Anesthesia for Ambulatory

Diagnostic and Therapeutic

R a d i o l o g y P ro c e d u re s
Daniel Rubin, MD

KEYWORDS
 Ambulatory  Radiology  Anesthesia  Interventional radiology

KEY POINTS
 Protection from ionizing radiation is achieved with appropriate shielding with aprons and
acrylic shields, along with maintaining distance from the source.
 The magnet creates projectile risks and may cause interference with the electrocardio-
gram, whereas the generation of electromagnetic energy may cause significant thermal
injury in coiled wires.
 Iodinated contrast may cause severe cardiorespiratory compromise and should be
immediately stopped, followed by an assessment of the severity/progression of the
reaction and the potential need for supplemental oxygen, fluids, epinephrine, and
intubation.
 A discussion should occur between the anesthesiologist and radiologist about potential
concerns including length of procedure, level of procedural stimulation, positioning,
need for patient cooperation, and recovery.
 There is currently no anesthetic technique that is clearly superior, and the same procedure
may be performed under light sedation or a general anesthetic depending on patient char-
acteristics or procedural concerns.

INTRODUCTION

Moderate sedation administered by nurses under the supervision of radiologists is

used for most radiology procedures.1,2 The presence of anesthesiologists is
increasing because of the increasing complexity of the procedures and comorbidities
of the patients. The radiology suite poses unique challenges to the anesthesiologist
because of the physical obstacle of the imaging equipment, the distance from the pa-
tient, and the hazards of ionizing radiation or magnetic fields.

Disclosure: The author has no relationships with any with any companies that have any direct
financial interest in any of the material provided in this article.
Department of Anesthesia and Critical Care, University of Chicago, 5841 South Maryland
Avenue, MC-4028, Chicago, IL 60637, USA
E-mail address: drubin@dacc.uchicago.edu

Anesthesiology Clin 32 (2014) 371–380

http://dx.doi.org/10.1016/j.anclin.2014.02.015 anesthesiology.theclinics.com
1932-2275/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
372 Rubin

CONTRAST

Intravascular ionized contrast reactions can result in chemotoxic reactions because of

the physical properties of the contrast agent. The high osmolality of the contrast re-
sults in intravascular fluid shifts and may exacerbate congestive heart failure. In addi-
tion, molecular binding, particularly of calcium, may decrease inotropy. Because these
reactions are secondary to the properties of the contrast, the severity of the reaction
depends on dose and concentration. Patients with congestive heart failure, acute/
chronic kidney disease, chronic obstructive pulmonary disease (COPD), and other
critical illnesses are at increased risk for intravascular volume shifts, decreased ino-
tropy and contrast-induced nephropathy (Table 1).
Contrast-induced nephropathy is likely another chemotoxic reaction resulting from
renal artery vasospasm or direct action on renal tubules. Preexisting renal dysfunction
is the greatest risk factor, because no reports have been described with normal func-
tion. The risk of injury may be diminished by adequate hydration with crystalloids,
N-acetylcysteine, and sodium bicarbonate.3,4
Anaphylactoid reactions result from an undefined immune-mediated reaction.5 The
cause of these reactions is not clear but likely involves the kinin and complement sys-
tems, resulting in direct histamine release.5 Symptoms include hives, nausea, vomiting,
pruritus, angioedema, bronchospasm, hypotension, and cardiovascular collapse. The
severity of symptoms is not dose dependent and may be triggered by even small
amounts of contrast. Treatment includes discontinuing the contrast and may require an-
tihistamines, fluids, supplemental oxygen, steroids, epinephrine, and airway manage-
ment. A history of asthma or previous anaphylactoid reactions are risk factors and
pretreatment with diphenhydramine and steroids should be considered. There is no
evidence to suggest that an allergy to seafood or shellfish increases the risk (Table 2).6

OTHER CONTRAST MEDIA

Gadolinium contrast for a magnetic resonance (MR) imaging study may lead to nephro-
genic systemic fibrosis in patients with either acute or chronic kidney disease or injury.7
Ultrasonography contrast involves the intravenous administration of echogenic micro-
bubbles, and patients with pulmonary hypertension or unstable cardiopulmonary condi-
tions should be closely monitored during and for at least 30 minutes after administration.8

