PMSNA SB9706 AAPM SS – 1 Fluoroscopic Radiation Safety Stephen Balter, Ph.D. AAPM Summer School – June 1997 § § Presentation originally developed with the support of Philips Medical Systems Reproduced courtesy of Philips Edited June 2002

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PMSNA SB9706 AAPM SS – 3 Educational objective Introduce basic concepts of: –Radiation quantities and units –Fluoroscopic system operation –Radiation bioeffects –Radiation hygiene to operators performing fluoroscopically guided invasive procedures.

PMSNA SB9706 AAPM SS – 4 Exposure Measure of the amount of radiation at a point (Roentgens) {Air KERMA}

PMSNA SB9706 AAPM SS – 5 Dose Energy absorbed by matter at a point {gray (Gy)}

PMSNA SB9706 AAPM SS – 6 Irradiation

PMSNA SB9706 AAPM SS – 7 Contamination

PMSNA SB9706 AAPM SS – 8 Patient entrance skin dose Skin effects can start at less than 1 hour of fluoroscopy

PMSNA SB9706 AAPM SS – 9 Image receptor dose Image Noise

PMSNA SB9706 AAPM SS – 10 Ionizing Radiation 3 eV required for ionization in tissue (UV and higher energies) Diagnostic X-rays 20, ,000 eV

PMSNA SB9706 AAPM SS – 11 Stochastic effects Probability proportional to dose Severity independent of dose Assumed zero threshold Risks are Radiogenic Cancer and Genetic Damage

PMSNA SB9706 AAPM SS – 12 Deterministic effects Certainty of effect Severity is a function of dose Substantial threshold High dose risks are: hair loss, skin damage, cataracts, and congenital abnormalities

PMSNA SB9706 AAPM SS – 13 Hair loss due to radiation

PMSNA SB9706 AAPM SS – 14 A very rare example of a major burn (estimated 10++ Gy)

PMSNA SB9706 AAPM SS – 15 Follow up times Most radiation effects will NOT be seen during hospitalization. Injury expression: Days – Years It is highly likely that their occurrence is under-reported.

PMSNA SB9706 AAPM SS – 16 Benefit – Risk The risk of deterministic injury must be balanced against clinical benefit. If such effects are anticipated and planned for, they might be considered side-effects rather than complications. Patient consent should be considered when planning complex or multiple procedures.

PMSNA SB9706 AAPM SS – 17 Patient dose record keeping Information should be recorded in the patient’s record which permits estimation of the absorbed dose to the skin (FDA 1994) Long and complex procedures Multiple procedures

PMSNA SB9706 AAPM SS – 18 Mobile fluoroscopic system X-ray Tube & Collimator Image Intensifier & Video Pickup Radiation & Collimator Controls

PMSNA SB9706 AAPM SS – 19 Automatic dose rate control

PMSNA SB9706 AAPM SS – 20 Fluoroscopy ONLY to observe motion

PMSNA SB9706 AAPM SS – 21 Fluorography (Acquisition) ONLY for later clinical review

PMSNA SB9706 AAPM SS – 22 Collimation

PMSNA SB9706 AAPM SS – 23 Patient - image intensifier distance

PMSNA SB9706 AAPM SS – 24 Distance effect

PMSNA SB9706 AAPM SS – 25 Step back for safety

PMSNA SB9706 AAPM SS – 26 Time Radiation is only produced when the beam is on! Irradiate only when it is necessary to observe motion. Last-image-hold and instant replay can usually save dose.

PMSNA SB9706 AAPM SS – 27 Shielding Protective shielding can markedly reduce staff risk. (when used!) Structural Shielding Mobile Shielding Personal Shielding

PMSNA SB9706 AAPM SS – 28 Protective Clothing Well tailored apron Thyroid collar Eye protection ? Gloves ?

PMSNA SB9706 AAPM SS – 29 Hand exposure Chronic overexposure of the operators’ hands is a significant hazard. Clinical necessity? Improper tools? Poor Work Habits

PMSNA SB9706 AAPM SS – 30 No bony fingers Exit BeamPrimary (raw) Beam

PMSNA SB9706 AAPM SS – 31 Personnel monitoring For your benefit Readings should correlate with workload Over-lead monitor on midline at neck level (Under-lead monitor on midline at waist level) Weighted average for estimating stochastic risk

PMSNA SB9706 AAPM SS – 32 ALARA As Low As Reasonably Achievable Radiation risk similar to other ‘normal’risks (e.g. where to live). Effective Dose (E) < = Variations in Background

PMSNA SB9706 AAPM SS – 33 Fluoroscopic safety management program A safe environment for patient and staff (not just radiation) An appropriate level of image quality Minimize waste radiation. Radiation information for continuing patient risk-benefit assessment ALARA for staff