been tested as a unit. So radiology nurses are able to monitor all MR conditional device. An MR nonconditional device is one that is not FDA approved.

That might mean that a conditional generator was inserted with a nonconditional lead or leads or vice versa. It might mean that the device is programmed outside of the parameters that are expected. But what you need to know is anything

that is not conditional, is not MR conditional is MR nonconditional. Not is not FDA approved, and with that goes some specific considerations, some special considerations. With the nonconditional device,

that physicians need to be notified both from cardiology and from radiology. And that's in case you have an emergency, you want to make sure that these docs know right away to come down to your area and that that patient is on the table at that time.

Also, a radiology nurse can monitor all nonconditional devices. They're fine for us to monitor. However, if a person is pacemaker-dependent, they would need to be monitored by someone that can instantly reset that device

to their programmed parameters. So we can't monitor the nonconditional pacemaker-dependent patients. And the nonconditional devices would need to have either an informed consent or we use an information sheet,

that the information is intended to give patients an understanding about what's happening with them and their device at that time. And they need an opportunity to ask questions. So a physician would, they would need to have the opportunity if they didn't understand something,

to speak to a doc. A device is actually a system. It's a system of batteries, a battery, or it has another name, a pulse generator or a generator. Everything has many names. It's actually the brains of the device system,

and it's either a pacemaker or an ICD generator. The replacement time is getting longer and longer, and it is usually minimally five years, up to 10 years, and they're actually going longer. And the earliest time frame is sometimes even eight years of replacement.

When it's replaced after a pacemaker or an ICD has been implanted, the replacement of that generator is like changing the battery. And it's a very simple in and out EP procedure and the patient goes home with conscious sedation in just a few hours.

Leads are flexible wires that are inserted through a blood vessel, and they attach on one end to the heart muscle and the other end attaches to the generator. They're named for the chamber that they're placed in. They're either A leads, V leads or LV leads.

That means it's either in the atrium, the ventricle or the left ventricle. And a system would have one, two or three leads attached to their generator. The pacemaker is smaller, and it's also, as I said, system of the generator and leads

and it strictly paces or inhibits, it means it's not going to pase if it doesn't need to. An ICD generator is larger. It has all the functions of a pacing system. However, it can also overdrive or shock a lethal rhythm. The shocking lead is different.

It has the ability to pace, but it also has the ability to provide a shock. And it's always placed in the right ventricle. This is a pacemaker generator. This is an ICD generator. And the weight is different.

The pacemaker is much lighter. And this, whoops, is a shocking lead. This is the lead that would be in the right ventricle, and it's able to, this portion here has got a coil on it that allows the generator to send a signal to actually shock internally.

This is the end that would insert to the device. It has a little place in here that is attaches to. And that goes into the heart muscle. This is a pacemaking lead, a pacing lead, and it's just very, very flexible. So I'm going to have them up here,

I have a couple of samples if you want to play with them afterwards. Now how does the device work? Well, signals travel between the generator and the leads that are in the heart muscle. If no beat is detected, the small electrical stimulus

comes from the generator into the heart muscle and it stimulates the contraction and that causes the heart to pace. If there was a heart beat detected, the lead will be sending a signal up to the generator and that signal is interpreted.

And it says, hey, that patient had a heart beat, I don't need to pace. So it just stands by and it inhibits. This is a picture of a pacemaker system with the pacer under the left clavicle. It's usually inserted subcutaneously.

And the lead goes down to the right ventricle. You can see that. And the other lead you don't see as well. However, that in the right atrium, which is near where the sinus node is so that it can stimulate a sinus-ish contraction.

Now pacing indications are for either a peacemaker or an ICD. It just means why does that patient need to have their heart paced? Some examples are brady rhythms. Either sick sinus syndrome,

symptomatic sinus bradycardia could be an indication. Heart blocks are second degree Mobitz type II. Mobitz I doesn't require a pacemaker. Complete heart block or third degree heart block are indications. Irregular rates and rhythms are another category of rhythms

that would potentially require a pacemaker. Someone with tachy/brady syndrome or atrial fibrillation may have slow heart rates at times and they might have very fast heart rates and they need medication to control the rates so that the heart rate stays manageable

and that the patient doesn't have symptoms. But when you give these medications to treat a tachy rhythm, the reflex is that they can have a brady rhythm and so then they may be needing to have a pacemaker to maintain a decent heart rate.

