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.
program is the stuff requirements and
stuff education all personnel who works in this department the radiology department have to complete successfully the web-based training for level 1 and level 2 safety MRI training including the housekeeping
and also the hospital staff that comes to the department have to fill up a screening form after doing so you'll be given a sticker placed in the back of your ID and it's good for a year and that serves as your pass coming to MRI
so you don't need to fill it up every time you come in and the initial radiation safety training is given by our safety radiation safety officer in the start all it's on higher and also the best training for RT Sundarbans
course training to nuclear med and the pet department it is important if you work in the radial pharmaceutical area that you know the basic concept of spill management the acronym cares I would like to acknowledge that this acronym is
done or formulated by our nurse leader le carré leer C stands for contains pill and opened the checklist the checklist should be available or posted to all areas where major pharmaceutical agents are administered a s alert the
technologist and supervisor they're very knowledgeable in taking care of the spills our is to restrict the area don't let anyone come in and step onto his areas of spill remove the patient if possible he is to educate the patient
you have to reassure the patient there is no health hazard or nuclear hazard to them yes is to sanitize sanitize the area of spill and record in the medical record is very important but what to do when this bill occurs in the zone for of
the MRI we were prior to going that I would like to show you the how our Rachel active spill checklist looks like this is formulated by Pierre Robson it would take you I would give you guidelines on how to do step by steps in
case of nuclear spill and what to do for spills that occur in MRI so on for first cover the area with absorbable material remove patient from stone for prior to proceeding to the decontamination process contact
radiology leadership they're the one to direct surface contamination within zone four and remember the Geiger counters are MRI unsafe so how we check the Geiger counts you have to use an absorbable material you keep wiping and
then bring it out and measure the Geiger level until you keep doing that until it gets cleared also remember that the MRI magnet is always on so have someone is done guard outside the door so anyone that would need to go inside the room
would have to be scanned again and screen this is our ms KCC clinical
so we have some human factors that reduce situational awareness situational
awareness is our mental model of the world around us so I'm sure you're all very familiar with your interventional radiology rooms your CT rooms your MRI rooms and it may take you a little while because of
different human factors that are going on many of which I have listed here to realize that perhaps over a weekend weekend a blue wall got painted beige so some of these factors are insufficient communication fatigue and stress task
overload tasks under load group mindset press on regardless mentality have you ever had that from some of your Doc's in the IR room it's like you've got three cases to go and you know it's getting time that you know your staff have been
there for a while and they're let's push on we gotta get these cases done we're really opening ourselves up for air so again here's that action versus non action so we could really have some of that non action and maybe reassess those
patients and see if we can't have them wait till the next day it's a little bit safer to do those procedures and degraded operating conditions so I have a little test ready all right so this is actually a commercial that came out of
the UK and the UK was using this to heighten awareness for their drivers for motorcyclists being on the road but what it goes through is that we have a kind of a clue a clue ask type of setting where we have our trench coat detective
and we have a lineup of suspects for the murder of Lord Smythe who unfortunately is there on the floor and he's going to go through his lineup and ask them questions and he's gonna name the question but this is about the
world around you I want you to pay attention not only to what's going on but there are things that are happening in that environment that are changing and I'd like you to see how many you notice while you're watching our
detective go through his inquiry clearly somebody in this room murdered Lord Smythe who at precisely 3:30 4:00 this afternoon was brutally bludgeoned to death with a blunt instrument I want each of you to tell me your whereabouts
and precisely the time that this dastardly deed took place I was polishing the brass in the master bedroom I was buttering his Lordships scones below stairs so what I was planting my petunias in the potting shed
cussed of all a rest lady Smythe but how did you know madam has any horticulturist will tell you one does not plant petunias until May is out take her away it's just a matter of observation the
real question is how observant were you all right so how many changes did you happen to see I was gonna say would it surprise you I hit stop it in time um would it surprise you that there were 21 changes during this little yeah yeah
right yeah so how many caught late about five yeah but yeah right right so that's why communication is important and it is often one of those human factors that we don't pay attention to how key communication is in
preventing patient safety errors so let's take a look at what we what we did or didn't see clearly somebody in this room murdered Lord Smythe who at precisely 3:30 4:00 this afternoon was brutally bludgeoned to death with a
blunt instrument I want each of you to tell me your whereabouts at precisely the time that this dastardly place I was polishing the brass I was buttering his Lordships scones below stairs or something but I was fucking my petunias
in the potting shed touch the ball arrest lady Smythe right right originally yes is to increase that situational awareness where you've got motorcycles coming in from sides or in front or behind you or coming you know
all different directions that's what that was originally done for but there are a lot of those situational videos that are out there the probably the most famous is the one with the gorillas and you've got like I don't know ten people
that have the basketball and they're in different shirts and the task is you're supposed to watch the number of times that the white shirts versus the black shirts catch the ball right and in the middle of it comes this dancing gorilla
and most of the people miss the dancing gorilla because you're so focused on watching the ball well the same thing here you're so busy watching our trench coat detective interview to get to the end who did it
cuz you know they're gonna tell you I told you who's that they're gonna let you know who did it that you've miss all those things that are occurring around you so the reason why I did this is because it does involve a lot of
situational awareness and and situational awareness is around us every day and when we're taking care of our patients so it's those little things that we see when we see those changes in the monitor of our patient those little
things that happen in the room that you know maybe they're doing some reconstruction in your IR lab and your your MRI or something and and you've got to do a little workaround well that's not in your and we're gonna cover this a
little bit later with James riesen but that's not what you're used to and so your situational awareness changes and if you don't realize what's going on you may miss something and that something may be something very significant for
your patient and that's where those human factors come in where we have task overload under load communication factors that press on regardless how dangerous that can actually be so James
the ablation concept in general is to provide an environment that is
completely hostile to tumor minus 40 degrees Celsius 150 degrees Celsius 500 gray which is a radiation dose we say it's very hard for it's about anything to survive but so why is it that it doesn't always work well that's a
function of all those parameters that you see there we got to make sure we pick the right patients we got to make sure that we treat tumor where we think it is and avoid trading things that don't need treatment avoid causing
damage to collateral structures and getting a reasonable margin where we actually get some of the tumor that's microscopic there are a lot of ablation modalities radiofrequency alternates electrical current very rapidly so that
generates friction within the lesion and causes heat it looks like this a lot of times you see these little times that stick out so that you can increase the size of your blasian zone and here's a one of those deployed in a patient who
