Practical aspects of setting up a Cardiac PET service Caroline Hurley

Rubidium-82? Rubidium-82 is a generator produced isotope from the decay of strontium-82 Rb-82 has T ½ of 75 seconds Potassium analogue, good uptake in Cardiac muscle, with images possible from 2 minutes. Short half life means the patient can be repeated with a stress scan after 10 minutes. Rubidium-82 is a generator produced isotope from the decay of strontium-82. It is eluted into normal saline and injected direct into the patient. Rb-82 has T ½ of 75 seconds and is a potassium analogue so had good cardiac uptake and images of the cardiac muscle are possible form two minutes. The short half life of 75 seconds mean that the patient can be repeated with a stress scan after 10 minutes with the same dose, and the patient is not radioactive at the end of imaging.

Scanning sequence Topogram Ca Score AC CT AC CT Rest 7min Stress 7min Adenosine Imaging starts with an initial topogram to identify the heart and set the limits for the CT and PET images. At this point you could add in additional CT information with a calcium score CT, this is followed by the Attenuation correction CT. The bed then moves into the PET position. After the CT we enter the scan room to start the Rubidium infusion while simultaneously starting the images from the control room. WE exit the scan room during imaging. We repeat the process for the stress starting the adenosine infusion 2 minutes before starting the rubidium. Occasionally we may need a second attenuation correction CT and the end. ? Contrast CT. Rb-82 infusion Rb -82 infusion 10 minute interval

Scheduling 39-43 cardiac scans per week 32 FDG -28 Oncology - 4 other Mon Tues Wed Thur Fri 7:00-8:30 Rubidium Cart QC and PETCT QC 8:30 - 12:00 6 Rb 7 Rb 7Rb 4 Rb 12:30 16:30 3 Rb 4 FDG 3 FDG 20:30 39-43 cardiac scans per week 32 FDG -28 Oncology - 4 other (cardiac viability, infection imaging, Brain imaging) Paediatric Imaging F-Dopa with GA Since January 11 we have extended the cardiac service, to 37 patients per week, and around 25 oncology patients per week. We have accommodated this with 3 extended days with the oncology service in the evening. And two standard days. Smooth running requires a team of people. A technician or nurse to prepare the patient and canulate. A technician in the control room setting up the images and checking registration and staring the reconstructions. A technician to position the patients and deal with the patients in the recovery area. And a trained person to administer the stress in our department this can be either a doctor, nurse or technician, and this person usually prepares the infusion system on the rubidium cart and the adenosine infusion. The day runs best with 2 people sharing the stressing.

Staffing 2 Stressors - either Nurse, Technician or Doctor alternate patients 2/3 Technicians Computer Camera set up Patient prep 1 Technician QC

QC tests Rubidium QC Wash,Strontium level test and calibration elution PET and CT QC tests 1hour measurement of strontium level test

CardioGen-82 generator and cart Generator sits inside a shielded container in the cart Automatic infusion system Positron detector Control Panel The generator is housed inside a shielded container in the cardioGen cart. There is another shielded container which contains the waste. On the front of the Cart is the control panel for the automatic infusion system. When the infusion is started, saline is pumped down into the generator and the Rubidium chloride is taken back up to the valve shield and passes over the positron detector, this initial part of the elutant will be directed back down into the cart into the waste container. When the elute reaches a dose rate of 1millicuri per second, the valve will switch from the waste to the patient until the full dose is delivered, then the will stop and the valve will switch back to waste. The initial part of the elution which goes to waste is well shielded and typically takes about 10 seconds which is enough time for the operator to leave the room. The imaging is started form the control room. Generator needs a cart which houses the generator in a shielded container and a was

Position of the cart Space at the PET side of the camera for the cart. Socket Space for gloves, admin sets, wipes, saline Stress infusion pump Clear exit route The generator cart is positioned at the PET side of the camera. ? 1m of line to reach the patient, socket. Space for gloves, cleaning wipes, admin sets and syringes and Saline to prime the new lines Space for the stress equipment, infusion pump for adenosine, After each patient the terminal part of the infusion system is changed. Equipment to clean down the area and prime the new line with saline and attach the new line using good aseptic technique. Also need somewhere to store the used lines.

Remote Monitoring 12 lead ECG with remote monitoring Integrated BP monitoring CCTV Timers Intercom Emergency equipment Oxygen Cardiosoft 12 lead ECG system. We did try a an ECG equipment in the room visualised by CCTV but that didn’t. work very well. Purchased cardiosoft where the ECG is beemed to a PC in the control room. So when we leave the camera room we can keep a close eye on the ECG from the control room and we can initiate addition BP measurement if required. CCTC to identify the end of the Rubidium infusion and start a timer for 10 minutes, and to monitor the patient during the scans. Intercom – but we try to complete the scan in silence as taking tends to cause movement.

Preparation room Explain procedure Check preparation instructions have been followed Identify any concerns Attach ECG Cannula (18G) The key to completing the scan without having to talk through the scan is good preparation. So you need a separate room to explane the procedure, attach ECG leads, canulate. Identify any concerns regarding claustrophobia, arm position The room we use is actually an FDG dispensing room. This is not ideal too cramped doesn’t had an alarm call.

Recovery room Remove the cannula Space for the patient to get dressed Final check that the Patient feeling well. Slick turn around time 30 min in camera room.

Image Registration Images are acquired in list mode A static reconstruction is made during imaging from 3-4min. Adjust the registration between the PET data and the CT data Reconstruction of Static, Gated and dynamic data sets Images are acquired in list mode. The first Static reconstruction is complete before the end on imaging and is used to check the PET registration with the CT image. WE can adjust the registration if necessary. This initial CT is also used to for the stress scan. If registration is good, and it usually is, then a second CT not needed and this is decieded before the imaging sequence is complete.

Expiry of generator 42 days post calibration date or A total volume of 17Litres has passed through the generator column An elute Sr-82 level of 0.01µCi /mCi of Rb-82 or An elute Sr-85 level of 0.1µCi /mCi of Rb-82. Alert Limit 14 litres of elution volume has passed over the column or Sr-82 level reaches 0.002µCi per mCi of Rb-82 or Sr-85 level reaches 0.02µCi per mCi of Rb-82

And Finally.. Generator change Day Waste Return of the Generators – CAA approved training

Thank you Thank you Film editor Matthew Memmott Louise Crook as The Patient