Omnia Max Clinical Applications

SIEMENS Healthineers SIEMENS Healthineers Uroskop Omnia Max Clinical Applications Job Aid : = Uroshop Omnia Max Effective Date:04 l 04 l 2019 HOOD5162003004414 Clinical Applications SIEMENS Healthineers Practice of Medicine The information presented in this Job Aid is for illustration only and is not intended to be relied upon by the reader for instruction as to the practice of medicine. Any healthcare practitioner reading this information is reminded that they must use their own learning, training and expertise in dealing with their individual patients. This material does not substitute for that duty and is not intended by Siemens Healthineers to be used for any purpose in that regard. Contrast Agent The drugs and doses mentioned herein are consistent with the approval labeling for uses and /or indications of the drug. The treating physician bears the sole responsibility for the diagnosis and treatment of patients, including drugs and doses prescribed in connection with such use. The Operating Instructions must always be strictly followed when operating Uroskop Omnia Max. The source for the technical data is the corresponding data sheets. 2 Clinical Applications – Table of Contents SIEMENS Healthineers Clinical precautions 4 Radiation Protection 6 Diagnostics - Upper and lower Urinary Tract System 8 Diagnostics - Lower Urinary Tract System 12 Functional Diagnostics 20 Endourology - Lithotomy position 26 Percutaneous Interventions - Prone position 32 3 Clinical Applications SIEMENS Healthineers Clinical precautions When X-raying patients, please observe the following guidelines: • To examine children or very slender adults with lower dosage, SIEMENS Healthineers move the scattered radiation grid into its parking position. • Additionally, a special dose-saving organ program for children is available. • Pregnant women must not be X-rayed except in emergencies. • X-ray exposures are taken with the lungs in the nd-expiratory state. • Is the patient allergic to contrast medium? Clinical precautions 4 Clinical Applications SIEMENS Healthineers Clinical precautions During interventions • Pay attention to the creatinine level. • Is the emergency kit close by and ready to use? • Is the oximeter close by? • Does the oxygen system function? Note: All cloths and covers placed beneath or on the patient may be visible on the fluoroscopic image or the X-ray image, which can lead to misinterpretations during evaluation. Clinical precautions 5 Clinical Applications SIEMENS Healthineers Radiation protection General The diagnostic use of X-rays is governed by the X-ray ordinance. It stipulates that only persons who can provide proof of adequate expert knowledge of radiology and radiation protection measures are allowed to use X-rays on humans. Practical radiation protection for the staff The best way to protect patients and staff from radiation is to reduce dose to a minimum and to maintain the greatest possible distance from the REFERENCE radiation source. The dose decreases proportionally to the square of the distance. Staff members who are frequently exposed to radiation at their workplace must wear radiation protection clothing. Lead-rubber protective clothing is merely intended to protect against scattered radiation. The parts of the body most difficult to protect are the head and the neck. It is therefore recommended to additionally wear eye and thyroid protection. Radiation 6 protection Clinical Applications SIEMENS Healthineers Radiation protection Retrograde_Ureterapyelografie_links, FEMALE_1940 Forchhet Radiation protection for the patient AOT COMPACT 17-06-2010 2.42:05 PM It is permissible to expose people to X-rays only for medical examinations and RAD Exam ination therapeutic purposes. In doing so, radiation must always be as low as possible for the person being examined and redundant examinations need to be avoided. Radiographic Postprocessing Documentation examinations must be performed only on doctor’s orders by persons authorized to do so. It is particularly important to protect the testicles and the ovaries of patients. Gonadal shields and lead aprons are used for this purpose. 0:00 win.Ca 30 ma In addition, the radiation beam must be collimated as much as possible to ensure that inan the level of scattered radiation generated within the irradiated body volume is as low as 28 Ma 21 possible. Additionally, special organ programs allow optimal settings for each D 3,90 1440 x 1440 1 0.40 Uro Slanker application. They also help reduce patient dose, while maintaining the necessary image WWW. 1750 WC 1393 quality. ¹ CARE (Combined Application to Reduce Exposure) Dose reduction – Siemens Healthineers CARE program Siemens Healthineers has developed a special program to ensure optimal dose reduction – CARE1 For more information on our CARE program, please refer to the . appendix of this application guide. Radiation 7 protection Clinical Applications - Diagnostics SIEMENS Healthineers Upper and lower Urinary Tract System Abdomen (KUB) Both sides or one side only • Noncontrast