had a colorectal Curren after hepatectomy cryoablation freezes things and it pushes a gas that once it goes through a pin hole tends to expand and cause rapid freezing he can also push another gas right through it and cause
rapid heating but this is just bringing tumors to that minus 20 degree minus 40 degree threshold the nice part about cryoablation is that you can visualize your ablation zone so we're right up against the bile duct here and it tends
to be a little more respectful of tissues so that's why cryoablation is chosen every once in a while we're do frequency ablation is an excellent tool we have lots of data for it but likes it sometimes it's difficult determine where
the ablation zone is interprocedural e microwave ablation there was just a randomized study that came out that compared microwave ablation to radiofrequency ablation and the results are very similar
it was a very very experienced institution doing it but the whole point here is that a lot of these tools work pretty well there's no clear superiority on them but one thing that microwave offers it's very fast so generates
temperatures to boiling within the tumor in about five minutes and so it's certainly very fast as compared to radiofrequency and you can see boiling happening within this tumor that's been accessed eventually there that gas is
actually literally fluid that is boiling away from the tumor couple of cool ones this one's reversal expiration what we do here is we place probes throughout the lesion and we pulse it to confuse the membrane on the cell to think that
it's a it has holes in it that it cannot close and so what is happening is the contents inside the cell leave and that's pretty much consistent with not being able to survive the nice part is we can accomplish all that without
thermal ablation what do we mean that we don't go over about 40 degrees Celsius so if something is involving a bile duct or involving a critical structure like the ureter it's not actually going to damage it it just basically tells all
the the cells within there to stop stop undergoing the cellular mechanisms responsible for life it's a little more finicky to place you have to place these little parallel probes here's one we did that was directly write on the
bifurcation of the main bile ducts and you can see here afterwards is an immediate post contrast scan how that whole area is ablative it does not take up contrast and this patient never developed biliary strictures that side
turned the mic to my FA which she will be speaking about program implementation staff education requirements clinical work form and review some case studies
Thank You rose and good afternoon ladies and gentlemen I'm Rafael Donna I'm one of the regular genders at Memorial sloan-kettering I'd like to thank you now because I don't know later I might pass out because just a nervousness if
that possible let me know later okay I would like to acknowledge Pyrrha she's trying to leave now she's have to go back to New York thank you for helping us to make this presentation possible and Renee
he's here he's our clinical radiology director he's very supportive of us and thank you too Larisa Sanchez our nurse leader and Erika leer and are in for making this giving us opportunity to present before
I go into my part of the presentation let's say let's do a PET scan into to our MRI team you see the white floating areas over there let's pretend us the normal uptake from pet SDG but if we do pet MRI look what happens yay you see
their smiles it's very very vivid colors our team is very diverse you could see from all we come from all over different parts of the world they are awesome they help us give us this very good images that we're going to present today
the MS Casey pet MRI program planning and implementation took over a year the department have to hire dual modality artis who specifically trained for pet and MRI the cross training of our ends because we all MRI nurses we have to
cause cross train to nuclear medicine and pet department the construction of the radio pharmacy in the MRI suite and the development of the pet amar protocols in collaboration with the bio engineers physicists the radiology
leadership the attending radiologist the radiology leadership our ends and the artis also the compliance with the State Department of Health regulation guidelines very important part of this
workflow for pet MRI upon arrival the patient have to fill out questionnaires the MRI screening for contrast and allergy assessment pet screening form
the RT will review MRI screening for after he checked that the patients at MRI safe and no presence of a Mia Ferris fragments or anything he would give the paper to the RN the patient then will be escorted through the change room and
asked to put on robe and non slip shots this is these are the responsibilities of the nurse in our clinical workflow for pet MRI RN to review pet screening form and contrast questionnaire if patient have to receive gadolinium check
kidney function EGFR below 15 you notify the radiologist except for a of s below 30 you notify the radiologist check for allergies if allergic make sure patients is properly pre-medicated
check for Medicaid presence of medication patches and implanted infusion pumps now also you have to check for patient's blood glucose monitoring I have one but I would but I don't go inside the scanner so I'm safe
check for pregnancy status with pediatric patients we have a special process to follow the iron then obtains blood glucose and record if blood glucose is 70 to 199 we proceed with the scan anything above 200 we follow the
glycemic management with PET imaging flow chart and here's how our PET imaging flow chart looks like it looks complicated by its color coded it's three pages but I would like to show you some key points like the administration
of insulin is also based on the level of BMI you see on the arrow says BMI below 25 and there's another flow chart is if it's above 25 after that the patient will be brought back to the pet designated injection room
remember our pet MRI is located in zone three of the MRI area so prior to that the RT would the screen the patient again the patient would pass through the wall-mounted metal detector and nobody could go into song free without escorted
by the IRT or a nurse you have to swipe your ID to open the door mission when the patients in the hot room are in would obtain the height in centimeters and weight in kilos after that the RN now could do IV access once
secured you call the range of pharmacists that you're ready to inject so we wait until and the FDG dose would come up through the pneumatic children this is how our hot lab looks like the pneumatic tube to your left above is the
shower and we have the hoop to prepare for the dose or check for the dose and the wash station and once the those arrives the nurse injecting and the RT is scanning or the RT assisting just always two artists in one machine in our
MRI Department we have four magnets and only one is for MRI PET MRI it's always two artists in each machine so one RT is assisting you and with the patient so once the FDG arrives we do a patient identification using two patient
identifiers we check the label and the dose if it's correct the FDG then will be injected to the patient once injected we tell the patient they have to wait for 40 minutes during this time we instruct them to stay still not stay
still but limit movement and stimulation and inform them that we have a camera inside that room and the nurses in a and the nurses could monitor them in the nurse's station one RT will set up the scanner and computer
and patient will be screen and wondered prior to so on for so you get wandered twice check for ferrous presence patient then will be positioned on the scanner table by the pet mr technologies it takes 15
to 20 minutes for setup you have seen how the patient is position the whole body is covered by the coils and head is covered by another coil as anybody among he works in the institution who requires time out prior to injection raise your
hand please at ms KCC we do this is done by the injecting nurse and the RT is scanning the RT is reading information directly from the monitor not anywhere in the monitor while the nurse is comparing and listening into the using
the documents on hand this is done to ensure the five rights the right patient the right scan the right area your scanning the right contrast those and rate and method of administration as you all know is either given IV push or by
the dynamic or the injector timeout will be done if patient will be receiving gadolinium once the scan is finished IV access will be removed our artists are trying to remove and inject also so they are capable of removing the IV the
radiation card will be handed to the patient and paste after that patient would be assisted to the change room and discharge there is good thing when you change the patient into the robe and the non-skid
sucks because just in case there's a spill you're not sending that patient into the paper outfit they're not gonna be happy at all now I'm gonna bring you
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.
