radiation safety for staff in fluoroscopy suites · radiation safety for staff in fluoroscopy...

CE: Dose III

Beth Schueler, AAPM Annual Meeting 2011

Radiation Safety for Staff in Radiation Safety for Staff in Fluoroscopy SuitesFluoroscopy Suites

Beth SchuelerBeth SchuelerMayo ClinicMayo Clinic

Rochester, MinnesotaRochester, Minnesota

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Learning ObjectivesLearning Objectives

For staff performing fluoroscopicallyFor staff performing fluoroscopically--guided guided interventional procedures:interventional procedures:

What are typical radiation exposure levels?What are typical radiation exposure levels?How should the radiation exposure to staff be How should the radiation exposure to staff be monitored?monitored?What type of radiation safety education is needed?What type of radiation safety education is needed?Is there anything new and novel available that can Is there anything new and novel available that can help reduce staff exposure levels?help reduce staff exposure levels?

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ResourcesResources

Joint SIR / CIRSE Joint SIR / CIRSE Guideline for Guideline for Occupational Radiation Occupational Radiation Protection in IR Protection in IR (Miller et al, 2010)(Miller et al, 2010)

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NCRP Report No. 168 NCRP Report No. 168 Radiation Dose Radiation Dose Management for Management for FluoroscopicallyFluoroscopically--guided guided Interventional Medical Interventional Medical Procedures, 2011Procedures, 2011

Operator Exposure During Operator Exposure During Fluoroscopy ProceduresFluoroscopy Procedures

Mean Dose per Mean Dose per Procedure (Procedure (µµSv)Sv)Procedure TypeProcedure Type

NeckNeck LensLens HandHand

ReferenceReference

Mixed general IRMixed general IR 3030--325325 300300 270270--400400 NCRP 168NCRP 168

ERCPERCP 450450 550550 640640 NCRP 168NCRP 168

Endovascular surgeryEndovascular surgery 300300 400400 NCRP 168NCRP 168

Percutaneous coronary Percutaneous coronary interventionintervention

1010--130130 1010--170170 3030--350350 Kim et al, 2008Kim et al, 2008

Cardiac ablationCardiac ablation 88--200200 5050--320320 4040--230230 Kim et al, 2008Kim et al, 2008

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Typical Operator Exposure LevelsTypical Operator Exposure Levels

Annual doses for a workload of 1000 proceduresAnnual doses for a workload of 1000 proceduresNeck: 10Neck: 10--450 mSv450 mSvLens of the eye: 10Lens of the eye: 10--550 mSv550 mSvHand: 30Hand: 30--640 mSv640 mSv

Survey of interventional radiologists with a Survey of interventional radiologists with a mixed workload (Marx et al, 1992)mixed workload (Marx et al, 1992)

Mean annual dose (dosimeter on chest over Mean annual dose (dosimeter on chest over protective apron): 49 mSv (range: 3protective apron): 49 mSv (range: 3--115 mSv)115 mSv)

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Mayo Clinic RochesterMayo Clinic Rochester

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0

50

100

150

200

250

A B C D E F G H I J K

Interventional Radiologists

Nec

k D

osim

eter

Rea

din

g (m

Sv)

200820092010

Mean: Mean: 73 mSv73 mSv

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Operator Exposure LevelsOperator Exposure Levels

Typical doses for operators performing Typical doses for operators performing fluoroscopicallyfluoroscopically--guided interventional guided interventional procedures are highprocedures are high

May exceed annual dose limitsMay exceed annual dose limitsLens of the eye: 150 mSvLens of the eye: 150 mSvHands: 500 mSvHands: 500 mSv

Values generally well exceed those for other Values generally well exceed those for other healthcare workershealthcare workers

Annual US healthcare workers (NCRP Report No. 160): Annual US healthcare workers (NCRP Report No. 160): 81% with recordable dose are < 1 mSv81% with recordable dose are < 1 mSv

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Personnel Dose MonitoringPersonnel Dose Monitoring

Due to the potential for high occupational Due to the potential for high occupational doses, appropriate monitoring is criticaldoses, appropriate monitoring is criticalMonitoring considerations:Monitoring considerations:

11--dosimeter or 2dosimeter or 2--dosimeter monitoring?dosimeter monitoring?Dose calculation method?Dose calculation method?When should dose readings be investigated?When should dose readings be investigated?