MRI
Magnet Safety
The magnetic field poses hazards from static magnetic fields, gradient magnetic fields,
and radiofrequency (RF) energy. The American College of Radiology (ACR) guidelines
require patients and non-MR personnel to have a safety screening performed by
authorized MR personnel before entering zone 3 (Fig. 1).9 The constant static magnetic
field of the MR scanner poses the most obvious danger if ferromagnetic objects are
within range.10 Gradient magnetic fields occur with the rapidly changing magnetic
fields during image acquisition and may cause excitation of peripheral nerves or car-
diac arrhythmias if external leads are present. RF energy produced during image
acquisition may be focused by metallic materials such as electrocardiography leads,
pulmonary artery catheters, and external pacemaker leads, leading to excessive con-
centration of RF energy and thermal burns (Table 3).11
Anesthetic Considerations for MRI
Moderate to severe claustrophobia, anxiety, and fear of the MRI machine occur in
37% of patients, with 5% to 10% of these choosing to abort the scan.12 Most proceed
 Anesthesia for Radiology Procedures 373

Table 1
Selected chemotoxic effects of intravascular contrast media

Effects Responsible Physicochemical Properties

Vascular Changes
Increase in plasma osmolality Hyperosmolality
Hypervolemia —
Increase in cardiac output —
Alteration in vascular permeability Hyperosmolality
Inflammation or pain —
Formation of microthrombus —
Dilatation of vessels Hyperosmolality
Increase in blood flow —
Decrease in blood pressure —
Pain —
Cerebral Changes
Dilatation of external carotid artery Hyperosmolality
Stimulation of chemoreceptors Hyperosmolality and sodium ion
concentration
Alterations in systemic blood pressure —
Alterations in heart rate —
Tachypnea —
Alterations in permeability of the blood- Hyperosmolality
brain barrier
Alteration in neuroelectrical activity Presence and concentration of ions
(with disruption of blood-brain barrier)
Cardiac Changes (During Coronary Angiography)
Dilatation of coronary artery Hyperosmolality
Electrocardiographic alterations Hyperosmolality
Bradycardia —
Conduction delays —
Ventricular fibrillation Calcium binding
Depression of myocardial contractility Calcium binding
Renal Changes
Renovascular constriction (sustained) Hyperosmolality
Decrease in renal blood flow —
Alteration in glomerular permeability Hyperosmolality
Proteinuria —
Osmotic diuresis Concentration of nonresorbable solutes
Renal tubular toxic effects Possible molecular toxicity

From Bush WH, Swanson DP. Acute reactions to intravascular contrast media: types, risk factors,
recognition, and specific treatment. AJR Am J Roentgenol 1991;157:1154; with permission.

under light sedation (eg, oral or intranasal midazolam) but some require deeper seda-
tion or even general anesthesia.13 The anesthesiologist should take into account the
severity of the anxiety, the ability to maintain a patent airway, the ability to lie supine
and motionless for extended periods of time, and any comorbid conditions. Upper
body examinations present the greatest challenge because access to the airway is
374 Rubin

Table 2
Frequency and type of mild and moderate reaction to intravascular contrast media from
84,928 injections

Mild Manifestations No. of Reactions

Urticaria 286
Pruritus 131
Erythema or rash 114
Scratchy throat 28
Nasal congestion 25
Sneezing 24
Localized facial swelling 15
Chest discomforta 14
Transient cough 8
Rigors or chills 5
Tachycardia or palpitations 5
Thickened tongueb 2
Injected eye 1

Moderate Manifestations No. of Reactions

Shortness of breath 55
Cardiaclike symptomsc 48
Laryngeal edema 38
Facial edema 14
Bronchospasm 10
Rigors 7
Hypotension 4
Diaphoresis 2
Tongue swelling 2
Hypertension 1

Many patients had more than one manifestation. Many patients also had mild manifestations,
including cutaneous symptoms (n 5 66), as well as moderate manifestations.
a
Thought to not be cardiac.
b
Patient reported a subjective sensation.
c
Chest pain or pressure, jaw pain, left arm numbness, or a combination of these symptoms.
Data from Wang CL, Cohan RH, Ellis JH, et al. Frequency, outcome, and appropriateness of treat-
ment of nonionic iodinated contrast media reactions. AJR Am J Roentgenol 2008;191:409–15.

severely limited during the examination and choosing a general anesthetic with a
secure airway may be prudent. The airway should be secured outside zone 4 if
more advanced airway techniques become necessary. If problems occur during the
examination, emergency resuscitative equipment (oxygen, suction, ventilator, defibril-
lator, and medication) should be readily available outside zone 4 and basic life support
and relocation should happen immediately and concurrently.

Monitoring/patient access
Patients should be monitored in a manner that is consistent with the American Society
of Anesthesiologists (ASA) Standards for Basic Anesthetic Monitoring14 and must be
labeled MR safe/conditional before applying them to patients in zone 3 or 4. Even
 Anesthesia for Radiology Procedures 375

Fig. 1. Zoning layout for MRI scanner. (From Kanal E, Borgstede JP, Barkovich AJ, et al.
American College of Radiology white paper on MR safety. AJR Am J Roentgenol
2002;178(6):1336; with permission.)