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.
after having these two cases one in our institution and one at University of North Carolina Chapel Hill that we would then basically upsize our particles to
100 micron and we have not seen that and we're doing a second clinical study and I'm not seeing that as either we had about a 70% reduction in pain so if you look at our visual analog score out to six months and if you look at our
disability it actually paralleled this exactly which is pretty impressive considering mostly patients had bilateral knee pain so out to six months very good results 90% of patients were responders so two
out of our twenty patients did not really respond one patient didn't respond at his one-month follow-up but did respond at his three and six so I still consider him a clinical failure because we expect
these patients to respond by one month here's just an example of a baseline MRI before and after and you can see all that joint effusion there the white that decreases just even after a month how much it decreases and we looked at this
in terms of synovial thickness and distension and even on MRI you can object objectively count calculate synovitis scores and we calculated that they actually statistically decreased this is another patient on the left the
image shows diffuse white enhancement if you will of the synovium of the lining on the right it shows the fluid this is an image just of embolization and I show this image because it's really shocking and this is actually one of our nurses
who's enrolled in a clinical study is this is before this is all we did we embolized the medial aspect of the knee this is one month later 30 days in fact somebody just asked me this when I was in the booth over at the meeting across
the street and basically I said listen I don't know why this happened so quickly I have no idea we didn't tap renu-it into anything else if you look at this premium post it's pretty dramatic so clearly there's an inflammatory process
that we are arresting or stopping in such a short period of time so is there a future for this I don't know it may just we may just fall down and find out that there really is in a great future but so far we know it's at least
technically successful it's the results are positive in the short term long term we're not so sure yet we do need to better understand these risks and I think in my opinion in the long term it'll probably be really really good for
this 40 to 65 year old patient population who's not yet ready for knee replacement surgery this is the algorithm for our clinical study which were almost done enrolling right now it's a randomized control study against
placebo so it's two to one randomization which means one third of the patients actually get a sham procedure so we do an angiogram on their leg they're asleep they have no idea for embolizing they're genetical it arteries or not we wake
them up I think about the table and we follow them up if they're no better they're allowed to cross over and get the treatment the other 2/3 of the
them so my particular area of interest is a blade of radium ization and what we'd like to do is to break the liver
down into a bunch of little tiny perfused volumes off of a single vascular pedicle or what we call angio zones and those are those allow us to segment out if you only have small volume disease for example like here in
segment three why do I have to treat the entire left to paddock low I can actually treat just that small portion just like it what it tastes only now I'm administering y9t but since it's expendable liver I
can administer doses that are way higher orders of magnitudes higher than what I could if our infusing into the liver just on its own so here's an example of that if you look at this lesion in the right of panic lobe you'll see these
little lines over them what we want to achieve is around a 205 GRA threshold for these lesions that's the red line everything that's south of red in terms of color orange Holly to blue is not cold enough to kill tumor so if we
administer a dose of a tea grade to the lobe we get this coverage which is to be a partial response if I administer 150 grey suddenly that red line gets larger what happens when you administer 400 grey now you've officially covered the
entire lesion and so you're going to lose the adjacent liver at those kind of doses and as well - what what the real question then is not sort of how much dose you give it's you give what you need to to ablate the tumor in its
entirety and you see what the patient's left with if someone's left with anatomically a lot of remnant liver because of how you've segmented out that lesion then go ahead and dose extremely high and that's essentially what we've
seen in pathologic results it's one of the highest things of high school pathological crosa rates you can achieve with a trans arterial therapy it's highly competitive with thermal ablation in the correctly selected bleezin
so this is an example of what it looks like when you segment out a little lesion like this and this patient ultimately went to resection and this was a complete pathologic necrosis but as you can see even it was a cirrhotic
patient we chose a very small volume of liver that we felt the patient would tolerate so that's a blade of vernalization let's take a look at what looks like in real time so we have a little capsular lesion we felt that
ablating this patient who was a potential transplant candidate we felt we can probably with a blade of radium realization so you go in and this is the comb beam CT that looks at a complete enhancement of the lesion within the NGO
zone this is what the MAA looks like when we administer it you can see how it tends to cluster within the tumor but you can see what the adverse territory is the liver adjacent to it this is what the engine room looks like how highly
selective it is the day of and this is what the wine ID actually looks like is the wine 90 doing its job and you can see how conformal it is there's no risk whatsoever to the liver that's adjacent outside of that field of
a maximum of around 11 millimeters and this is a patient at one month with a complete imaging response and this patient never developed a recurrent to the site and what's actually sole mode of treatment for this person's liver
cancer this is how you get complete pathologic response if you look at those little tiny grey dots in there those are actually the spheres within tiny little vessels within the tumor sometimes they go even to the portal branch but you can
see how they're not clustered uniformly but when you make them super hot that allows them to give range where otherwise they would be fine a little bit short so this also applies to the whole lobe this was a patient that had a
very unusual presentation of colon cancer that was invading the portal II we weren't sure what to do with this patient no one was because a very rare occurrence so we said well we would like
to resect him but there's not enough liver and we're not sure if this person's gonna survive because we've never seen portal cancer invading the portal vein so we said let's treat it with the radiation lobectomy and what's
cool here is if you look at the the arteries even though the tumor is invading the portal vein it's bringing arterial supply along with it like a vagabond and that's the conduit that allows us to treat these patients so
when we saw that we felt this patient we good candidate for irradiation lobectomy which is applying an ablative dose of y9t to the entire low not just a small segment in patients where otherwise cannot because of the anatomy the tumor
or if you're trying to shrink that lobe to get that person ready for surgery why because if you look at the size of the lobe on the left from this first image and compare it here you can see how much larger it got what happens is that part
that the surgeon ultimately tens on resecting in volutes over time and becomes completely vitalized and turns into scar tissue so we know that if a surgeon goes in afterwards to cut it out it's going to not result in liver
failure and that level of security allows people to have sir who otherwise wouldn't this patient is not going to have metastatic disease because we followed their blood level markers let me see how low they are and
is going to have enough liver remnant so the patient went to resection and this is the pathologic specimen and this was also a complete pathologic necrosis so I
study I would like to share to you in personal note that my training school