radiography of the abdomen (a.p.) from the lower edge of the symphysis to the upper renal pole Indications: • Acute abdominal pain Both sides • Abdominal injuries • Renal or biliary colic • Suspected floating kidney (standing position) During diagnosis, pay attention to the following: • Position and shape of the organs • Accumulation of air or fluid in the bowels and the abdominal cavity • Stones in the kidneys, ureters, bladder, and gall bladder • Psoas shadow • Take notice of gross skeletal disorders One side only Diagnostics Upper 8 - and lower Urinary Tract System Clinical Applications - Diagnostics SIEMENS Healthineers Upper and lower Urinary Tract System Patient positions: Abdomen (KUB) Examination: • For patient positioning, use the light localizer (for both sides – umbilicus in the center, for one side only – umbilicus at the right or left edge) or fluoroscopy Supine position a.p. Standing position a.p. • Usually one radiography a.p. (p.a. if the bowels are superimposed (on footboard) on the exposure) Place pillow, knee If necessary, abdomen elevated on bolster or large cushion under knees the left or right side / lower legs Diagnostics Upper 9 - and lower Urinary Tract System Clinical Applications - Diagnostics SIEMENS Healthineers Upper and lower Urinary Tract System Intravenous Pyelogram (IVP), Urogram • Series of radiographies of the urinary tract (calices, the renal pelvis, the ureters, and the bladder) after intravenous injection of a contrast medium Indications: • Inflammatory processes (pyelonephritis) • Hemorrhaging from the kidneys / bladder (hematuria) 7 min after injection of contrast medium • Tumors (i.v.) • Stones (nephrolithiasis) • Colics • Before and after urological surgery • After accidents and injury During diagnosis, pay attention to the following: • Position and shape of the organs • Urinary tract (obstructions in the kidneys, the ureters, and the bladder) • Symmetrical and timely drainage of the contrast medium 14 min after injection of contrast medium (i.v.) Diagnostics Upper 10 - and lower Urinary Tract System Clinical Applications - Diagnostics SIEMENS Healthineers Upper and lower Urinary Tract System Patient position: Intravenous Pyelogram (IVP), Urogram Examination: • The patient’s bladder should be empty • For patient positioning, use the light localizer (umbilicus in the center) • Take a noncontrast radiography (a.p.) of the abdomen • Administer the necessary amount of contrast medium Supine position a.p. Place pillow, knee bolster or large intravenously to the patient cushion under knees / lower legs • Adults receive 75 – 100 ml of contrast medium i.v.; infants, toddlers, children, and young adults receive doses adjusted to their body weight • Take additional X-rays after 7–10, and 15 – 20 minutes. If necessary, further X-rays are taken, for example after one hour or later Diagnostics Upper 11 - and lower Urinary Tract System Clinical Applications - Diagnostics SIEMENS Healthineers Lower Urinary Tract System Pelvis Noncontrast radiography of the pelvis (overview) Indications: • Hemorrhaging from the bladder (hematuria) • Bladder stones or prevesical ureteral calculi • Before and after urological surgery • After accidents and injury Pelvis (overview) During diagnosis, pay attention to the following: • Symphysis • Dense opacities (stones, phleboliths) • Foreign bodies Diagnostics- 12 Lower Urinary Tract System Clinical Applications - Diagnostics SIEMENS Healthineers Lower Urinary Tract System Patient position: Pelvis Examination procedure: • For patient positioning, use the light localizer (use your hand to feel for the symphyseal edge and use the edge as the lower limiting line) • Usually one exposure a.p.; if necessary, p.a. with the abdomen Supine position a.p. Place pillow, knee bolster or large elevated on the left or right side cushion under knees / lower legs • Additional exposure with / without zoom according to the findings Diagnostics- 13 Lower Urinary Tract System Clinical Applications - Diagnostics SIEMENS Healthineers Lower Urinary Tract System Cystogram Usually, a routine cystogram consists of two to four exposures: • Pelvis, overview • Bladder filled with contrast medium • X-ray with the patient’s left or right side elevated, if necessary with zoom • X-ray after contrast medium is voided Indications: Before and after urological surgery a.p. • • Cystocele, descensus, fistulae • After accidents and injury • Suspected tumors, diverticula • Suspected rotatory or vertical descensus During diagnosis, pay attention to the following: • Shape and position of the bladder • Leakages, fistulae • Foreign bodies in the bladder • Direction and shape of the urethra (lateral view) Lateral Diagnostics- 14 Lower Urinary Tract System Clinical Applications - Diagnostics SIEMENS Healthineers Lower Urinary Tract System Cystogram Patient positions: Examination: • The patient’s bladder should be empty • Use the light localizer of the collimator to position the patient (lower edge of the collimator should be visible approx. 