1. Introduction
Magnetic resonance imaging (MRI) is a non-invasive diagnostic imaging modality that has revolutionized medical imaging because of its ability to provide high-quality images without the use of ionizing radiation. The increased availability and utilization of anesthesia services for MRI have played a crucial role in facilitating the imaging process, especially for pediatric patients and individuals who may struggle with remaining still during the procedure. By providing sedation or general anesthesia, healthcare professionals can ensure the comfort and safety of patients, thus enabling high-quality imaging results.
Emerging research highlights that a significant percentage of pediatric patients—ranging from 48% to 91%—require anesthesia during MRI procedures [
1,
2]. This escalating demand can be partly attributed to the expanding utilization of MRI surveillance for children with cancer and cancer predisposition syndromes. Furthermore, there has been a noticeable rise in the number of geriatric patients with dementia who require MRI examinations. These patients often require sedation or general anesthesia to ensure their cooperation and comfort during the procedure. The growing range of conditional monitoring devices that use MRI enhances access to MRI for individuals with pacemakers, cochlear implants, and other implantable devices, thus eliminating previous barriers and expanding the possibilities for accurate diagnostic imaging. This breakthrough enables previously ineligible patients who were unable to undergo MRI scans to now benefit from this diagnostic modality [
1,
2,
3].
However, it is essential to recognize that administering anesthesia in an MRI environment presents unique challenges. MRI departments are characterized by the presence of strong magnetic fields, radiofrequency (RF) waves, excessive noise levels, and restricted access to patients during imaging studies. These factors create a distinct set of risks that need to be carefully managed to ensure patient safety and the smooth operation of the MRI procedure. Previous studies have shed light on the significance of MRI-related incident reports, which account for approximately 13% of all incident reports within radiology departments [
3,
4]. These incidents can include a range of issues, such as equipment malfunctions, patient misidentification, medication errors, and adverse events related to anesthesia administration.
In a study by Jaimes and colleagues [
1], the utilization of sedation or general anesthesia during medical procedures was found to be associated with a significantly higher rate of safety reports. This association remained significant even after accounting for potential confounding factors, such as patient age and location. Specifically, the rate of safety reports in sedated patients was 0.8%, which was nearly twice as high as the rate of 0.45% observed in non-sedated patients. The specific reasons for this difference were not investigated in the study. However, the study suggested that factors such as the administration of anesthesia to inpatients and the involvement of multiple staff members who may be less familiar with MRI hazards and monitoring equipment could contribute to MRI safety-related hazards. The complex and dynamic nature of the MRI environment necessitates rigorous adherence to safety protocols, effective communication among healthcare providers, a requirement for experienced personnel, and ongoing monitoring. This comprehensive approach is essential for proactively preventing and rapidly addressing any potential risks or complications that might emerge [
1,
2,
3,
4,
5,
6].
To mitigate these risks, comprehensive guidelines and protocols for anesthesia administration in MRI settings have been developed to enhance patient safety and optimize the quality of imaging results. The Association of Anaesthetists in the UK published guidelines in 2002, with an update on the safety of MR units in 2019 [
6,
7,
8,
9]. Furthermore, the American Society of Anesthesiologists released a practice advisory providing specific recommendations for safe anesthesia administration in MRI environments [
7,
8,
9,
10]. These guidelines address factors such as patient selection, medication management, monitoring, emergency preparedness, and staff training and education. Adhering to these guidelines, along with implementing robust quality assurance and incident reporting systems, is crucial for promoting a culture of safety within MRI departments.
Despite the existence of national and international guidelines, the Ministry of Health in the Kingdom of Saudi Arabia currently lacks written guidelines or regulations specifically addressing the administration of anesthesia in MRI units [
8]. As a consequence, local healthcare institutions often depend on policies and guidelines established by international organizations to guide their anesthesia practices in MRI settings. This lack of national guidelines and regulations presents potential risks to patient safety within Saudi Arabia. The absence of standardized protocols tailored to the specific needs and practices of the country may result in variations in anesthesia administration, inadequate safety measures, and suboptimal patient outcomes. Given the unique challenges associated with providing anesthesia in an MRI environment, it becomes crucial to establish comprehensive and locally adapted guidelines that ensure the safe and effective delivery of anesthesia services.