books and experiences never prepared me for all the different types of cancer I have seen while working at Memorial sloan-kettering I have come to realize that cancer does not discriminate it doesn't matter how old you are
socioeconomic status gender race color of your skin and geographical location and religious beliefs and taking care of the young pediatric patients makes me the saddest if cancer hits you it hits you
the youngest patient that ever took care of is two months old infant diagnosed with glioblastoma I remember that day clearly because I booboo the whole day based on this here comes the third case study this is a four year old child
diagnosed with hepatoblastoma a pet MRI with anesthesia is done the image to your left is pet and on the right is pet MRI you see the difference in the images this scan is done for the doctor to evaluate the extent of the disease you
could see there is a hypermetabolic uptake in the liver and in the pelvic area the color red on top of the head the patient that's normal that's a normal uptake there is no increase in the uptake so this considered normal
we're gonna do our closer look and I would like to show you the difference between the PET CT and the pet MRI the image on the middle is the PET CT done on March you could see how where are the areas that are you could see all the
increased uptake on the areas like the chest the neck thoracic region and the abdominal region the the bright area there at the bottom Dustin or my bladder up take look at the image on to your right that's a close-up loop of the
sagittal PET CT done on same month you could see clear I could see where the location of the abnormal act uptake are circled by the the white circle there is abnormal uptake in the spine and in the chest and
of course where the hepato blastoma is located but looking to your left that's the bet MRI you see how the image is so clear and defined you could now count from the you could count where the exact location is it's on T 11 and is in the
vertebra and there's evidence of the actual cord compression with all you know all you know is a neuro emergency this is a four year old child and the other abnormal app takes you could see also so this child don't only have
hepatoblastoma but also have OSHA's metastases so the scan is done to evaluate the extent of the cancer the last cases study is the 41 year old
technically step by step of how tips are done okay and and the ideal tips with
every step of this procedure I'm gonna show you two ways of doing it okay and the advantages and disadvantages of the two ways in every step okay so first of all the primary thing is to get into the portal vein and how do you visualize the
portal vein okay so one way is to do co2 Vinogradova nog Rafi to hit the portal vein me with experience no I don't need co2 venography to hit the portal vein but I still do it in an in a teaching institution because I have texture that
are learning nurses they're learning and physicians are learning so I actually do the imaging for them so they actually can get the general idea of what we're doing this is our target this is where we're coming off and that's it but in an
experience hands is it necessary absolutely not okay so co2 photography very helpful for in teaching and teaching institutions so everybody and the whole team can actually know exactly what our target is so not essential like
like we discuss and there are two methods of doing this and in a funny way I'm gonna show you that's actually the same method but one is a micro of the other one okay so two ways one way is then wedge a catheter that's the old way
kind of more traditional way than let's not call it always more traditional way of doing a co2 port and the other one is using a balloon of balloon occlusion castra and this is wedging it with a four French five French catheter you
take it all the way to where the catheter is larger than the hepatic vein and now you've wedged it okay and this is kind of a mag up you see that that's a little that's a little wedge okay you wedge you inject contrast the contrast
just sits there it's wedged it's trapped okay and then this is with a balloon to your left is a balloon full of air to the right full of contrast and you basically trapped it again you fill contrast and consciousness it's there
what's the difference between this image and this image no difference the only difference is size that's all it's the same idea you're just trapping a segment of the liver the difference is this is a very
small segment and this is a larger segment okay so essentially it's actually the same technique one is just well technically when it comes to your side all one needs a four or five French calf the other one needs a balloon
occlusion caster okay same image so then you inject co2 the key thing here if you're the type of physician where you put contrasts you have a balloon sitting or a wedge and you have to count contrast there okay
rookie mistake is that they leave the contrast and then they hit the co2 okay what is that you've lost the advantage of the co2 in the beginning of your bolus is actually contrast okay so you need to bleed out the contrast and
replace it completely co2 so your entire bolus okay is co2 and not and not and not the and not the contrast okay that defeats the purpose why is co2 advantageous over contrast contrast is a thick fluid co2 is gas is viscous it's
volatile it actually can squeeze through tight spaces as it's a gas and that's what we want we want to squeeze that co2 which is a contrast through the sinusoids reflux it back into the portal circulation so we're trapping it and
we're trying to push co2 squeezing it through the sinusoids refluxing it back into the portal circulation so you can actually visualize the portal circulation okay and all and the disadvantage of a wedge is what you see
here if you're a wedge and you're immediately sub capsular and you slam you slam that co2 aggressively what you will get is an explosion you get a rip of those of the hepatic capsule scroll the glisten capsule and then you've got
a leak and if the patient is quite low is a quite low path they can actually die from this believe it or not they will die from this and not die from the needle passes okay so that's kind of co2 and that's kind of
a little a little passive air into the perineum nice imaging not a good outcome so one way to avoid this is to still wedge but wedge away from the hepatic capsule so you're out in the periphery in the paddock veins but you're deep
inside the liver you're not you're not right underneath the capsule so that's one way of doing it the other another way is to actually use a balloon okay so this is this is just another wedge here okay and you actually use a balloon I'm
just showing you a correlation with a balloon it's a little safer because you're a little distance away from from the hepatic capsule I'm just showing you a more and more image of the same thing co2 with correlation after you access
since it's a beautiful correlation with with the portal vein venogram okay there are problems with wedges and with balloons is that sometimes you get a gas you know a co2 leak you're wedged but there's hepatic veins at vadik vein
connections and all you see is a fatty veins you can't force reflux the co2 into the portal circulation so that's one problem okay so what do you do with that you change the sights just change a different different branch okay try to
avoid that connection between the badeck veins and it back veins go somewhere else where there is no connection where you can actually make a true hip wedge and force that co2 into the portal circulation okay another way this is
just a draw a drawing out whether it alone or a catheter you get that you get the escape from the Patek vein to fatty vein is to go distal go beyond that connection so if you can go distal go distal if you can't go distal then
change your branch try to find a place where there is no hepatic vein tip a degree engine attraction preferably but not necessarily not the same branches connected to because that usually goes both ways but not always sometimes
you're lucky and if that connection is kind of like a one-way valve one way street and it's not a two-way street but that's just sheer luck okay this is an example hepatic vein to about a vein connection and what we did was basically
switch to another place another vein and we actually get the portal venogram here okay next up sting crafts Viator's thank
Sean I know you have not seen these slides at all you wanted I John can talk about this with his eyes closed so it's