MR-conditional electrocardiography leads may display interference during the scan

and interpretation of arrhythmias or ischemia may be limited during these times.
The patient and monitors must be easily viewable either directly or with a monitor in
a location outside zone 4. A test run using the full length of the scanner should be per-
formed to ensure adequate length and unrestricted travel of intravenous and ventilator
tubing and monitor leads. Intravenous lines and stopcocks should be easily accessible
in case a medication needs to be given.

Ear safety
The noise generated by an MR machine can reach greater than 110 dB and may cause
hearing loss. Ear protection (eg, foam ear plugs) should be placed in all patients,
including those under general anesthesia.15

INTERVENTIONAL RADIOLOGY
Radiation Safety
The 3 primary sources of ionizing radiation are direct (ie, from the radiation beam);
radiation leakage from the source; and, most significantly, radiation scatter from the
patient. Increasing distance reduces exposure by the square of the distance, so intra-
venous and breathing circuit extension tubing should be used to provide for this. Lead
aprons, including a thyroid collar, reduce exposure by a factor of 10 and transparent
376 Rubin

Table 3
New and old terminology describing MR safety of implanted devices

Old Terminology
MR safe The device, when used in the MR environment, has been shown to
present no additional risk to the patient or other individuals but may
affect the quality of the diagnostic information. The MR conditions in
which the device was tested should be specified in conjunction with
the term MR safe, because a device that is safe under one set of
conditions may not safe under more extreme MR imaging conditions
MR compatible A device shall be considered MR compatible if it is MR safe and, when
used in the MR environment, has been shown to neither significantly
affect the quality of the diagnostic information nor have its operations
affected by the MR system. The MR imaging conditions in which the
device was tested should be specified in conjunction with the term MR
compatible, because a device that is safe under one set of conditions
may not be safe under more extreme MR conditions
New Terminology
MR safe An item that poses no known hazards in any MR environment. Using the
new terminology, MR-safe items include nonconducting, nonmetallic,
nonmagnetic items, such as a plastic Petri dish
MR conditional An item that has been shown to pose no known hazards in a specified MR
imaging environment with specified conditions of use. Conditions that
define the MR environment include static magnetic field strength,
spatial magnetic gradient dB/dt (time-varying magnetic fields), RF
fields, and SAR. Additional conditions, including specific
configurations of the item (eg, the routing or leads used for a
neurostimulation system), may be required
MR unsafe An item that is known to pose hazards in all MR environments. MR unsafe
items include magnetic items such as a pair of ferromagnetic scissors

Abbreviations: db/dt, time rate of change of magnetic field (tesla/second); SAR, specific absorption
rate (Watts/kg).
From Levine GN, Gomes AS, Arai AE, et al. Safety of magnetic resonance imaging in patients with
cardiovascular devices: an American Heart Association scientific statement from the Committee on
Diagnostic and Interventional Cardiac Catheterization, Council on Clinical Cardiology, and the
Council on Cardiovascular Radiology and Intervention: endorsed by the American College of
Cardiology Foundation, the North American Society for Cardiac Imaging, and the Society for
Cardiovascular Magnetic Resonance. Circulation 2007;116:2880; with permission.

leaded acrylic eyeglasses can help prevent premature cataracts.16 Pausing the study
while making an intervention should be requested, as should inserting a transparent
leaded shield between the anesthesia provider and the patient. Digital subtraction
angiography exposes providers to high levels of radiation so remote monitoring is
best during the study. Another caveat is that biplane fluoroscopy often directs the ra-
diation toward the side of the anesthesia provider (Fig. 2).

ANESTHETIC CONSIDERATIONS FOR INTERVENTIONAL RADIOLOGY

Anesthetic
Anesthetic technique depends on the procedure and the patient’s comorbidities. Con-
siderations include the ability to access and secure the airway during the procedure;
risk of aspiration; ability to remain supine and motionless for extended periods of time;
and conditions such as obstructive sleep apnea, COPD, and congestive heart failure.
There is no definitive evidence to suggest that one anesthetic agent or technique is
 Anesthesia for Radiology Procedures 377

Fig. 2. Distribution of scatter radiation from a lateral C-arm with the radiation source on the
same side as the anesthesiologist. Note the significantly higher amount of radiation exposure
that the anesthesiologist encounters when a lateral C-arm is used with the radiation source
on the same side as the anesthesiologist. (From Anastasian ZH, Strozyk D, Meyers PM, et al.
Radiation exposure of the anesthesiologist in the neurointerventional suite. Anesthesiology
2011;114:517; with permission.)

superior to others. There should be a discussion between anesthesiologist and proce-

duralist to determine the optimal anesthetic. The discussion should also include the
expected length of the procedure, expected level of procedural stimulation, posi-
tioning, need for patient cooperation, and goals for any physiologic parameters
such as arterial blood pressure.