A special category of indication for pacing is an AVJ ablation, and that's a procedure that occurs in an EP lab. And it actually burns the junction at the AV node. And sometimes they're called AV nodal ablations, but it makes the patient pacemaker-dependent.

Those rapid atrial signals of atrial fib are just not controllable with medications so they cut the junction so there's no more communication and that patient would need to be paced from the ventricle. Another category it's chronotropic incompetence, and that just means that there's a loss

of the ability to regulate heart rate.

So an ICD is implanted for basically two main reasons. One is primary prevention, and I call it prevention. It means that the patient has a high risk for sudden cardiac death, which is SCD, Vtach or Vfib,

but they've never actually had an episode. The ejection fraction is either less than or equal to 35%. So ejection fraction is the pumping action of the heart and it just means that with each beat, a low percentage of blood is being extracted

and that patient, when that happens, it's been proven that a low ejection fraction person with a low EF has a higher risk of sudden cardiac death. Now I call the other one treatment, but it's actually named secondary prevention. It means that patient has actually survived

an episode of sudden cardiac death, and there's no known correctable cause. They didn't have a severe electrolyte imbalance that caused them to have a cardiac arrest. They didn't happen an MI and they've been stented and reopened and they would no longer be

a candidate for a device because of that reason. Congenital reasons are also another reason for implanting a device, an ICD. Now a patient who requires an ICD, as I said, an ICD can both do pacing and shocking functions, but they may also have pacing needs.

So the ICD (mumbles) implanted because it can do both.

Now a special category of device monitoring is patients who have cardiac resynchronization therapy or CRT, or it's a biventricular device. A lead goes into both the right and left ventricle. And I'll just tell you about this so that you,

it doesn't change our device monitoring really. However, it's something that you'll hear about. And a person with a low ejection fraction is a candidate for this. They have a wide QRS complex. It means as that muscle is big,

like cardiomyopathy or someone who has a large heart muscle, the conduction from south to south to south takes longer and so they have a wide QRS complex. A third lead is implanted so that it paces the right ventricle synchronized with the left ventricle.

And the goal is to have the left ventricle contract more efficiently and uniformly. By beating symmetrically, it helps to improve the ejection fraction. The heart pumping action is improved. And it mimics, resynchronization mimics

healthy heart contractions. Okay, now don't be afraid (chuckles) but it's quiz time. If a patient had complete heart block, just think, what kind of device would they have? They just have complete heart block. Ideas? Think about it.

They would have a pacemaker. If someone has tachy brady syndrome, sometimes fast, sometimes slow but their ejection fraction is norm, it's normal, it's 50%? Maybe a little on the low side, but what type of device would they have?

(indistinct chattering) Excellent. A patient who has survived sudden cardiac death, what type of (mumbles)? (indistinct chattering) ICD. Now if a patient has congestive heart failure and an ejection fraction that's low, it's 15%,

what type of device would they qualify for? (indistinct chattering) They would have an ICD. They would have an ICD, and they may need pacing indications. Right now we don't know that by just their diagnosis.

However, this patient has congestive heart failure and they have a sick sinus syndrome so they have maybe a low heart rate that they're not tolerating very well and their ejection fraction is above 35%, it's 40%. What would they have?

(indistinct chattering) You guys are good. I must be saying it right. If they have only need for pacing, they'll have a pacemaker. If they have a need for pacing and they have a risk for sudden cardiac death or they've had a prior event of sudden cardiac death,

they would have a defibrillator placed. And that patient, if they had the pacing indication, would utilize those pacing functions of their ICD. So remember, all ICDs can do everything a pacemaker can do. ICDs can pace, but pacemakers cannot shock. Sometimes a patient, and this is why I'm sort of saying this

because there is a little misunderstanding, they come in in there insistent they have a pacemaker and an ICD. Well, no. They don't, they actually have an ICD that's doing both functions.