not like there's anything but this is the data that was published from the Jade publishing jvi are from what Sean has written and it's just the current standards relating to what you should be expecting what we tell our patients that
they should expect for outcomes as it relates to uterine artery embolization again I'm not really here to try to point this I know you can google these you can get the information yourself but just to say that all of our procedures
have risk and we need to be clear with our patients about them now I believe that with all of these risks combined the benefits of doing uterine fibroid embolization for most patients is far greater than the risk and that's why I
really do have my practice so these are the benefits right shorter hospital stay and I would say more cost-effective and that is really debatable because gynecologists have become smarter and smarter now they're doing like same-day
hysterectomies if you have a vaginal hysterectomy then maybe a UFE is not as cost-effective because they don't have to do an MRI beforehand and they don't get an MRI afterwards and do all of that anyway and if you look at the long-term
cost of that then maybe having a hysterectomy in some patients could be that but we know for sure that patients are more satisfied when they get a embolization procedure than in my MEC to me not in the beginning run because the
procedure can be very painful that is not the procedure itself is painful but post embolization syndrome which could last anywhere from five to seven days can can be very painful again this is the comparative data that was published
by dr. Spees who is our gold medal winner this year understand a lot a lot of work in this space has allowed us to have this conversation with our gynecology partners but also with our patients as we talked about like when
can you return to work how long are you going to be all for you know am I going to need extra child care or whatever how long would I be in the hospital this information helps us to inform our patients about that then on average
you'll stay in the hospital around you know a day or so and most uterine artery embolization procedures are same-day procedures and interventional radiologists are doing these in freestanding centers as well as other
providers without any issues so we're almost down to the end we know that fibroid embolization is proven to be an effective and durable a procedure for controlling patient symptoms it's minimally invasive and it's outpatient
most patients can go back to some normal activity in one to two weeks it has a low complication rates and some patients mein neatest to surgery and should have surgery so in our practice we send around 1/3 of our patients or so to
surgery and the reason that that is that high is that patients are allowed to come and see myself or dr. de riz Nia from the street they do not have to be referred from their gynecologist and so they're just coming from the street then
you will be referring them to a gynecologist because of some of the things that may not make them a good candidate for embolization such as this
to our case study the first case study is the normal whole body pet MRI the the
image song to your left it's a regular pet MRI the one on the right as you could see it's a big difference there is very vivid image and you could pinpoint the organs they are not to me of the patient this is normal
scan there is normal uptake on the brain the ureters the bladder the kidneys those are normal there's no abnormal uptake or there's no hypermetabolic uptake noted the next case study is a 59
there are advantages of this modality one there's less radiation exposure for
the patient we receive about three millisieverts of background radiation every year with one PET scan a patient can get up to eight years worth of background radiation in just one skin the only exposure of radiation a patient
gets in a pet MRI is through the isotope pet MRI has a better disease characterization especially for areas in a Patou biliary region the pelvic areas and the kidneys information and the relationship between lesions and
adjacent tissue is better delineated with the pet MRI so it's easier to see which part is cancerous and which partners normal cells there are varying opinions and research studies are being done to make a determination if pet MRI
is a better modality than pet CTS well PET CT is a lower-cost skin has increased accessibility there are more PET scanners available and more more technologists are trained for this modality PET CT is a shorter skin there
are no contraindications for affairs implants pet CTS are preferred method for imaging the lungs of thoracic nodules and bone structures however with a pet MRI it's good for soft tissue organs such as the brain the muscle
delivered the kidneys the pancreas our GYN pelvic structures such as ovaries the uterus and cervix and also the prostate there are limitations of this skin one it is a much longer skin one whole body pet MRI can last at least
about an hour there are contraindications with certain implants due to the magnetic factor of the of this test and is not preferred for imaging air-filled structures because it can give off artifacts there
are weight limitations for our machine our machine holes can hold up to about 500 pounds of weight it is this our machine as smaller bore compared to the white board MRI the MRI whiteboy is about 70 centimeters in diameter
our pet MRI machine is only 60 centimeters in diameter in this picture the difference of the 10 centimeter difference doesn't seem much however if you put a patient in there and this is one of our coworkers
he is 270 pounds and 6 feet tall and the white board MRI his shoulders fit comfortably well inside it in the sky inside the scanner however in this pet MRI machine he said he did feel a little snug and a little tight inside
but you also have to take an account that we have to put coils on top of our patients that 10 centimeters does make a big difference the coils will help us give the good quality images that we like and I also have to note that we
have to put the head coil or the helmet on top of the patient's head to give good images of the brain the reason why the pet MRI scanner is smaller is because we have to make room for the pet detectors we try to make it bigger the
gradient coil on the radiofrequency coil have to be further away from the center of the magnet and that compromises the quality of our images so which patient
do anesthesia for some of our cases mostly to our pediatric patients but we are also capable of doing it through the adults they need some anesthesia clearance patient is asked to be NPO
after midnight we have equipment available that are MRI compatible such as the monitors the IV pumps and the anesthesia ventilator machine when we set up the the patient inside the scanner we have to be wary of the lines
the table does move in and out during the test we don't want any of those IV tubing's get snagged we've done pretty good job in securing these lines usually by taping it on top of the coils after the pet MRI with
anesthesia is done they go to the PO 70 anesthesia care unit for recovery and I
positron emission tomography is the use
of a radioactive tracer in this case FD gee her fluorodeoxyglucose to assess the metabolic activity of ourselves ftg is tagged with glucose and glucose is used by our body for energy cancer cells are thought to be our Armour hypermetabolic
so if we inject FDG to our patients it goes to areas with hyper metabolic activity this area is called a hotspot and when a hotspot is noted in a PET scan its it's thought to be cancerous this is an example of a hyper metabolic
region noted in the pelvic area of the patient this patient is diagnosed of cervical cancer and what is MRI as you all know MRI is the use of radio frequency currents produced by strong magnetic fields to provide detailed
anatomical structures it is the preferred method for imaging soft tissue organs and there's no ionizing radiation present now what is pet MRI pet MRI is a combination of these two modalities instead of going to two scans using two
scanners we have one scanner that is able to obtain pet and MRI images simultaneously so why can't we just call this pet well we run through a few problems we have fdg-pet CT where it's a PET scan with low-dose CT accompanying
it and there's fdg-pet CT with diagnostic CT we're full sequences of CT is coupled with a scan and a pet MRI always has a diagnostic MRI done with it
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.
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.