4 cm below the penis / the external vagina) • Radiography of the pelvis overview a.p. (without contrast medium) Standing position a.p. Supine position a.p. • Instill contrast medium (approx. 200 ml) into bladder through a catheter. This (on footboard) Both legs bent, with elevated catheter is also used as a marker of the course of the urethra In an extreme lateral position left or right side (appr. 15°) • Radiographies with contrast medium a.p., with right side elevated and after in relation to the table, with his / voiding; if necessary with zoom her right leg flexed / in contact with Extreme lateral view in standing position: the tabletop and the left leg extended backwards • The patient’s bladder should be filled with 150 – 200 ml contrast medium; catheter must be left in place as a marker • Use the light localizer of the collimator to position the patient (lower edge of the collimator should be visible approx. 4 cm below the external vagina) • In standing position, the first X-ray is taken with patient at rest (before voiding) • The second X-ray is taken with patient bearing down hard, as if voiding Diagnostics- 15 Lower Urinary Tract System Clinical Applications - Diagnostics SIEMENS Healthineers Lower Urinary Tract System Conduitogram, Pouchogram • Contrast radiography used on patients with an ileal conduit / pouch, an artificial reservoir for urine created by implanting the ureters into an isolated ileal loop / isolated • bowel loop after loss of the bladder (low-pressure reservoir) • Usually, a routine augmented bladder / pouchogram consists of four or five exposures: • Abdominal radiography (overview) Conduitogram • Abdominal overview after administration of 150 ml CM • Abdominal overview when conduit is full • (if possible additional X-ray during micturition) • X-ray after contrast medium is voided Indications: Before and after urological surgery • Suspected vesicoureteral reflux • Febrile urinary tract infections • Pain in the renal region • Pouchogram a.p. Pouchogram lateral Diagnostics- 16 Lower Urinary Tract System Clinical Applications - Diagnostics SIEMENS Healthineers Lower Urinary Tract System Conduitogram, Pouchogram Patient position: During diagnosis, pay attention to the following: • Shape and position of the ileal conduit / pouch, the ureters, the area where the ureters have been implanted in the ileal conduit / pouch and the kidneys • Traces of contrast medium in the kidneys after it left the ileal conduit / pouch Examination: Supine position a.p. • The patient’s conduit / pouch should be empty or extremely lateral, with • For patient positioning, use the light localizer (umbilicus in the center) elevated left or right side • Plain abdominal radiography a.p. • The ileal conduit / pouch is filled with contrast medium through a catheter using an infusion set • Additional radiographs are taken after instillation of contrast medium and after the contrast medium (150 ml) has left the conduit / pouch • Abdominal overview when conduit / pouch is full (if possible during micturition) • X-ray after contrast medium is voided Diagnostics- 17 Lower Urinary Tract System Clinical Applications - Diagnostics SIEMENS Healthineers Lower Urinary Tract System Retrograde Urethrogram Contrast radiography of the urethra, the sphincter, the prostatic urethra, and if necessary the bladder. Usually, a routine urethrogram consists of two to three exposures: • Pelvis, overview • During instillation of the contrast medium During instillation of the contrast medium with zoom a.p. • Indications: • Before and after urological surgery • After accidents and injury • Suspected urethra strictures During diagnosis, pay attention to the following: • Lesions in the urethra • Shape, possible leakages and position of the urethra Diagnostics- 18 Lower Urinary Tract System Clinical Applications - Diagnostics SIEMENS Healthineers Lower Urinary Tract System Retrograde Urethrogram Patient position: Examination: • The patient’s bladder should be empty • For patient positioning, use the light localizer • (the lower edge of the collimator should be visible approx. 4 cm below the penis) Supine position a.p. • Radiography of the pelvis Left leg bent, right side slightly elevated (approx. 15°); place pillow, • (overview, without contrast medium) knee bolster or large cushion under • 30 – 50 ml of contrast medium is instilled into the urethra by knees / lower legs the retrograde route through a syringe or through a catheter which is blocked just behind the glans penis using 2 – 3 ml of fluid • One or more radiographies are taken during instillation, if needed with zoom Diagnostics- 19 Lower Urinary Tract System Clinical Applications - Functional Diagnostics SIEMENS Healthineers Reflux Cystogram Contrast radiography of the bladder, the ureters, and the kidneys (reflux of urine from the bladder through the ureter to the kidney, in adults and children). • Usually, a routine reflux cystogram consists of two to four exposures: • Pelvis, overview • Bladder filled with contrast medium • X-ray with the patient’s left or right side elevated, if necessary with zoom • X-ray after contrast medium is voided Indications: • Before and after urological surgery a.p. • Suspected vesicoureteral reflux • Febrile urinary tract infections • Pain in the costovertebral angle if bladder is full and during voiding During diagnosis, pay attention to the following: • Shape and position of the bladder, ureters, and kidneys • Traces of contrast medium in the kidneys after voiding • Abnormalities in the urethra (during voiding) Functional 20 Diagnostics Clinical Applications - Functional Diagnostics SIEMENS Healthineers Reflux Cystogram Patient position: Examination: • The patient’s bladder should be empty • For patient positioning, use the light localizer (umbilicus in the center) • Instill contrast medium (approx. 