Okay, this is another very delightful category, and I love casing nomenclature. So are these programming letters Greek? It sounds like it. It sounds like a code, VVI, DOO, OVO. But actually, it's a code that's fully understandable.

When I say 32619, you don't even calculate that. You just think, oh, that's today. There's a chart, and you have it in your paperwork. It's the NASPE chart, and this is how programming nomenclature comes about. The first chamber is position I,

and that's the chamber that pace is. So if a patient has several responses, it can pace no chambers, it can pace the A or the atrium, it can pace V or ventricle or it can pace dual, D, which is the atria and ventricle. Position II is the sensing chamber.

And again, it has those same options as a response. Position III, and that's as many as I'm going to go through, is the response to sensing. It has a response to have no response to what is sensed. It has a response to inhabit or to trigger, or it can do D, which is both to inhibit and to trigger.

Now these numbers, letters are used in determining the device programming. There are a few options. One is the option of an inhibitive mode. We don't really use inhibited too much at UVA. However, it's in this consensus statement

so I want to make sure and review it. This is a mode where if native beats occur, the device doesn't pace, it just inhibits. If there is not a native beat sensed, the device will pace and it will pace the appropriate chamber at the rate that its programmed.

The heart rate will be no lower than the set rate. So a patient that is programmed VVI, V is the first position and that's the ventricle. So it tells you that lead is in your ventricle and it would pace the ventricle. The second position is the position that it senses,

which is also the ventricle. Of course it's the lead that, you know, it's in. So it will sense the activity in the ventricle. If it senses that the patient has any of their native beats, it will inhibit or not pace. So that nomenclature is used in general programming,

but these are MRI options as well. Now asynchronous pacing is one that we do use fairly regularly. That patient would be paced at a non-competing rate that's faster than their native rate. So if the patient had a heart rate of 60,

we may or the device nurse would program them to be doing the study at a rate of 80. So the thought is that the patient normally beats at 60 and that's where they've been running, they would override that so to that wouldn't have any need to be paced during that study.

And it paces at this programmed rate. Say they're pacing them at a rate of 80, it will pace regardless of what's happening underneath. It will mostly override it. So probably nothing will happen underneath. But it's going to pace all the time,

and you would anticipate that you would be paced at the programmed rate and now below. Now an example, I'm using the ventricle again. So that second example is VOO. It would pace the ventricle. It would not sense what's happening in the ventricle,

and it would not respond to anything that it of course then sensed. So the other mode is the non pacing mode, and that's a mode for a patient who has a strong underlying rhythm. Maybe they had an ICD implanted

and their ICD was implanted because they had a sudden cardiac death but they have no issues. Or it's just (mumbles) because they're high risk for sudden cardiac death, but no pacing needs. So the pacing indicator or the pacing need is turned off.

So they only have their native rhythm. You would expect that patient to have a variable rate and rhythm because that's what you and I do. All rate response, of course an ICD shocking therapy and tachy therapies are turned off for an MRI, always turned off for an MRI

and I want to mention that again because it's important that we talk over that with the person that's doing the programming prior to their MRI. Now do risks exist for patients that are having an MRI? Yes.

There are concerns, and these concerns are several. One is the device reset with the batteries getting low. So that's why important to make sure that the person has a good battery. Any potential heatings at the lead, at the tissue interface. This is (mumbles) determine to not be

significantly clinically significant. There could be a failure to sense or a failure to pace. Those are some things that we'll talk about. Or inappropriate shocking. Or there is also the option at the device study because of artifacts might increase,

or decrease rather the image quality. Clinical studies however have shown that MRI is safe for both MR conditional and MR nonconditional patients when proper precautions are taken. The risks are rare.

However, with having a well-established monitoring protocol, these risks are minimized, we're prepared for them.

Now the consensus statement shapes our institutional guidelines. It's not intended to tell us exactly what to do, but it gives us guidelines and how to go about it.

