Modulette2 MRI SandBag InstructGuide

							                       Modulette G-2 Instructors Preparation
                       Sand Bag Hazard in MR Imaging of Patients
                               By Luke Chelluri and Micheal DeVita
                              University of Pittsburgh Medical Center


Objectives:

          Describe the general hazard types for MR Imaging of patients
          Understand and describe the specific example of “sandbag” hazards in MR Imaging

Applicability: Applicable to residents, nursing staff, and other professionals and trainees
involved in ordering, transporting to and executing MR Imaging


Background and General Hazard Information
According to ECRI’s Health Devices in July 1998, “While sandbags are often assumed to
contain only sand, some contain ferrous pellets or iron oxides that add weight to the sandbag
without increasing its size. Several journal articles report cases of a sandbag containing ferrous
pellets creating a hazard in an MRI environment…the force needed to remove a 5 lb
ferromagnetic sandbag was estimated at 500 to 700 lb.”
A 1997 FDA Working Group report (www.fda.gov/cdrh/ode/primerf6.html) and ECRI
(www.ecri.org) describe events with O2 bottles, scissors, IV poles, traction weights, pens, & hair
barrettes.

Specific Case (compilation of many cases in and out of VA):

A Patient had a “sand bag” attached to his leg while being prepared for an MRI. Staff did not
realize this leather-sectioned arm weight contained iron pellets encased in heavy vinyl. When
the patient was being moved into the “bore”, the iron-filled bag flew into the magnet and pinned
the patient’s leg to the side of the magnet. Emergency measures were used to turn the magnet
off. Fortunately, the patient was unharmed (i.e., close call). Sometimes, “sand bags” = “iron
bags”.

Possible Remedies:
1) Purchase “sand bags” for patient care that do not contain iron (or other materials specified by
the vendor to be used safely). These bags should be labeled MRI-safe (i.e., intended for use in
your specific MRI environment)
2) If your facility continues to use “sand-bags” for patient care that contain iron, those bags should
be clearly labeled “Contains Iron: DO NOT expose to MRI”
3) Patients should disrobe and wear clothing tested for your MRI environment
NOTE: DO NOT verify that a “sand-bag” is compatible by testing it with the MRI magnet – this
could have catastrophic consequences.


2/8/2012                                     1                L Chelluri, M DeVita; Univ Pittsburgh; Modulette G-3
General Recommendations:
      1) Staff should consider all items to be unsafe for the MRI environment until “proven”
      otherwise. This could be done with a checklist, where each item is explicitly determined
      “safe” by manufacturer documentation and removal of any metal items
           2) To help understand hazards with MRI, you will need to read the “Supplemental MRI
           Hazard Summary” on the NCPS Web site (www.patientsafety.gov).


References
“Supplemental MRI Hazard Summary” on the NCPS Web site (www.patientsafety.gov).

The safe use of equipment in the magnetic resonance environment. Health Devices.
2001;30:421-44.

Chaljub G, Kramer LA, Johnson RF, et al. Projectile cylinder accidents resulting from the
presence of ferromagnetic nitrous oxide or oxygen tanks in the MR suite. AJR Am J Roentgenol.
2001;177:27-30.

FDA/CDRH resources page. U.S. Food and Drug Administration Web site. A primer on medical
device interactions with magnetic resonance imaging systems.
[ go to related site ]

Kanal E, Borgstede JP, Barkovich AJ, et al. American College of Radiology White Paper on MR
Safety. AJR Am J Roentgenol. 2002;178:1335-47.

Kerr JD. MRI safety: everyone's job. Radiol Manage. 2001;23:36-9.

Shellock FG. Magnetic resonance procedures: health effects and safety. Boca Raton, FL: CRC
Press; 2001.




2/8/2012                                      2              L Chelluri, M DeVita; Univ Pittsburgh; Modulette G-3