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11--Dosimeter Method:Dosimeter Method:At neck, outside apronAt neck, outside apron

22--Dosimeter Method:Dosimeter Method:At neck, outside apron and At neck, outside apron and

at waist or chest, under apronat waist or chest, under apron


22--Dosimeter method recommended Dosimeter method recommended (NCRP Report No. 168)(NCRP Report No. 168)

Provides an indication of apron attenuationProvides an indication of apron attenuationAllows for better estimate of operator effective Allows for better estimate of operator effective dosedoseDosimeters should be clearly labeled to avoid Dosimeters should be clearly labeled to avoid mixmix--upsups

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Dose Assignment with Protective ApronsDose Assignment with Protective Aprons

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Operator Exposure During Operator Exposure During Fluoroscopy ProceduresFluoroscopy Procedures

Procedure TypeProcedure TypeMean Annual Mean Annual

Effective Dose* Effective Dose* (mSv)(mSv)

ReferenceReference

Mixed general IRMixed general IR 2 2 -- 1515 NCRP 168NCRP 168ERCPERCP 2121 NCRP 168NCRP 168Endovascular surgeryEndovascular surgery 2323 NCRP 168NCRP 168Percutaneous coronary Percutaneous coronary interventionintervention

0.2 0.2 -- 99 Kim et al, 2008Kim et al, 2008

Cardiac ablationCardiac ablation 0.2 0.2 -- 1010 Kim et al, 2008Kim et al, 2008

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* * assuming workload of 1000 procedures per yearassuming workload of 1000 procedures per year

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Annual Dose LimitsAnnual Dose Limits

NCRP Report No. 116 recommendation:NCRP Report No. 116 recommendation:Effective dose: 50 mSvEffective dose: 50 mSv

ICRP Publication 60 recommendation:ICRP Publication 60 recommendation:Effective dose: 20 mSv, averaged over 5 Effective dose: 20 mSv, averaged over 5 years, not to exceed 50 mSv in a single yearyears, not to exceed 50 mSv in a single year

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Lens ExposureLens Exposure

Annual dose limit recommendations Annual dose limit recommendations (NCRP Report No. 116):(NCRP Report No. 116):

Lens of the eye: 150 mSvLens of the eye: 150 mSv

Measurements for an annual workload of 1000 Measurements for an annual workload of 1000 procedures,procedures,

Lens of the eye (unprotected): 10Lens of the eye (unprotected): 10--550 mSv550 mSv

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Lens Dose EstimationLens Dose Estimation

Exposure level at the eye is Exposure level at the eye is typically somewhat lower typically somewhat lower than at the neckthan at the neck

Lens:NeckLens:Neck dose ratio varies dose ratio varies with Cwith C--arm angulationarm angulation

Neck dosimeter reading Neck dosimeter reading provides conservative provides conservative estimate (NCRP No. 168)estimate (NCRP No. 168)

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4 2 1 0.5 0.25 mGy/hr

Leaded EyewearLeaded Eyewear

Typical lead equivalent thickness of radiation Typical lead equivalent thickness of radiation protective eyewear is 0.75 mmprotective eyewear is 0.75 mm

98% attenuation98% attenuation

Actual lens dose is higher due toActual lens dose is higher due toExposure from the side Exposure from the side and from belowand from belowBackscatter from headBackscatter from head

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Traditional styleTraditional style0.75 mm lead 0.75 mm lead equivalent lensesequivalent lenses120 g120 g28 cm28 cm22 surface areasurface area


SportSport--wrap stylewrap style0.75 mm lead 0.75 mm lead equivalent lensesequivalent lenses59 g59 g16 cm16 cm22 surface areasurface area

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Leaded Eyewear AttenuationLeaded Eyewear Attenuation

Attenuation FactorAttenuation FactorLeaded Leaded Eyewear Eyewear StyleStyle 00°° AngleAngle 4545°° AngleAngle 9090°° AngleAngle

1010

8.38.3

TraditionalTraditional 5.25.2 4.04.0

SportSport--wrapwrap 4.54.5 1.41.4

New Guideline on Lens ExposureNew Guideline on Lens Exposure

ICRP issued a new recommendation ICRP issued a new recommendation (ICRP, 2011)(ICRP, 2011)

Lower threshold for cataract formation: 0.5 Gy Lower threshold for cataract formation: 0.5 Gy (previous threshold 2(previous threshold 2--5 Gy)5 Gy)Lower occupational eye Lower occupational eye dose limit: dose limit: 20 mSv/yr 20 mSv/yr averaged over 5 years averaged over 5 years with no year > 50 mSvwith no year > 50 mSv