I've got a copy in this little red book over here that refers to the clinical studies and a lot of information from it, and it is available online. There must be the rigorous evaluation that I discussed to determine the safety and the need for the MRI.

The device needs to be interrogated before and after. All resuscitation for a code or an issue in MRI must take place outside of Zone 4. And an external defibrillator needs to be present, and the CIED programmer, that's the machine, must be present in the department.

There are special requirements for the MR nonconditional CEIDs such as the physician notification, the consenter information. And the device dependent patient can be monitored by radiology nurses

must be monitored by someone that could immediately reprogram that device if they're pacemaker-dependent.

Now I just wanted to review safety zones. Zone I is the general public zone. Zone II is the place that has unscreened people.

Zone III is the area outside of the MRI itself where there are only screened patients and personnel. Zone IV is the one closest or in the scanner. Of course anyone entering the scanner must be appropriately screened. Now the consensus statement shapes our protocol,

as well as giving a general nursing guideline. It does say that that person must have the ability to do advanced cardiac life support, arrhythmia recognition, defibrillation and transthoracic pacing. And it also states that that person

must be in attendance with the patient from the time they're reprogrammed until they're assessed and declared stable to return to unmonitored status and that continuous ECG and pulse oximetry must be monitored until the patient is assessed and declared stable.

So that means we're going to be monitoring that patient from the time the device nurse has programmed their settings to be changed for the MRI until they have reprogrammed them and set them back into the street. Now it has been a bit of a process

to adopt these requirements or recommendations into our workflow. Staffing and how we work up a patient and schedule actually occur relatively easily. The ACLS certification was also accomplished. Education has been multi faceted.

Rhythm interpretation took a fair amount of just becoming more comfortable with rhythms, and we're still working on it. We've had individual instruction, class instruction. We've done CBLs and the hospital made a competency this past year about rhythms.

The device change in our role in MRI monitoring and what we're going to do about it, we've had in-services on that as well. You have a device worksheet on your packet too I'm going to discuss, but that's a tool that we've changed periodically,

and it directs our nursing care, our nursing preparation and our care for device patients. To prepare for an emergency, we also have had a mock code, and our MRI staff has also rehearsed their care for a device patient.

We included them in our preparation, and they included nursing in their evaluation.

This is a copy of the device worksheet, and I kind of like you to take a look at it. You're welcome to use this tool as you develop your own adaptation to your hospital protocol if it helps.

It's broken up into eight categories or sections that I actually just numbered so we can discuss them and make for easy reference. Section one is the demographic section, and that's information about the procedure, tracking, it's our look up.

We print a snapshot from Epic, which is our computer-based system and the order for the patient. So we have their background. The device information has all the information that we're able to obtain about the device

and a place to put information that we get from the programmer when we're down in MRI. One of the things that we try to determine ahead of time but can't always is, is the patient device dependent? And that's really a general term for a person with a heart rate less than 40,

or if they're symptomatic or have symptoms of presyncope, lightheadedness or any hemodynamic instability when they're evaluated with their pre MRI interrogation. So if during the MRI they turned on the rate to see if their leads are working well

and the patient's, "Woah, I get dizzy", well then we need to think about this. That patient is deemed at that point device dependent. Do they have a history of complete heart block or have they had an AVJ ablation? And just remember that if the person is nonconditional,

has a nonconditional device and they're pacemakers dependent, they have to be monitored by someone that can immediately reprogram their device. Next section is a reference section, and it has telephone numbers.

It's numbers that we obtained. We get this list to the MR coordinator so that we're prepared. If an emergency happens, they have that list ahead of time. And this is one of the changes that came out during our mock code.

When we did the mock code, one of the device or one of the people from MRI commented that, you know, it sure would be helpful to have that information ahead of time. So now we print or we put on a little Post-it note and give that to their coordinator

so that they could start making phone calls if we have an emergency. The MRI staff does their work up anticipated. They do their screening, get the patient dressed. A change that happened once we started to monitor MRI device patients was that all patients

needed to have an IV access. Prior to then, even... When device nurses were monitoring them, the ones that didn't get sedation weren't necessarily getting an IV. But we determined that we wanted to have,

be able to treat them immediately. So everybody gets IV even if they don't get contrast. They get our monitors ready so that we're all ready to come in and get started. If they haven't, we work with them and get it all done ahead of time.