gets pet MRIs right now our main focus are our oncology patients it helps us
determine the type of cancer they have the diagnosis of cancer assess disease progression treatment therapy and treatment planning and some antecessor treatment response so let's say a lesion is FDG avid and
has low blood perfusion that would help our physicians to us to say what kind of treatment they can give to the patient pet MRI is also good for patients who can tolerate longer scans right now it's a very young modality
there's still a lot of research goes on with this and coupled with that is advantage of research right now we actually in the Memorial sloan-kettering we have started using this instead of FDG we've used gallium 68 of to assess
neuroendocrine tumors who have also done cervical lymph Austin Tiger phim where FDG is injected directly at the patient's cervical cavity and that helps map out the lymph nodes in the survey in the pelvic area this can be used by the
surgeon and see what lymph nodes can be sampled during the surgery we provide some education and assessment before during and after the pet MRI we assess for the patient's allergies we tell the patient's they have to be NPO at least
six hours prior to FDG injection as for our anxious patients they often come pre-medicated and this just comes with some care coordination with their physician the physician would prescribe some low-dose anti-anxiety medications
and the patient would take it an hour before their test as for our claustrophobic patients we what we have done is we let them see the Machine we let we let them feel the Machine we put them inside if they would want to and it
would be up to them if they would be tolerating the scan we assess for their diabetes regimen and my refe will speak more about that later we assess for patients pregnancy status on patients loving to fifty years old process for
their breastfeeding status and screen their implants during the pet MRI we tell them about the coil placement we give them an emergency call bell and we tell them to decrease their movement well being is like although our some of
our patients would say I didn't move but then the image so differently there there's a possibility that the magnet can induce some involuntary twitching after the MRI we tell them that they can resume their
diet they can resume their diabetic diabetes regimen and as if they get MRI contrast they can pump and dump for about 24 hours after the test but if they don't get a contrast they can keep their breast milk inside the fridge just
to help to decay just to decay the isotope that was given to the patient it doesn't give any harm to the baby
I good afternoon everyone my name is Ross Lozada and today with Murphy Aldana we will be presenting pet MRI and you technique to obtain high quality diagnostic images for oncology patients we have no disclosures Murphy and I live in New York City it is the place with
over 8 million in population 3 million of which are foreign-born about 800 different languages are being spoken other than English and they love in floor MRI of Memorial sloan-kettering Cancer Center we are reflection of these
statistics we speak about 10 languages which includes Sigala Chinese Russian Korea and Albanian just to name a few and about 70% of our staff are foreign-born actually I can count in one hand or how many are born in the United
States but despite our differences we have a few things in common one is that we all love our jobs and we take pride at what we do and T in taking care of our cancer patients and also we love food
this is a typical potluck in our Union we love our pot Luck's we do it for every holiday for every birthday in even random days where we just say hey you want to eat here we have some stuffed cabbage some rice biryani some mac and
cheese and quiche some caldereta and adobo some curry goat and a Haitian rice called John John but back to our topic our objectives for today is to provide an overview of pet and MRI imaging modalities discuss the application of
pet MRI imaging of oncology patients describe the care of the patient undergoing paddan-aram identify the nursing implications and to review some case studies so what is pet pet or
year old patient diagnosed with
glioblastoma lesion is located on the left frontal lobe this is done after radiation and surgery the image to your left is just a regular MRI with contrast gadolinium is the one used this time we always be the drum in the context of
choice is gadolinium in our institution you could notice the big size of the glioblastoma lesion onto the left frontal lobe of the patient as indicated in the round ring patient went for treat radiation and surgery look at the two
images to your right the one in the middle is done Pet MRI without the contrast take a note on the area where the lesion was before there is normal uptake but you don't notice any abnormal uptake and on to your right is post
treatment MRI is that those two are done the same day and with gadolinium the deletion the area where the the ring it is enhanced by the contrast but look at it there is no hypermetabolic uptake that means that the lesion is not viable
so the malignancy is not viable this time this scan is done to evaluate the effectiveness of the treatment it's a good sign before I go to the third case
craft is basically the only FDA approved stain crafts and I'll show you a
different way of doing it as well besides the Viator especially in countries where the Viator does not does not exist okay the Viator stand sits in the liver just like just like in my hand here the bare
portion is on the portal venous circulation the covered portion is basically on the hepatic vein part of the circulation okay the bare portion is chain-linked and is very flexible that's why kind of cut can crimp like that okay
they're both self expanding the bare portion is self expanding held by the sheath only the covered portion is held by a court okay so they're both self expanding but they're constraints by two different two different two different
methods one's a sheath constraint and one is a is a cord constraint okay these are the measurements the bare portion theoretically allows portal flow to pass if you're in a branch so it doesn't cost from boses of the portal vein branch in
the covered portion is important to cover the parental tract the youth that you've created in the past you had a lot of billary leaks into the tips if it's a bear stance bile is from by genic so it causes thromboses bile also instigates a
lot of reactionary tissue such as pseudo intimal hyperplasia that actually causes the narrowings of the of these tips if you causing bear stance the coverage stance prevents the bile leaks from actually leaking into into the shunt
itself okay and that's why it has a higher patency rate okay ideally this is how it's it's a portal vein and hepatic vein you'll hear people say proximal and distal you'll he'll hear radiologists especially diagnostic
radiologist referring to proximal and distal proximal and distal some people refer to the portal venous and is proximal some people refer to the paddock venous and is proximal and vice versa okay and it
gets confusing nobody knows well what's proximal okay the people that say portal venous and is proximal there they're talking about its proximal to flow so it's basically the first thing that flow hits people that
call the paddock venous and proximal they're talking relatives of the body more central is proximal more peripheral is distal okay so they're using these the same terminology is very confusing so the best thing to use and I we tell
that to radiologists who tell that to IRS is to talk a portal venous and hepatic venous end you don't talk proximal distal everybody knows where the portal venous end is and where everybody knows where the peregrinus end
is and there's no confusion strictly speaking which is the correct one which is proximal for us as IRS tax nurses proximal is always to flow proximal is always anticipate to flow so the correct thing is actually proximal
is the portal venous ends remember P proximal P portal okay proximal is where the expected flow is coming in that's actually the correct one but just to leave e8 the confusion portal venous and hepatic venous end okay there's a new
stents which is the controlled expansion stents it's in my opinion it feels exactly like the old stance the only difference between it is that it's constrained still has the same twenty to twenty millimeter or two centimeter bare
portion chain-linked it still has that four to eight centimeter covered portion but it's constrained in the middle okay and has the same gold ring to actually market the to the to a bare portion and the cover portion self expanding portion
and is constrained down to eight millimeters you can dilate it to eight and nine and ten initially there was a constant there was a misconception that it was like a string like a purse string that you break and jumps from eight
and no this is actually truly a controlled where if you put a nine-millimeter balloon it will dilate to nine only eight balloon little dialect to eight only the only the only key thing is that the atmospheres has to
be ten millimeters at least okay so it has to be a high pressure balloon has to be at least 10 min 10 10 atmospheres okay so when you're passing that that balloon over make sure that it's that that it that at least it's burst is 10
millimeters or or EXA or more on a 10 mil on on 10 atmospheres okay next thing is when you're making a needle pass you got your target now with a co2 you got the portal vein you've got your stank craft and you know how it works okay how
do you make your needle pass okay and how do you know if your needle has hit the portal vein or not there are two schools to do this okay one school is to make a needle pass and aspirate as you pull back and when you get blood back
you basically inject contrast okay before you do all that when you make your needle pass you push saline and especially if you do if you're using a large system so there are several kits out there there is the cook kits that's
a color pinto needle that's a large gauge 14 gauge needle there is the new gore kits which is also 14 gauge needle it's a big system these large systems you need to push out that poor plug that's kind of like a biopsy you have to