Monitoring/Equipment
All anesthetics should comply with the ASA Standards for Basic Anesthetic Moni-
toring.14 In some patients it may be appropriate to use end-tidal carbon dioxide moni-
toring even under light sedation because of the difficulty of monitoring adequacy of
ventilation in patients once the imaging equipment and drapes have been posi-
tioned.17 Because most procedures are performed without an anesthesia team, suites
are seldom anesthesiologist friendly, and patient access and visual monitoring are
often challenging because of the significant distance from the patient and the obstruc-
tion by the imaging equipment. The anesthesia machine must be far enough away to
not interfere with the movement of equipment, so extensions on the intravenous
tubing, oxygen supply, and ventilator tubing are commonly required. Backup equip-
ment, especially adjunct airway devices, oxygen, and other resources, should be
readily available in the event of an unexpected difficult airway.

PROCEDURES

Some of the more common and more challenging ambulatory procedures that anes-
thesiologists may be used to perform sedation are presented in Table 4.
 378
Rubin
Table 4
Anesthetic implications for commonly performed ambulatory procedures in IR

Anesthetic Most
Procedure Name Patient Position Commonly Performed Complications Special Considerations
CT/Ultrasonography guided: Supine Light-moderate sedation Perforation May require breath holding
Abscess drainage (eg, abdominal abscess) Peritonitis GA required if unable to
Fluid drainage (eg, ascites) Pneumothorax lie supine
Biopsy (eg, liver) Hemorrhage
Contrast reaction
Biliary: Supine with right Moderate sedation Hemorrhage Patients may have failed ERCP
Biliary drainage (eg, acute cholecystitis) arm raised above Peritonitis Hepatic dilation can be
Biliary stent placement the head Contrast reaction stimulating
Cholecystostomy tube (eg, tumor obstruction)
Genitourinary: Prone Moderate sedation/GA Pneumothorax Prone positioning
Nephrostomy (eg, obstructive uropathy) Hemorrhage Dilutional anemia
Nephrolithotomy (eg, nephrolithiasis) Contrast reaction Blood loss can be significant
Abscess drainage (eg, pyelonephritis with Hydrothorax Pneumothorax if supracostal
abscess formation) approach is taken
Breath holding
CXR after procedure
Angiography: Supine Light-moderate sedation Hemorrhage Minimal stimulation once
Diagnostic angioplasty Vascular injury vascular access has been
Stent placement Contrast reaction obtained
Arthrectomy (eg, peripheral vascular disease)
Venous procedures: Supine Light-moderate Hemorrhage Breath holding to decrease
Catheter placement (eg, end-stage renal disease) Pneumothorax risk of VAE
IVC filter (eg, thromboembolic risk) VAE
AV fistulagram (eg, stenosis of AV fistula) Vascular injury

Abbreviations: AV, arteriovenous; CT, computed tomography; CXR, chest radiograph; ERCP, endoscopic retrograde cholangiopancreatography; GA, general
anesthetic; IVC, inferior vena cava; VAE, venous air embolism.
 Anesthesia for Radiology Procedures 379

POSTPROCEDURE CARE

The recovery of patients undergoing conscious sedation and general anesthesia in

the radiology suite should be consistent with the standards of postanesthesia care
set forth by the ASA.18 Patients who have undergone straightforward and uncom-
plicated procedures may be recovered in the radiology suite if the appropriate
nursing and physician staff are available. Patients who have undergone compli-
cated or physiologically taxing procedures, general or regional anesthesia, or
who have significant comorbidities may benefit from recovery in a dedicated post-
anesthesia care unit or intensive care unit. A discussion between the anesthesia
provider and the radiologist about the patient’s recovery needs should take place
before the procedure so appropriate arrangements can be in place before the
procedure ends.

SUMMARY

The radiology suite presents the anesthesia provider with a unique set of challenges
such as ionizing radiation, intravascular contrast, magnetic fields, physical separation
and barriers from the patient, so-called borrowed space, and the large range of pro-
cedures performed. Most of these procedures will continue to be performed without
the presence of an anesthesia team but, because of the ever-increasing complexity
of the procedures being performed and the increasing comorbidities of patients, the
anesthesia provider will likely be called more often to provide care. A thorough under-
standing of these challenges is essential to providing a safe anesthetic in a difficult
environment.

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