200 to 500 ml) into the bladder through a catheter and fill up with NaCl depending on Supine position a.p. bladder capacity Place pillow, knee bolster or large cushion under knees / lower legs • After radiography a.p. (without contrast medium), one abdominal overview is taken when the patient first feels the need to void with the bladder fully filled (or during micturition if the patient consents) and after the patient has emptied the bladder completely, with or without zoom according to the findings Functional 21 Diagnostics Clinical Applications - Functional Diagnostics SIEMENS Healthineers Voiding Cystourethrogram (VCU) Contrast radiography of the bladder and the urethra during voiding (in adults and children). Usually, a routine VCU consists of three exposures: • Pelvis, overview • During voiding • During voiding, with zoom Indications: • Before and after urological surgery Seated position • After accidents and injury • Suspected urethra strictures • Suspected reflux During diagnosis, pay attention to the following: • Degree of possible ureteral reflux of contrast media • Shape and position of the bladder • Lesions in the urethra • Foreign bodies in the urethra Functional 22 Diagnostics Clinical Applications - Functional Diagnostics SIEMENS Healthineers Voiding Cystourethrogram (VCU) Examination: Patient positions: • The patient’s bladder should be empty • For patient positioning, use the light localizer rima • (the lower edge of the collimator should be visible approx. 4 cm below the penis / the external vagina) • Radiography of the pelvis, overview a.p. (without contrast medium) Supine position a.p. Standing position a.p. • Instill contrast medium (approx. 200 ml) into the bladder (on footboard) Left leg bent, right side slightly through a catheter and fill up with NaCl depending on Left or right side slightly elevated elevated (approx. 15°); place pillow, knee bolster or large cushion under bladder capacity knees / lower legs • One or more radiographies are taken during voiding, if needed with zoom according to the findings Seated position a.p. (on the micturition seat in front of the table) Right side slightly elevated Functional 23 Diagnostics Clinical Applications - Functional Diagnostics SIEMENS Healthineers Video-Urodynamics Contrast radiography of the bladder during filling with contrast medium and voiding as well as the urethra during voiding (in adults and children) • The relevant urodynamic data are measured using an independent PC-based measuring system Indications: • Neurological disorders Before and after urological surgery Seated position • • Suspected vesicoureteral reflux • Suspected involuntary contractions of the detrusor • Detrusor-bladder outlet dyssynergia • Detrusor-pelvic floor dyssynergia During diagnosis, pay attention to the following: • The degree of sterility must be as high as possible to prevent infiltration of bacteria into the blood stream and the risk of urosepsis Functional 24 Diagnostics Clinical Applications - Functional Diagnostics SIEMENS Healthineers Video-Urodynamics Examination: Patient positions: • The patient’s bladder should be empty • For patient positioning, use the light localizer rina • (the lower edge of the collimator should be visible approx. 4 cm below the penis / the external vagina) ..... • One measuring catheter is inserted into the bladder through the urethra and another catheter into the anus. In addition, two perineal surface stick- on electrodes are put into position with the neutral electrode fixed on the thigh Supine position a.p. Standing position a.p. (on the footboard) If necessary, left Place pillow, knee bolster or large • During filling of the bladder with contrast medium and during micturition, or right side slightly elevated cushion under knees / lower legs values are continually measured, stored, and graphically displayed (intravesical and intraabdominal pressure, electromyogram (EMG), urine flow, filling rate, instilled volume, current bladder capacity, residual urine at the end of the measurement) • Fluoroscopy is used to observe the changing state of the bladder and X- Seated position a.p. rays can be taken as needed throughout the exam. Via the video interface, (on the micturition seat) the X-rays can be transferred to the urodynamic measurement system and If necessary, right side