push it out with saline first and then as you pull back aspirate okay the other system is a ratio cheetah or a Rocha cheetah it's actually pronounced rasa schita and that's a very small system that there won't be a core that you have
to push out okay so anyway if you're using a large system like a coop into a needle which is the cook system or the gore system you push that plug out and then there are two schools school two aspirates you get blood back you inject
contrast if you're in the hepatic in in the portal vein you basically access it with a wire the other school is to do a ptc style you actually puff contrasts as you pull back you do not ask for H saline you actually puff
contrasts as you pull back okay the latter puffing contrasts as you pull back is the minority I would say less than two percent of operators are gonna puff okay ninety-eight percent of operators at
least are gonna actually aspirate and not puff okay I'm actually in the minority I'm in the 2% and there are advantages and disadvantages like I promised you two different ways and advantages and disadvantage to each to
each one the advantages of puffing contrasts even if you missed the portal vein after a while you actually get contrast around the portal vein and you actually have a visual of the portal vein that's the advantage so when you're
actually injecting contrast and you're missing it you get contrast around the portal vein it actually goes around the portal and you actually see the portal vein and it takes training sometimes this one's easy
okay I'll show you some more difficult ones but this is a beautiful pussy typical portal vein okay in addition to that oh go back in do you see that you see that hole in the middle there see that signal signal you watch that
because you're gonna see it again and again that's usually a posterior portal vein posterior right portal vein heading heading away from you okay that's usually a good target and I'll show you that again here's a little
little bit less obvious to the untrained eye but this is actually where the portal vein sits right there okay so sometimes it needs training right just actually see where the portal vein is and once you've stained the portal vein
then you have a real-time image of where the portal vein is you can actually go go after it and it reduces your needle passes disadvantages of using contrast and puffing away is that it creates a mess okay if you make multiple passes
you and you miss on the multiple passes then you start creating a mess and even with your DSA you can't even see the portal you can't see the portal vein because you've got this great mess another disadvantage of using contrast
is that you have to stomach what you're gonna see okay you make a needle pass and you don't inject contrast you have no proof of where you've been but if you're making a needle pass and you're
injecting contrast you and everybody else is gonna see where you've been that's usually not a good thing sometimes you will see bowel you see gold bladder you'll see arteries you'll see veins you'll see all sorts of stuff
that nobody wants to see and you don't want to document okay so that's another disadvantage so I recommend especially young physicians especially young physicians in places that are not used to this especially young physicians that
are new to hospitals and they're gonna they're gonna make multiple passes not to do this was they're gonna be very they'll be criticized a lot by their texts and by the institution by their colleagues as to what have you done you
know big mass artery you've hit artery but the guys and gals that are just aspirating and not injecting they're actually not documenting what they're going through but they're going through the same stuff okay
okay next up this I think this video yep
I'm the FDG is have a radio pharmacy located on the second floor no New York State does allow nuclear medicine
technologist and nurses to inject the con the FDG isotope I know in other states one in particular is is New Jersey the the nurses are not allowed to inject isotope and the technologist has to do it also in addition certain
isotopes and certain scans the ducts have to inject the contrast like the the cervical Lin scintigraphy and some so my question has to do with discharge instructions so just like you give them that little card that they keep with
them so they trigger some radiation alarm and a bridge or on a highway do you give them discharge instructions about if there's small children at home that they're not sitting in their lap for extended period what kind of
instructions do you give on discharge after these patients so we when they come in coupled with the screening forms that they fill out we have some instructions attached to it and does that does have
the discharge instructions but we reiterate to them you know if they have small children or babies and pregnant women and just try to keep their distance for the next 12 to 24 hours just to until the really activity has
wear off so the FDG is like two hours almost for the half life FDA FDA has 60 minutes 116 minutes half life and usually by 12 hour by the 12 hour period they're mostly background radiation okay thank you
we had they have a written instruction like it's like a packet that we give into the market that we do to the patient and the patient have accessed to the web portal that they have and they can be the instructions from there
this is correct so betta bar is still investigational for the most part the only way you can build for it is two different scans you build for a pet and you build for our mr so you've got to get approval for both what you are not
going to get reimbursed for is the registration and that's where it gets a little bit challenging because then you need a radiologist who is both certified uncredentialed to read a pet and an mr so right now most institution bill it as
two different procedures so that's why you that's how we get the approvals just a little information on the side I went back to this case study because I forgot to tell you that in order for the PET CT to have as clear image as the pet MRI
the pet portion I mean the city portion and the pet city would have to be done diagnostically and that this would expose the patient to radiation three times that's why they prefer the pet MRI because yeah the reason why we do it if
we do it mostly for for for pediatrics and it's it and it's because of radiation because you know like our my team is saying you you are going to have this patient have constant follow-up so if you can reduce the amount of
radiation they have from a younger age as we all know it work in radiology DNA injuries occur when you're younger then more is more severe than than later our MRI the pet MRI injection they're all lined with lead and our MRI the pet
MRI room is actually lined with lead so we don't really have Needham let aprons we don't know we don't have wear aprons they are allowed to go to other appointments after they are pet MRI usually with the FDG most of the
radiation after the Tessa's finish is gone they're not more than what not more than radioactive than background radiation so they are are safe to be around people yes that's more for precautionary
measures yes no they go straight to the PACU so we our MRI table is detachable we have an area for where we keep our inpatient bay area we have a structured ready for them to go into right after the test and the
anesthesiologist and if they are Pediatrics the pediatric nurse is with them and they go straight to pack you do like probably like probably less than ten a week right now some weeks we are busy we do for how we do that much some
it varies like we'll do three or four but we are trying because the reimbursement that's one of the big issue our institution is actually eaten eating the cost for some of these to provide a patient with less radiation
especially or pediatric population we have one pet MRI machine for the whole institution three at the main campus we have two we have multiple and other regional sites so the yes
no less than 15 GFR except for the EU vist less than 30 then we notified the radiologists eeeh this is harder to so you this is the it's a linear contrast as opposed to the Catalan bettervest which is
macrocyclic so it's easier for the body to get rid of well there yes well they're only they're already getting dialysis so it's really not much of a harm yes we do patients on dialysis but we make sure the dialysis is done within
24 hours after receiving the contrast yes um sometimes you know you just have it to have it we don't require it for all the tests if you have it we have it we check if it's already in the chart we
acknowledge it you know we don't require for outpatient we don't require but in patients we do all right anything okay so Bernie pet/ct the scanning time for pet/ct is about 30 minutes to 45 minutes Patsy pet/ct is about 30 to 45 minutes
with the pet MRI sometimes they they order dedicated pet MRIs so that is a little longer you have to take note that we do a whole body scan whole body scans for even just for a regular MRI is at least an hour so we try to eliminate
just you know having them have to have to or point to different appointments and just one waiting room one waiting time so that cuts down the response for the patient themselves yes we do for adults it's 12 for the
whole body and then for the pet brain it's about 10 if I'm not mistaken and then plus or minus 10% and then the pediatric doses are cultured calculated base of their height and their weight and there are all protocol by a
radiologist because we have a lot of whole-body protocols we have the bone survey actually that's about 30 or 40 minutes and yes that's an hour and then we have longer whole body protocols diseases
specific and sometimes they try to depends on what the patient's diagnosis is we have whole body scans where they have to check the bone marrow and that needs to be from tips of the toes and tips of the fingers and that can be a
challenge especially if the patient is tall because that has to be in sequest sequestered and sequential patient and positioning is also a challenge alright thank you so much thank you thank you so much
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?