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RadiationRadiation--Induced CataractInduced Cataract

Problems with earlier studies:Problems with earlier studies:Short followShort follow--up period up period –– latency period is longer for latency period is longer for low doseslow dosesInsufficient sensitivity to detect early lens changesInsufficient sensitivity to detect early lens changesFew subjects with doses below a few grayFew subjects with doses below a few gray

Significant studies:Significant studies:Chernobyl nuclear reactor accident cleanup workers Chernobyl nuclear reactor accident cleanup workers ((WorgulWorgul et al, 2007)et al, 2007)US radiologic technologists (US radiologic technologists (ChodickChodick et al, 2008)et al, 2008)

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Hand DoseHand Dose

Ring dosimeters recommended if hand dose > Ring dosimeters recommended if hand dose > 50 mSv in a year (NCRP Report No. 168)50 mSv in a year (NCRP Report No. 168)Monitor for a trial period of several months for Monitor for a trial period of several months for new staff and new procedure typesnew staff and new procedure typesWear with sensitive area toward Wear with sensitive area toward exposure sourceexposure source

Inward for underInward for under--table xtable x--ray ray tube configurationstube configurations

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Investigation of Dose ReadingsInvestigation of Dose Readings

Recommended investigation trigger level Recommended investigation trigger level (WHO, 2000):(WHO, 2000):

E, effective dose > 0.5 mSv/monthE, effective dose > 0.5 mSv/monthLens dose > 5 mSv/monthLens dose > 5 mSv/monthHand dose > 15 mSv/monthHand dose > 15 mSv/month

Verify validity of measurementVerify validity of measurementLook for changes in procedure volume, Look for changes in procedure volume, procedure type, equipment, procedure type, equipment, ……

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Investigation of Dose ReadingsInvestigation of Dose Readings

It is common for personnel who may receive a It is common for personnel who may receive a high occupational dose to not wear their high occupational dose to not wear their dosimeters to avoid investigationsdosimeters to avoid investigations

43% of surveyed interventional radiologists indicate 43% of surveyed interventional radiologists indicate they rarely or never wear monitoring dosimeters they rarely or never wear monitoring dosimeters (Marx et al, 1992)(Marx et al, 1992)

Dosimeter readings that are lower than expected Dosimeter readings that are lower than expected for a specific work assignment should also be for a specific work assignment should also be investigated (NCRP Report No. 168)investigated (NCRP Report No. 168)

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Radiation Safety EducationRadiation Safety Education

Credentials and privileges for fluoroscopy Credentials and privileges for fluoroscopy operators are neededoperators are needed

Help for developing a program is comingHelp for developing a program is comingAAPM TG 124 (Chair AAPM TG 124 (Chair –– Mary Moore)Mary Moore)

““A Guide for Establishing a Credentialing and Privileging A Guide for Establishing a Credentialing and Privileging Program for Users of Fluoroscopic Equipment in Program for Users of Fluoroscopic Equipment in Healthcare OrganizationsHealthcare Organizations”” is in the worksis in the worksWill include suggestions to encourage your facility to Will include suggestions to encourage your facility to approve a program, didactic content, evaluating approve a program, didactic content, evaluating competency and information resources for teachingcompetency and information resources for teaching

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Occupational Radiation Safety ResourcesOccupational Radiation Safety Resources

IAEA RPOP web pagesIAEA RPOP web pageshttps://rpop.iaea.org/RPOP/RPoP/Chttps://rpop.iaea.org/RPOP/RPoP/Content/InformationFor/HealthProfessiontent/InformationFor/HealthProfessionals/index.htmonals/index.htm

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IAEA slide presentation IAEA slide presentation seriesseries

https://rpop.iaea.org/RPOP/RPoP/Chttps://rpop.iaea.org/RPOP/RPoP/Content/AdditionalResources/Training/ontent/AdditionalResources/Training/1_TrainingMaterial/Radiology.htm1_TrainingMaterial/Radiology.htm

Occupational Radiation Safety ResourcesOccupational Radiation Safety Resources

Image Gently pediatric IR Image Gently pediatric IR presentationpresentation

http://www.pedrad.org/associations/5http://www.pedrad.org/associations/5364/ig/364/ig/