slightly elevated or up to an extreme be stored and displayed synchronously lateral position • Video-Urodynamics should be applied carefully because it is very stressful for the patient. It should ideally be scheduled to the end of the procedure Functional 25 Diagnostics Clinical Applications - Endourology SIEMENS Healthineers Lithotomy position Retrograde Pyelography Contrast radiography of the ureters and kidneys. A ureter catheter (UC) is employed to obtain images of the ureter from the bladder up to the renal pelvis and of the renal pelvis itself. During the procedure, contrast medium is instilled into the ureter in a retrograde fashion (in the opposite direction of the urine flow) through the catheter. Indications: Gross hematuria of unknown origin • Ureter stenosis Right side • • • Suspected radiosilent kidney Subpelvic stenosis • Fistula • Ureter and kidney tumors • After injury • If the kidney is not shown sufficiently in IVP • Stones • Tumor During procedure, pay attention to the following: • The degree of sterility must be as high as possible to prevent infiltration of bacteria into the blood stream and the risk of urosepsis • Keep the radiation field as small as possible Zoomed Endourology- 26 Lithotomy position Clinical Applications - Endourology SIEMENS Healthineers Lithotomy position Patient position: Retrograde Pyelography Examination procedure: • The patients bladder should be empty • For patient positioning use the light localizer • After cystoscopic examination of the bladder, a radiopaque ureter catheter (UC) is inserted in the required ureter ostium Lithotomy position a.p. Attach the leg supports and and contrast medium is injected slowly. the plastic drain bag at the table. The contrast medium flow must be documented. X-ray the Cover the tabletop sufficiently (30 to • 40 cm overhang at each side) with a right or left side of the abdomen or both sides. fluid-repellent drape so that no blood, urine, contrast medium etc. can run under the tabletop or the table paneling. Endourology- 27 Lithotomy position Clinical Applications - Endourology SIEMENS Healthineers Lithotomy position Double-J stent insertion and replacement Insertion of a catheter extending from the bladder to the renal pelvis. The special shape of the catheter ends, a kind of loop shape (double-J), prevents the catheter from slipping from its position. Indications: • After urological stone surgery • Suspected radiosilent kidney Stones Catheter placement after • Tumor Streinstrasse • • Ureter and kidney tumors • Impaired kidney function • Ureter stenosis • Subpelvis stenosis • Fistula • After injury During procedure, pay attention to the following: The degree of sterility must be as high as possible to prevent infiltration of bacteria into the blood stream and the risk of urosepsis. Control of catheter position Endourology- 28 Lithotomy position Clinical Applications - Endourology SIEMENS Healthineers Lithotomy position Patient position: Double-J stent insertion and replacement Examination procedure: • The patients bladder should be empty • For patient positioning use the light localizer • After cystoscopic examination of the bladder, a radiopaque ureter catheter (UC) is inserted and contrast medium is injected slowly A fluoroscopy image or a radiography of the corresponding half of the abdomen is used for documentation Lithotomy position a.p. • of the contrast medium flow Attach the leg supports and the plastic drain bag at the table. • The ureter catheter is irrigated with NaCl or sterile water and the guide wire is carefully inserted up to the Cover the tabletop sufficiently (30 to kidney through the ureter catheter under fluoroscopic control. The catheter is removed while taking care 40 cm overhang at each side) with a not to dislocate the guide wire from its position. The double-J stent is inserted up to the kidney with the fluid-repellent drape so that no help of the guide wire under fluoroscopic control. By carefully retracting the guide wire, the J end of the blood, urine, contrast medium etc. stent is fixed in the renal pelvis. Sufficient length of the stent must be visible in the bladder. can run under the tabletop or the table paneling. • A fluoroscopy image or a radiography is used for documentation of the correct positioning of the double-J stent Replacement of a double-J catheter • The catheter is replaced with the help of a guide wire Endourology- 29 Lithotomy position Clinical Applications - Endourology SIEMENS Healthineers Lithotomy position Ureterorenoscopy (URS) Visual inspection of the interior of the ureter and kidney by means of a flexible fiber optic endoscope or semi-rigid endoscope (ureterorenoscope), as for biopsy, removal or crushing of stones or for diagnostic reasons in case of suspected tumors. Indications: • Stones Left side • Ureter and kidney tumors During procedure, pay attention to the following: The degree of sterility must be as high as possible to prevent infiltration of bacteria into the blood stream and the risk of urosepsis. Note: The two TFT monitors display images from