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.
this is nursing case volume per hour so
staffing is a consistent challenge as I mentioned before having dashboards helps to make real-time decisions to help allocate nursing resources during high-volume times so this dashboard indicator
identifies the distribution of nursing workload over the course of the day I love this one for me especially as a nurse manager especially since me knows Tommy says they they feel like oh my god it's so busy it's so busy it's so
chaotic and you're trying to help them you know well of course I understand why it is now so I actually have data to understand their story and help them to see the data and why they feel it's chaotic so again with the help of color
coding the ability to look and interpret the data is simple so here since I've taken you through a few I thought I'd throw it out to everybody and see what if you wanted to kind of take a stab at using our model so if showing or if
anyone wants to raise their hand so what are you seeing here in this dashboard a lot of what you owe to our cases yeah anything else are you seeing yes correct there's nothing happen at 8 o'clock anything else right yep
sort of a lull here correct so what might you interpret from that in other words so what would you kind of see your say about this I'm sorry can be allowed a long time oh yes yep exactly right and so so then
what action might we take here to help sort of get rid of sort of the high volume times yes exactly so here's where you would shift the staffing to help cover the high volume areas and so I'll just take you through what how since
it's what we do at D H I'll take you through so exactly right I think someone pointed out that you have nurse cases except for say at 8 and at 6 and 6 generally we're just doing recovery at that point we don't need any more cases
going through interpret wise so we have this Pio nurse as you can see in the magenta and I'll tell you a little that's our MRI nurse to specific for MRI doing Pio sedates as Chris mentioned we have an MRI nurse there and we also do
cover pacemakers as well and those that's her caseload as far as non sedation we actually just have we sort of as people aren't busier in between rooms is when they might go you know give lasix for a year gram or you know
port access or what have you so what I'm looking as interpret I have a Pio nurse available seven several times a day so only in the magenta is she busy or he and then the best times may be for IR addons is between like say 11 and 12
here I would potentially my action would be to say hey this pio nerves could actually come and help get cases started and get them on time and then also come and maybe relieve lunches that's another I'm sure probably an issue for everyone
is like you're down a couple staff during that time but we're still running our rooms great that was a great job very good okay so a couple more to just kind of quickly show the pending patient workup documentation so this gives the
ability of the frontline RN to have instant visuals of the electronic medical records documentation that needs workup and phone calls that are needed to be completed for future patients so again let's use our model
so look there are a lot of workup phone calls pending and remember this is real time so in this case if you were looking this is just a snapshot but say today is March 4th okay going around so the first thing I'm saying yep there's a lot of
cases I've got 14 here and it shows a couple of days worth obviously you can see how the numbers add up I'm looking at the high number of same-day pending work for procedures so you can see here three four five six work ups and I have
nine phone calls to be made and I'm looking at the MRI work up calls and right now there are a couple days out so I'm opening less concerned about that so how would I apply and what action would I take well first I would clarify that
these same day workup and phone calls are actually pending sometimes they might have been done or someone missed hitting the icon on our computer and then I would prioritize completion of pending work so I might say to a couple
nurses that are in between rooms or whatever can you make a couple of phone calls we've missed this and we need to get contact with the patient and then of course I would obviously prioritize the I our work ups before the MRI ones
because there are a couple days out okay
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.
so why staging important well when you go to treat someone if I tell you I have a lollipop shaped tumor and you make a lollipop shape ablation zone over it you have to make sure that it's actually a lollipop shaped to begin with so here's
a patient I was asked to ablate at the bottom corner we had a CT scan that showed pretty nice to confined lesion looked a little regular so we got an MRI the MRI shows that white signal that's around there then hyperintensity that's
abnormal and so when we did an angiogram you can see that this is an infiltrate of hepatocellular carcinoma so had I done an ablation right over that center-of-mass consistent with what we saw on the CT it
wouldn't be an ablation failure the blasian was doing its job we just wouldn't have applied it to where the tumor actually was so let's talk about
new data of the Emmy trial that came out last year our ten-year results saying
that after ten years after ten years women who wanted to retain their uterus they looked at them in ten years three-quarters of those women were still very very satisfied and also were still able to retain their uterus so ten-year
data came out randomizing people for uterine artery embolization versus hysterectomy of the women who chose you to an artery embolization ten years later they were still very happy so I tell my patients that this is what you
should expect that you will have symptomatic improvement in 12 months around 85 to 95 percent of the patients are pretty happy there is a entry intervention rate it is not zero and it can be higher than ten
depending on what kind of Imogen is seen ahead of time and that we know that dysfunctional uterine bleed tend to do a little bit better than bulk type symptoms and that's partly because of subjective nature of that so this is one
of the patients that I treated when I was in in Virginia and Riverside and she's a former miss Brazil and she came to see us with what she also called reversed cycles like she would bleed more than she would not and she was
wearing depends and it took everything to just coach her out of the car to come inside to do a consultation because she was so afraid that if she got out she would be sitting in a pool of blood and she had an MRI showing what looked like
a eleven point seven centimeter fibroid she had embolization and that was her six month follow-up MRI to the right which looks like a very impressive result they don't all look this way which is why I save this image something
that looks like a normal uterus now I for the persons that I told to hold your high horse here is the time okay so what happens if I want to have a baby because these are the things you remember we're being ambassadors for this procedure we
need to be having the answers for the things that are our friends and family members are going to be asking us so if you want to have a baby I would say that the data that informs us as to what to do with you is still very weak but the
only randomized prospective trial that we have out there says that you should actually have myomectomy and a Cochrane review was also done and it still says that there's very low level evidence suggesting that myomectomy may be
associated with better fertility outcomes as opposed to UAE but more research is needed and we still require more research so at the very least what I have to do and now you feel compelled to do is to send my patients to see
someone who is a fertility specialist in consultation so we can make this decision together so if your poor surgical candidate if you have the gazillion fibroids and if you've had surgery before a hostile
abdomen and the patient says you know what dr. Newsome there's nothing that you can tell me ever to say that I'm going to have surgery then we're going to be doing something else that is not surgery okay the other thing that your
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