Our section four is the nursing assessment. Here we get our baseline assessment, their name, all that kind of stuff and we document it. We determine if the special requirements for the nonconditional device are met, and we expect that our physicians are going to call us

when we page them and tell them that we have a nonconditional device patient on the table because that's how we know they got the page and that's what we say, and I put a little note on the device sheet just prompting the nurses so that we all know what to say to the docs.

That was initially something that they all wondered, why do I need to do this? You know, we hear about patients at the beginning of the day, why do I need to do that? And our answer is, because if we have an emergency, we want you to come right away

or note to somebody else that will respond immediately to us. We do safety checks in the MRI. We make sure that our defibrillator is ready, our code cart's ready available, oxygen suction, and we think about our emergency plan.

Setting up the monitor is like major. Our primary objective is to monitor the ECG. However, we realize that that can't always happen so we use the sat probe, and that's what's recommended in this consensus statement of course as well.

Monitoring the heart rate from the sat probe gives us a consistent heart rate. If we were to monitor from the ECG during the MRI sequences, sometimes, as it shows in this picture, that looks like static and we can't really interpret.

However, when you look at the sat probe waveform, you see that your heart rate is good so you're not going to get alarmed. But it is important to correlate as best you can your ECG with your EKG, with your O2 sat waveform. And we've found that by placing the leads

way over on the left lateral chest, you get a better R wave. So you see even sometimes during the wave, during the MR sequences, they don't fade away. So having the leads way over helps. Adjust the lead and the scale for the best positions,

and we monitor two leads. And you cannot discern no matter what, and people, I don't know what rhythm they're in, that's why it's important to get that from a handoff with the device nurse. You can't see your PQRS and T waves

just because of where your leads are positioned. We record the heart rate and the sats every five minutes once we take over from the device nurse, and that's our standard for continuous monitoring. So we just have adapted that into our monitoring for device patients.

Now section five is the device, the handoff that we receive from the device nurse. And prior to making any changes in their programming, we expect that we'll be prepared with our IV in place and our continuous monitoring is already active. They will interrogate the device and the leads

pre and post scan as I said. If the patient has had a recent shock or override tachy therapies, we don't want to have an unstable patient in the MRI scanner. And they're not a candidate for that MRI at this time. A conversation will need to be held with the physician,

and no changes should happen to the device at that stage if you determine they've had an issue. Now if during interrogation, as I mentioned, it's deemed that the patient is dependent and they have a nonconditional device, they're not a candidate for radiology nurse to monitor.

Nonconditional pacemaker dependent needs a device nurse or physician or whoever does your monitoring. We had a patient just not too long ago that did have, it was listed as an MR conditional device. However, in interrogation, they determined that the patient had a nonconditional lead.

So that changed the status of that system to be a nonconditional system. And when that patient was interrogated, they turned on the rate, she got really dizzy, turned up the rate and kept her paced throughout the study. Our nurse continue to monitor that patient.

But as we've been talking about things, it was like, should I have done that? No, that should've turned over to the device nurse, and the device nurse didn't even know that. So they're learning things too as we're adapting these work up into our protocol.

But that patient should have been monitored by someone that could immediately reset that device. We would get report of their underlying rhythm, how have they programmed or set that patient for the MRI, and what's the anticipated rhythm? Like I said, do they expect them to pace

like at a rate asynchronous at a rate of 80, or are they going to be on their own and we would expect to see whatever the patient's underlying or native heart rate is? We confirm with them that the shocking and tachy therapies are turned off.

During the MRI when the patient goes to the table, you want to make sure that they have their inner calm, available and ready. Retest it, make sure that they can talk to you over the intercom and that their ball is working. You want to be able to see them to some extent,

and you want to make sure that you've told them, if you have any issues, let me know. Any warmth or anything like that or pain or anything you feel that's weird just so that you know they're on the alert to let you know if they're not feeling good.