different modalities side-by-side: X- rays, fluoroscopy, endoscopy, ultrasound and reference images. Endoscopy image of ureter Endourology- 30 Lithotomy position Clinical Applications - Endourology SIEMENS Healthineers Lithotomy position Patient position: Ureterorenoscopy (URS) Examination procedure: • The patient’s bladder should be empty • For patient positioning, use the light localizer or fluoroscopy Lithotomy position a.p. Attach the leg supports and the plastic drain bag on the table. Cover the tabletop sufficiently (30 to 40 cm overhang at each side) with a fluid-repellent drape so that no blood, urine, contrast medium etc. can run under the tabletop or the table paneling. Endourology- 31 Lithotomy position Clinical Applications - Percutaneous Interventions SIEMENS Healthineers Prone Position Percutaneous Nephrostomy (PCN) Catheter placement and replacement Percutaneous nephrostomy catheter placement is the term describing the creation of a kidney fistula (catheter) in the left or right kidney or in both kidneys through a skin incision (percutaneous). The purpose of this intervention is to drain the urine from the kidney(s) (relieve pressure). Indications: Stones One side • • Tumor • After failure of double-J insertion • Impaired urine transport from the kidneys to the bladder During procedure, pay attention to the following: • The degree of sterility must be as high as possible to prevent infiltration of bacteria into the blood stream and the risk of urosepsis • Gonad protection in male patients and lead apron for female patients; keep the radiation field as small as possible Both sides Percutaneous 32 Interventions - Prone position Clinical Applications - Percutaneous Interventions SIEMENS Healthineers Prone Position Patient position: Percutaneous Nephrostomy (PCN) Examination: • The patient’s bladder should be empty • Standard skin disinfection and sterile drapes • For patient positioning, use the light localizer • The puncture of the right / left kidney is performed from the front / back side of the table under ultrasound guidance. • Contrast medium is administered under fluoroscopic control to check the position of the Prone position needle Cover the tabletop sufficiently (30 Hint: to 40 cm overhang at each side) Use memory function to store the three positions and the collimator settings (bladder, with a fluid-repellent drape so that ureter, kidney). no blood, urine, contrast medium A guide wire (J-wire) is inserted through the needle shaft. The puncture canal is dilated (using etc. can run under the tabletop or • bougies) until it reaches the width of the nephrostomy catheter. the table paneling. Thin cushion for the head, knee bolster to place • The nephrostomy catheter is inserted / replaced with the aid of the guide wire through the shaft of the bougie and is positioned in the renal pelvis under fluoroscopic control. The guide beneath the feet, if necessary place wire has to be removed and a cutaneous suture to be used to keep the nephrostomy catheter gel cushions beneath the knees. in place. Note: Beside the live X-ray image, ultrasound or the X-ray reference images can be shown on the right-hand TFT monitor; this makes puncturing of the kidney much easier. Percutaneous 33 Interventions - Prone position SIEMENS Healthineers Please note that the learning material is for training purposes only! For the proper use of the software or hardware, please always use the Operator Manual or Instructions for Use (hereinafter collectively “Operator Manual”) issued by Siemens Healthineers. This material is to be used as training material only and shall by no means substitute the Operator Manual. Any material used in this training will not be updated on a regular basis and does not necessarily reflect the latest version of the software and hardware available at the time of the training. The Operator's Manual shall be used as your main reference, in particular for relevant safety information like warnings and cautions. Note: Some functions shown in this material are optional and might not be part of your system. Certain products, product related claims or functionalities (hereinafter collectively “Functionality”) may not (yet) be commercially available in your country. Due to regulatory requirements, the future availability of said Functionalities in any specific country is not guaranteed. Please contact your local Siemens Healthineers sales representative for the most current information. The reproduction, transmission or distribution of this training or its contents is not permitted without express written authority. Offenders will be liable for damages. All names and data of patients, parameters and configuration dependent designations are fictional and examples only. All rights, including rights created by patent grant or registration of a utility model or design, are reserved. Copyright © Siemens Healthcare GmbH Global Siemens Healthineers Headquarters Henkestr. 127 91052 Erlangen, Germany Phone: +49 9131 84 0 siemens.com/healthineers 34 Effective Date:04 l 04 l 2019 l HOOD5162003004414