British Journal of Radiology (2004) 77, 216-218
© 2004 British Institute of Radiology
doi: 10.1259/bjr/50404042
Anticipation and planning for anaesthesia provision within MR units in the UK
C G Morris, MRCP, FRCA
M E McBrien, FRCA
and
P A Farling, FFARCSI
Department of Anaesthesia, Royal Victoria Hospital, Grosvenor Road, Belfast BT12 6BA, UK
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Abstract
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We surveyed 33 UK MR units that have been developed by New Opportunity Funding (NOF) with reference to planning for and provision of anaesthetic services. The likely clinical and resource implications were documented. Units were developed predominantly in acute general hospitals with paediatric, critically ill and neuroscience patients represented. It may be predicted that up to 50% of newly built units will require anaesthetic provision and this should be anticipated at the planning stage. A senior anaesthetist should be involved in the planning process.
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Introduction
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Provision of anaesthesia within MR units can be challenging and hazardous [1]. Patients requiring general anaesthesia typically include children (often with concurrent neurological or syndromic disorders), critically ill and claustrophobic adults. Previous surveys have shown large variations in standards and practice of anaesthesia and the need to standardize care in this setting [2]. In May 2002 the Association of Anaesthetists of Great Britain and Ireland (AAGBI) published guidelines on the "Provision of Anaesthetic Services in Magnetic Resonance Units" following recommendations of a multidisciplinary working party that included radiological representation [3]. These remain the most comprehensive and specific guidelines in this field.
In 1999 the Department of Health allocated National Lottery revenue to 33 UK MR units in the form of New Opportunity Funding (NOF) to enable development of existing services or complete new builds. This provided a unique opportunity to determine the nature of this "new generation" of MR units with regard to planning and anticipation of anaesthetic services and the likely resource implications that MR will incur.
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Methods
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We devised a structured telephone questionnaire (Appendix 1) and contacted each of the 33 units detailed in the Department of Health NOF plans in December 2002 and January 2003. Responses were accepted from a consultant radiologist or senior radiographer involved with the planning of the unit. It was agreed that individual units would not be identified by this survey.
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Results
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Of the 33 units initially identified 32 were contacted, one hospital site having been demolished. 31 units were operational at the planning stage, with one in advanced construction to come on-line in mid 2003.
The specialties represented at the hospitals with new scanners are included in Table 1
. Only three centres provided restricted services: two exclusively adult oncology and one predominantly tertiary referral centre for paediatric neurosciences.
22 (68.8%) units involved a nominated consultant anaesthetist in the planning process, and of the 10 units which did not two described "no interest" despite approaching their anaesthetic department.
Piped medical gases (PMG), suction and scavenging were present at 22 (68.8%) units. One unit installed PMG after the building phase, two supplied piped oxygen only and one PMG to the control room but not the scanning room. Of the 10 units lacking PMG, one provided remote ferromagnetic cylinder gases, one had pipework but no connection to the external hospital gas supply and one unit had holes in the shielding but no pipework connected.
Among units in operation (n=31), 22 units (71.0%) did not provide regular anaesthetic sessions, although three of these did provide paediatric oral sedation and one adult oral sedation if required. Of the 9 units (29.0%) providing regular anaesthetic sessions, all were covered by a consultant anaesthetist and varied in frequency from three per week to one in alternate months as detailed in Table 2.
Eight units (25.8%) described an "unanticipated need for anaesthetic provision" following construction and of these, four said they could not meet this need. One regularly transferred patients to a neighbouring unit, one had added extra anaesthetic sessions and two coped as the need arose. Only 16 units (50%) were aware of regional planning of MR units and in all cases this involved transfer from or referral to a neighbouring unit that could provide anaesthesia.
Further features of the 10 MR units lacking anaesthetic consultation during planning are given in Table 3.
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Discussion
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The vast majority of MR units surveyed were developed in multidisciplinary hospitals rather than in specialist units: 75% provided in-patient paediatrics, over 90% adult intensive care units (ICU) and over 80% emergency departments. The cases requiring anaesthetic involvement for MR are likely to be highly varied. The care of these patients must be supplied by staff experienced in these areas with skills in airway management, sedation, anaesthesia, monitoring and transport medicine.
The inclusion of PMG, suction and scavenging proves a useful index of anticipation and planning for anaesthesia. AAGBI guidelines state, "Piped gases and suction will be required in the anaesthetic room, the MR examination room and the recovery area [3]. Adequate gas scavenging systems will also be necessary. The installation of facilities such as piped medical gases is easiest and least costly during the initial construction of the unit" [3].
