MRI検査における安全管理 事故事例の検討
Contents
1. MRI H MRI Noisy Narrow Ner vous 3 N Nervous 2 MRI nervous2. B D MRI 19 5 303 310 1999 2 Kelly WM Paglen PG Person A et al Ferromagnetism of intraocular foreign body causes unilateral blindness after MR study AJNR 7 243 245 1986 3 Klucznik RP Carrier DA Pyka R et al Placement of a ferromagnetic intracerebral aneurysm clip in magnetic field with a fatal outcome Radiology 187 855 856 1993 4 Shellock FG Severe burn of the finger caused by using a pulse oximeter during MR imaging letter AJR 153 1105 1989 5 MR Innervision 16 11 76 79 2001 6 http teleradiologyjp MRI 7 No 97 3 1997 8
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22. 1 B C 1 105 9 11 GE 3 http wwwnnervision cojp 2001 1 7 13 8 2002 9 MRI GE
23. 52 257 264 2004 MRI MRI 3 MRI MRI D Safety in MRI Case studies for the prevention of accidents RF
24. http wwwr jcr orjp 9 MRI 1996 pp413 415 10 Elster GIO MRI E 264 HERE SEDE Aa MYW 1996 pp214 230 11 18 MR 2000 pp238 248 12 Kanal GR MRI Q amp A 19 482 489 1999 13 Shellock FG Swengros Curtis J MR imaging and bio medical implants materials and devices An Updated Re view Radiology 180 541 550 1991 14 Shellock FG Morisoli S Kanal E MR procedures and biomedical implants materials and devices 1993 update Radiology 189 587 599 1993 15 http www aso group co jp aih kouhou kakuka housya metal metal html 16 MRI JJOMT Vol 52 No 5 17 Katayama H Yamaguchi K Kozuka T et al Adverse reaction to ionic and nonionic contrast media a report from the Japanese committee on the safety of contrast media Radiology 175 621 628 1990 18 m WX 2002 p302 16 3 31 981 8563 4
25. 3 21 Reprint request Takeo Hikichi Department of Radiology Tohoku Rosai Hospital 4 3 21 Dainohara Aoba ku SENDAI 981 8563 JAPAN 19 5 311 321 1999 SAFETY IN MRI CASE STUDIES FOR THE PREVENTION OF ACCIDENTS Takeo HIKICHI Department of Radiology Tohoku Rosai Hospital It is important to first learn how to operate MRI with safety rather than operating the MR system or operating scan sequences This paper presents an approach for preventing accidents in MRI The following are three themes of accidents 1 Unusual environmental factors and their effect on the procedure 2 Oxygen cylinder adsorption which oc curred in the U S 3 Side effects resulting from the contrast medium for MRI In Section Unusual environmental factors and their effect on the procedure the author first reviewed the highly magnetic environment caused by the main magnet the frequently changing magnetic field environment due to gradient coils and exposure to the RF pulse which are high frequency radio waves A number of significant ac cidents reported in journals are then discussed Examining these cases is useful because they involve loss of eye sight due to a foreign substance a metal fragment in the eye death resulting from brain aneurysm and a burn caused by the lead lines of a pulse oximeter In addition the author details
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27. cases in which heat damege by a gold dental crown and an acupuncture needle were prevented in Tohoku Rosai Hospital In relation to the highly magnetic environment the author outlines a well known accident concerning oxygen cylinder adsorption in which a 6 year old boy died to present measures to prevent recurrence with medical staff In addition the author reports a stretcher adsorption accident that occurred in Tohoku Rosai Hospital Finally the side effects of the contrast medium for MRI are discussed and an example of a fatality of a bronchus asthma patient is introduced The author furthermore discusses safety in contrast medium administra tion and emergency measures In addition to risk management in medical treatment it is important to share experience of accidents to pre vent recurrence
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