We do a full set of vital signs when they get on the table, and that's just so that we have their base line there. But we'd leave the cuff on. Usually we put it on their, well, depends on what part of the body we're scanning

but we would leave that cuff in place so anytime we had questions or needed to assess them, we could do that. We contact the device nurse during the study if we have any concerns, and we page them near the end so they can timely reset it.

We're thinking about the emergency in our head. Following the MRI, we do continuous monitoring until they've been declared stable. And that's when we would take off their ECG and sat probe. We confirm that the therapy is turned back on. We write a little note and we coordinate discharge

with the MRI staff. You're the monitor, and you're the defibrillator. You want to rehearse your plan and just kind of think what are my potential issues? Is patient's heart rate going fast as you're thinking about (mumbles)

are you having an emergency? Is it too fast, is it too slow? And how are they doing? That's like the main thing. Just how are you doing? Get the emergency care handled outside of Zone IV.

So one of the options that can happen is the absence of bradycardia pacing. So your patient's either known or unknown to be pacemaker dependent. They may have turned off their pacing function. And the MRI could sense that artifact

with the patient's heart rate, and it would withhold pacing. So what do you do? If it's even transient, a brady or a pause episode, you abort the scan. You escalate care as needed. You activate your emergency contacts

and you're going to be anticipating transthoracic or external pacing as they're getting your programmer person back to the MRI scanner to set them back on their own programming. So another emergency would be tachy arrhythmias, untreated tachy arrhythmias.

So that can occur because your patience is or has a known or high risk of ventricular fibrillation. They may be set on asynchronous pacing and there's a risk when someone is pacing at the set rate, if the patient starts to override and their heart rate goes up to 100

and you're pacing at 80, that it could hit, a pacemaker spike could hit on the T wave, the vulnerable T wave as we call it, and it could induce R on TVF. So what do you do? That one's pretty easy.

You get them out of the scan, do CPR, call your emergency teams, get your device people back to reprogram it, but you're preparing to defibrillate. You know your defibrillator's ready. So pad placement for devices are two options, either the typical, classic I call it,

right sub clavicular and left lateral or you can do anterior posterior. If the patient has a right-sided device, which sometimes they do, you want to make sure that your pad is placed at least an inch away from that.

The goal will be to sandwich the heart with electricity so that the electricity will traverse the heart, either front to back or here to here. The need for an elective shock or pacing does not change if the patient has a device. They still need to be shocked or paced

if they're having an issue.

So in expecting the unexpected, you're prepared. You're the defibrillator, you know where it's at. You know your patient, what rhythm you're going to anticipate. You have done your emergency checks, you know everything's ready for you.

You thought, how am I going to get the patient out of the scanner? You might need to have a stretcher nearby. Your monitor is going to be accurately set. You've done that ahead of time. You know that the rhythms you're seeing

are the rhythms that are there. Your ECG has clear leads, as clear as possible. You got blood pressure cuffs, you can access your patient anytime you want. You thought about your plan in your head you've shared your numbers,

you've tested your communication so your patient can talk to you, you can talk to them, and your programmer is there so anybody that responds to your emergency can reset that programmer or device. So you're prepared. So in closing, it's important to have a picture

of where we've been and knowing where we're going and that your preparation has already occurred and it's started when you were asked to monitor that patient. The role of nursing has changed. Understanding pacemakers and defibrillators

is an important part of that change. And you monitor these patients, understanding that will help you to be prepared. Using a consistent, reproducible approach will help you in knowing that you're safe and caring for your patient.

You know what to anticipate. And if you have any issues or questions or concerns, you're prepared.

So question. I do have a wonderful group of nurses, an excellent group that I get the chance to work with

and they have asked 100 questions and they've listened to me talk a few hundred times. Anyway, hopefully, they have helped to make this a clear presentation. One of our EP physicians looked over the information and he and a device nurse also agreed

and they were wonderful. I do have the samples here, the Medtronic grip Trip Walker gave me. Anyway, you're welcome to come up and take a look at them. But before I do, do you have any questions? Yes.