Five units lacked PMG, three of which included no anaesthetic consultation during the planning process and eight units described an unanticipated need for anaesthesia, of which three lacked PMG.
This questionnaire surveyed units conceived and planned in many cases before the AAGBI guidelines were published but the data presented here provide strong support for the following recommendation: "Whenever a new MRI unit is planned the possibility of managing sedated or anaesthetised patients should be considered. A nominated consultant anaesthetist should be made available for the provision of anaesthesia services" [3]. Among the eight units experiencing an unanticipated need for anaesthesia, five (62.5%) had not included an anaesthetist during planning and failure to consult an anaesthetist resulted in no anaesthetic sessions being provided.
Nine (29.0%) units provided regular consultant-led anaesthetic sessions detailed in Table 2
. If these are added to the 6 units which originally lacked sessions but subsequently met an unanticipated need for anaesthesia then just under half (48.4%) of new MR units require anaesthesia provision.
Anaesthesia generates additional costs beyond initial expectations, e.g. the service contract for anaesthetic and monitoring equipment is typically 8–10% of the purchase price per year [3]. Seven units were unable to provide anaesthesia because of insufficient funding for recovery facilities (1 unit), equipment and monitoring (3 units) and anaesthetic personnel (3 units). In order to provide safe anaesthesia, in line with national standards and guidelines [4], funding must cover these "hidden" costs.
Even with inclusion of anaesthetists, purchasers must remain vigilant for the unique demands of the MR environment. This was demonstrated to us following a potentially lethal experience with a 25 kg "MR compatible" anaesthetic monitor which was attracted by the magnetic field and required five adults pulling on a bed sheet to extract it [5]! One surveyed unit described a similar ferromagnetic restriction with an "MR compatible" monitor, and another non surveyed unit with an anaesthetic machine (personal communication John Pike, Leeds).
MR is justifiably becoming a routine investigation in many patients' care and inevitably the applications of MR are likely to increase for the foreseeable future. In addition to reasons of fear and claustrophobia, patients requiring MR are frequently children, neurologically impaired, trauma victims or critically ill. They will require monitoring, intubation, ventilation and/or inotrope support. Hence the demand for anaesthetic service provision at MR units is likely to increase over time with major resource implications for anaesthetic departments and subsequently, service provision by the MR unit.
Concern has been raised within radiology literature as to whether sedation administered by non-anaesthetists can be justified at all [6–8]. One American [9] and one UK audit [10] showed higher rates of complications when oral sedation was administered to children by a non-anaesthetist. Three units in this survey provided non-anaesthetist paediatric oral sedation and one unit provided adult sedation. One hospital sedated children, transferred by ambulance without monitoring or a medical escort to the MR scanner, and repeated the transfer following the scan. The unit involved felt this was "suboptimal". There are no prospective randomised data to suggest that anaesthetists improve outcome by managing sedated patients in MR, but it is reasonable to assume the specialists with the most experience of sedative agents, airway management, resuscitation, monitoring and transport will increasingly take over this role to comply with clinical governance.
Additional NOF funding has been allocated to MR recently and approximately 60 scanners are anticipated. While these are exciting times for MR and anaesthetic service provision, the situation will become unsatisfactory and dangerous if existing guidelines are not followed in these new units. MR frequently requires an anaesthetist, who should be involved in the planning and design of the unit. Patient safety, in what is most commonly a non-invasive diagnostic investigation, must be paramount and planning for anaesthetic provision is integral to this.
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Appendix 1
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Telephone questionnaire of UK new opportunity funded MR units
1) Is the centrally funded scanner in current clinical use?
2) Does your hospital provide:
- in-patient paediatrics
- adult intensive care
- paediatric intensive care
- accident and emergency?
3) Were the following included in the planning and construction of the unit?
- Piped medical gases
- Suction
- Scavenging
4) Do you have regular and dedicated anaesthetic sessions at your unit? (please specify)
5) At what point and level of seniority were anaesthetic providers included in the planning stage?
6) Have you encountered an unanticipated need for anaesthetic provision and if so how have you coped with this need?
7) Are you aware of any regional planning for MRI units and services within your area?
Received for publication April 28, 2003.
Revision received August 20, 2003.
Accepted for publication September 10, 2003.
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References
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- Working Party of the Association of Anaesthetists of Great Britain and Ireland. Immediate postoperative care. London: AAGBI, 1993.
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Abstract
Introduction