The primary objective of this study was to comprehensively assess the degree to which hospitals in Saudi Arabia align with international guidelines and recommendations for the safe and effective administration of anesthesia within MRI environments. Furthermore, the study examined the extent of collaboration between anesthesia departments and radiology departments. Through this multifaceted assessment, this study sought to provide a holistic understanding of the current state of anesthesia administration in MRI units in Saudi Arabia and identify areas for potential improvement.
4. Discussion
The present statistical survey not only provides valuable insights into the anesthesia standards in Saudi Arabia, but also contributes to the overall evaluation and positioning of these standards, particularly in the context of administering anesthesia in MRI units. The findings emphasize the need for continuous efforts to improve compliance with recommendations to ensure optimal patient care and safety. Identifying areas of lower compliance can guide targeted interventions and quality improvement initiatives. The risk prioritization assessment underscores critical risks, including the absence of specialized MRI emergency training, communication breakdowns, and unclear anesthesia policies in MRI units. Consequently, targeted interventions like specialized training, improved communication protocols, and well-defined guidelines are imperative.
The considerable inter-site variation observed in the degree of compliance, which ranged from 41.8% to 100%, is a concerning finding. This variation suggests that there may be significant discrepancies in the quality and consistency of anesthesia care provided across different units and institutions. Addressing this variability is of paramount importance for promoting standardized and optimal anesthesia practices throughout Saudi Arabia [
8,
13]. The study’s findings also shed light on the compliance rates regarding guidelines for anesthesia administration in MRI environments, revealing interesting patterns among different types of hospitals. The comparison between university and non-university hospitals in terms of their adherence to anesthesia-related guidelines reveals distinct variations in the implementation of these guidelines. While some aspects showed similar proportions in both categories, noteworthy differences emerged in safety education and specialized training for emergencies within MRI environments. One significant finding was that of the presence of written policies for safety regulations during anesthesia in MRI, which was notably greater in university hospitals (66.7%) in comparison with their complete absence in non-university hospitals (
p = 0.001). This underscores the commitment of university hospitals to well-defined safety protocols for anesthesia procedures in MRI settings. Additionally, the greater presence of pre-procedural notification protocols in university hospitals (88.9%) than in non-university hospitals (63.6%) suggests a proactive approach to ensuring adequate preparation before anesthesia procedures, although the difference was not statistically significant (
p = 0.1). Interestingly, university hospitals demonstrated a significantly greater focus on safety education, including general education about MRI environments (100% vs. 31.8%,
p = 0.001) and specialized training for MRI emergencies (77.8% vs. 5%,
p < 0.001). The higher compliance rate observed in university hospitals highlights the potential influence of factors such as advanced educational programs, research-driven environments, and a multidisciplinary approach to healthcare [
2,
14].
Moving on to the comparison between tertiary and non-tertiary hospitals, minor differences were observed in the fulfillment of guidelines for anesthesia practice. Although some variations were noted, no statistically significant differences were found in safety education, specialized training, or communication practices between these two categories of hospitals. This suggests that the complexity of the hospital setting may not be the sole determinant of compliance with anesthesia guidelines in MRI environments [
14].
Communication breakdowns between anesthesiologists and MRI teams can manifest in various aspects of patient care. In the context of this study, a noteworthy observation is that a majority of respondents, irrespective of their hospital types, reported encountering communication barriers with the MRI team. Previous studies have emphasized the importance of effective communication between anesthesia providers and MRI teams [
11,
13,
15]. Mahmoud et al. (2013) found that communication breakdowns between anesthesia providers and MRI technologists can lead to errors in patient care, such as delays in treatment and adverse events [
15]. Furthermore, the study found that a lack of communication and teamwork between the two groups could lead to poor patient outcomes. This could cause potential clinical risks for patients or health professionals [
15]. They include but are not limited to minor to severe permanent injuries and, in extreme cases, the deaths of the patients. Effective communication between anesthesia providers and MRI teams is essential for ensuring patient safety and improving the quality of care. Strategies such as regular interdisciplinary meetings, checklists, and standardized protocols for patient screening and monitoring can improve communication and collaboration between these groups [
15]. Therefore, it is important to establish training programs that emphasize the importance of effective communication and collaboration between these groups to ensure patient safety and improve the quality of care. Furthermore, ongoing quality improvement efforts should focus on identifying and addressing communication breakdowns in order to improve patient outcomes.