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RSNA/AAPM Online RSNA/AAPM Online physics modulesphysics modules

http://http://physics.rsna.org/default.aspphysics.rsna.org/default.asp

““Radiation Safety and Dose in Radiation Safety and Dose in Interventional RadiologyInterventional Radiology””

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Operator ShieldingOperator Shielding

Overhead and table Overhead and table shields can be very shields can be very effective effective But may be But may be cumbersome for cumbersome for certain procedures:certain procedures:

CC--arm angulationarm angulationBiliaryBiliary or or transjugular accesstransjugular access

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Orthopedic Complications from Orthopedic Complications from Lead Apron UseLead Apron Use

Back pain was reported by 50Back pain was reported by 50--75% 75% of interventional physicians of interventional physicians surveyed (Klein et al, 2009)surveyed (Klein et al, 2009)

Compare to typical incidence of 27% Compare to typical incidence of 27% in US adultsin US adults2525--30% reported that back problems 30% reported that back problems had limited their workhad limited their work

Options for reliefOptions for reliefLightweight apronsLightweight apronsVest/kilt designVest/kilt design

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Radiation Protective CabinsRadiation Protective Cabins

ZeroGravityZeroGravity1.25 mm lead 1.25 mm lead apron and 0.5 apron and 0.5 mm leadmm lead--equivalent face equivalent face shieldshield

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MarichalMarichal et al, 2011et al, 2011

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Radiation Protective CabinsRadiation Protective Cabins

CATHPAXCATHPAX2 mm lead walls and 2 mm lead walls and leadlead--equivalent equivalent windowswindows

33DragusinDragusin et al, 2007et al, 2007

RealReal--time Personnel Dose Monitoringtime Personnel Dose Monitoring

DoseAwareDoseAwareDisplays cumulative dose and Displays cumulative dose and dose rate on a monitor dose rate on a monitor Can be networked between Can be networked between multiple procedure roomsmultiple procedure roomsAllows for realAllows for real--time feedback time feedback to avoid high scatter to avoid high scatter conditions and implement conditions and implement radiation reduction radiation reduction techniquestechniques

34Sanchez et al, 2010Sanchez et al, 2010

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Heavy Metal Protective Patient DrapesHeavy Metal Protective Patient Drapes

RADPADRADPADGel pad with Gel pad with tungstentungsten--antimonyantimonySterile, dispose after Sterile, dispose after procedureprocedure1212×× eye dose eye dose reductionreduction2929×× hand dose hand dose reductionreduction

35DromiDromi et al, 2006et al, 2006

ReferencesReferences

ChodickChodick G, G, BekirogluBekiroglu N, Hauptmann M, et al. Risk of cataract after exposure to low dN, Hauptmann M, et al. Risk of cataract after exposure to low doses of ionizing radiation: A oses of ionizing radiation: A 2020--year prospective cohort study among US radiologic technologists,year prospective cohort study among US radiologic technologists, Am. J. Epidemiol. 2008; 168(6), 620Am. J. Epidemiol. 2008; 168(6), 620––631.631.Conference of Radiation Control Program Directors (CRCPD) SuggesConference of Radiation Control Program Directors (CRCPD) Suggested State Regulations, ted State Regulations, http://http://www.crcpd.org/ssrcr.aspxwww.crcpd.org/ssrcr.aspxDragusinDragusin O, O, WeerasooriyaWeerasooriya R, R, JaisJais P, et al. Evaluation of a radiation protection cabin for invasiP, et al. Evaluation of a radiation protection cabin for invasive electrophysiological ve electrophysiological procedures, Eur. Heart J 2007; procedures, Eur. Heart J 2007; 2828(2),183(2),183––189.189.Dromi S, Wood BJ, Oberoi J, Neeman Dromi S, Wood BJ, Oberoi J, Neeman Z. Heavy metal pad shielding during fluoroscopic interventions. Z. Heavy metal pad shielding during fluoroscopic interventions. J J VascVasc IntervIntervRadiol 2006; 17:1201Radiol 2006; 17:1201––1206.1206.International Commission on Radiological Protection (ICRP). ICRPInternational Commission on Radiological Protection (ICRP). ICRP Publication 60, Ann. ICRP 1990, 21(1Publication 60, Ann. ICRP 1990, 21(1--3) 3) (Elsevier, New York).(Elsevier, New York).International Commission on Radiological Protection (ICRP). StatInternational Commission on Radiological Protection (ICRP). Statement on tissue reactions. 2011. ement on tissue reactions. 2011. httphttp://://www.www.icrpicrp.org/page.asp?id.org/page.asp?id=123=123Kim KP, Miller DL, Balter S, et al. Occupational radiation dosesKim KP, Miller DL, Balter S, et al. Occupational radiation doses to operators performing cardiac catheterization to operators performing cardiac catheterization procedures. Health Phys 2008; 94:211procedures. Health Phys 2008; 94:211––227.227.Klein LW, Miller DL, Balter S, et al. Occupational health hazardKlein LW, Miller DL, Balter S, et al. Occupational health hazards in the interventional laboratory: time for a safer s in the interventional laboratory: time for a safer environmentenvironment. J . J VascVasc IntervInterv Radiol Radiol 2009; 20:1472009; 20:147––152.152.MarichalMarichal DA, Anwar T, Kirsch D, et al. Comparison of a suspended radiatiDA, Anwar T, Kirsch D, et al. Comparison of a suspended radiation protection system versus standard lead on protection system versus standard lead apron for radiation exposure of a simulated interventionalist, Japron for radiation exposure of a simulated interventionalist, JVIR 2011; 22:437VIR 2011; 22:437--442.442.Marx MV, Niklason L, Marx MV, Niklason L, MaugerMauger EA. Occupational radiation exposure to interventional radiologiEA. Occupational radiation exposure to interventional radiologists: a prospective sts: a prospective study. J study. J VascVasc IntervInterv Radiol 1992; 3:597Radiol 1992; 3:597–– 606.606.