- [Woman] So our Medtronic rep comes and does whatever he does, we never really know. We think you said (distant indistinct muttering) okay, they're sent to eight. We sit there with pulse ox on, they get scanned. We reset to whatever they were before and they leave,

so clearly I'm going to up it a little bit after seeing this talk. But he doesn't always stay. I know. So we don't have a device nurse. It's just this Medtronic rep.

Would that be-- - And how would you access him if you had an emergency? - [Woman] I don't know. That's what I'm going to work on-- - Totally. - [Woman] He has left the building before.

(indistinct chattering) I know! (distant indistinct muttering) - No, he shouldn't-- (distant indistinct muttering) - [Woman] So if he has the rest of these slides somehow, I mean, I got most of these but (mumbles) I got three pages here but the other things

that say like (distant indistinct muttering) stuff like that. - I don't, but it's going to be on the web or whatever they do, and it will all be there. distant indistinct muttering) Mm-hmm, mm-hmm. And your physicians, our docs know on the morning

of the procedure that all the devices that are going to happen, hopefully they will have reviewed that. - [Woman] This is how it works. Our scheduling calls the MRI, MRI says okay (mumbles) pacemaker.

An MRI technologist calls Medtronic. Medtronic or the other (mumbles) companies says yay or nay, this is our device. (distant indistinct muttering) Other than the ordering doctor, there's no doctor that knows that patient's there.

The cardiologist knows-- (overlapping dialogue) - According to this consensus statement, and it's all highlighted, you know, that if you're saying, "Hey, where are our guidelines "and how are we doing this and where does this come from?"

you have a really strong statement that is a little bit confusing. They've written a very concise guideline. It doesn't say a whole lot of information about much of anything actually in my opinion. But this statement is 50-some pages.

It has clinical studies and it has information about caring for these patients and how they should be assessed and programmed. (distant indistinct muttering) It is. And it's on the back actually of your paperwork too, the name of that study.

Mm-hmm? - [Woman] Just a question about traditional and nontraditional pace. Right now we only do, yeah, they did an x-ray (distant indistinct muttering). - You can't tell that from an x-ray.

- [Woman] Right, but I mean, the look of the model just to see if it's MRI compatible (distant indistinct muttering) just the actual pacer (distant indistinct muttering) and then we have, the EP comes down, (distant indistinct muttering) nurse that comes down and interrogates

and shuts the pacer, puts them in a certain mode before we do it, but I'm just concerned about the difference between traditional and nontraditional (distant indistinct muttering) - So she's questioning about conditional or nonconditional.

You can't tell by looking at the device. You need to have information from the programmer itself telling you what the device is and if there's a lead that matches it. Like I said one time we had recently had a patient that had a nonconditional lead,

but the device was deemed conditional. But it really would then made it a nonconditional system. And that has those extra requirements according to this guideline. Now it doesn't say this is the way it has to be. It says, your institution needs to adapt

or to make their own very clear protocols so that when you go into the scanner and you're taking responsibility for that patient, you know that they have been thoroughly, you're safe, as safe as can be. (distant indistinct muttering)

Nonconditional is a device that is not FDA approved. Conditional is FDA approved, whoops. And I think we're at about a couple seconds here, so if you have questions I'm glad to answer them. Back there too, but hmmm? (distant indistinct muttering)

She's been back there since the beginning. (distant indistinct muttering) I don't know that an LVAD would be compatible by any stretch of the imagination. Reveals or those monitors are actually, are MR compatible. There's also a single or a lead-less system

that is MR compatible. I have those up here too so if you want to take a look at those, you can. They're really cool little gadgets. But LVAD would not be. Whoops.

Sorry. - Just to keep on time because we have another like her starting. If we can just step out in the hallway and have her finish addressing your questions and getting the answers.

And to reiterate, just watch for your emails coming from ARIN and you'll have access to her lecture, her slides. So for people who want to make practice changes, it'll be available. - And I did put my contact information on those papers

that I handed you. If you have any questions, please let me know. (audience applause drowns out dialog) Thank you.

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