The findings of our study raise concerns about the low percentage of participants (19.4%) who received MRI safety training. This highlights the urgent need for medical facilities in Saudi Arabia to develop and implement specialized MRI safety training programs specifically designed for anesthetists. Building upon a previous study that revealed a 60% overall knowledge score among non-imaging healthcare workers in the country, it is crucial to address the identified knowledge gaps [
16]. Although the study did not provide specific details about the participation of anesthetists, it is important to recognize their unique role and tailor educational initiatives to enhance their understanding and practice of MRI safety. Based on the risk prioritization assessment in this study, it is crucial to prioritize MRI safety training programs for anesthetists to ensure the highest safety standards during MRI-related anesthesia procedures. By providing targeted education and training, medical facilities can enhance patient care, mitigate potential risks, and uphold the highest standards of safety and quality in MRI examinations. These training programs should cover a range of topics, including MRI hazards, patient positioning, equipment safety, emergency protocols, and effective communication within the MRI team, as is recommended by the ACR guidelines [
17]. Furthermore, ongoing assessment and continuous professional development initiatives should be implemented to ensure that anesthetists stay up to date with the latest advancements and best practices in MRI safety. Collaborative efforts among medical institutions, professional associations, and regulatory bodies are necessary to establish standardized guidelines and accreditation processes for MRI safety training programs tailored to anesthetists.
The international advisory suggests that it is crucial for anesthesiologists and their institutions to properly identify and label anesthesia-related equipment according to the conventions for each MRI scanner to ensure patient safety and prevent adverse events [
18]. In the current study, although most participants reported proper labeling of anesthesia-related equipment, a significant minority reported poor labeling (
Table 1). Mislabeled monitoring devices have been identified as a significant factor contributing to patient misidentification incidents, accounting for approximately 7% of such incidents across various medical practices [
19]. In a previous study specifically focusing on MRI-related incidents, identification and documentation errors were found to account for 3% of the reported incidents, and they occurred at a rate of 0.011% [
20]. Similarly, other studies have reported the rates of identification and labeling errors in radiology to be around 0.017% [
21]. These findings highlight the importance of accurate and meticulous labeling and documentation practices in radiology and imaging departments to mitigate the risks associated with patient misidentification and ensure patient safety [
17,
19,
20].
While general anesthesia is frequently employed, the utilization of sedation has significantly eased the assessment of pediatric patients undergoing MRI, especially for procedures that have shorter acquisition times and, thus, do not necessitate general anesthesia [
18]. The current study highlights the variations in the practice of sedation administration in the MRI departments of Saudi hospitals. The present study revealed that the majority (77.4%) permitted radiologists to perform sedation. This diversity in practice is influenced by factors such as the growing demand for imaging services and the limited availability of anesthesiologists, particularly in remote areas [
21]. However, it is important to recognize that the use of sedation techniques, particularly when administered by non-anesthetists, carries a potential risk of serious complications. The NCEPOD report from 2000 highlighted concerns regarding sedation-related issues in radiology within the UK [
22]. The report recommended the implementation of comprehensive monitoring during vascular procedures, as well as the presence of a responsible individual other than the radiologist overseeing the process. Furthermore, the sedation protocol should undergo regular review and assessment by the anesthesia department to ensure its alignment with best practices and patient safety. This collaborative approach can help mitigate the potential risks associated with sedation administration and contribute to enhanced patient care outcomes.
This study’s findings should be interpreted within the context of certain limitations. One notable limitation is the small sample size, which may restrict the generalizability of the findings to a larger number of hospitals, including private hospitals, which were not included in the current study in Saudi Arabia. Expanding the sample size to encompass a wider range of healthcare settings would provide a more comprehensive understanding of the knowledge and attitudes about MRI safety. Moreover, it is important to acknowledge the potential for selection bias in this study. As participation in the nationwide evaluation was voluntary, hospitals with higher compliance rates may have been more inclined to participate, while those with lower compliance rates may have been underrepresented. This could introduce a bias, leading to an overestimation of overall compliance levels within the healthcare system. Additionally, the study relied on self-reporting by the participants, which could have introduced biases and inaccuracies in the data collected.