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References (continued)References (continued)

Miller DL, Vano E, Miller DL, Vano E, BartalBartal G, Balter S, Dixon R, G, Balter S, Dixon R, PadovaniPadovani R, Schueler B, R, Schueler B, CardellaCardella JF, de JF, de BaereBaere T. Occupational T. Occupational radiation protection in interventional radiology: A joint guidelradiation protection in interventional radiology: A joint guideline of the Cardiovascular and Interventional ine of the Cardiovascular and Interventional Radiology Society of Europe and the Society of Interventional RaRadiology Society of Europe and the Society of Interventional Radiology. J diology. J VascVasc IntervInterv Radiol. 21(5): p. 607Radiol. 21(5): p. 607--15.15.NCRP Report No. 116. Limitation of Exposure to Ionizing RadiatioNCRP Report No. 116. Limitation of Exposure to Ionizing Radiation.. Bethesda, MD: National Council on n.. Bethesda, MD: National Council on Radiation Protection and Measurements, 1993.Radiation Protection and Measurements, 1993.NCRP Report No. 122. Use of Personal Monitors to Estimate EffectNCRP Report No. 122. Use of Personal Monitors to Estimate Effective Dose Equivalent and Effective Dose ive Dose Equivalent and Effective Dose to Workers for External Exposure to Lowto Workers for External Exposure to Low--LET Radiation. Bethesda, MD: National Council on Radiation LET Radiation. Bethesda, MD: National Council on Radiation Protection and Measurements, 1995.Protection and Measurements, 1995.NCRP Report No. 168. Radiation Dose Management for FluoroscopicaNCRP Report No. 168. Radiation Dose Management for Fluoroscopicallylly--guided Interventional Medical guided Interventional Medical Procedures. Bethesda, MD: National Council on Radiation ProtectiProcedures. Bethesda, MD: National Council on Radiation Protection and Measurements, 2011.on and Measurements, 2011.Sanchez R, Vano E, Fernandez JM. Staff radiation doses in a realSanchez R, Vano E, Fernandez JM. Staff radiation doses in a real--time display inside the angiography room. time display inside the angiography room. CardiovascCardiovasc InterventIntervent Radiol 2010; 33:1210Radiol 2010; 33:1210--1214.1214.WorgulWorgul BV, BV, KundiyewKundiyew YI, YI, SergiyenkoSergiyenko NM, et al. Cataracts among Chernobyl cleanNM, et al. Cataracts among Chernobyl clean--up workers: Implications up workers: Implications regarding permissible eye regarding permissible eye exposuresexposures, Radiat. , Radiat. ResRes. 2007; 167(2), 233. 2007; 167(2), 233––243.243.World Health Organization. Efficacy and radiation safety in inteWorld Health Organization. Efficacy and radiation safety in interventional radiology. Geneva: World Health rventional radiology. Geneva: World Health Organization, 2000.Organization, 2000.

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radiation safety for staff in fluoroscopy suites · radiation safety for staff in fluoroscopy...

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