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Physician Credentialing for the Use of Fluoroscopy

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Physician Credentialing for the Use of Fluoroscopy Physician Credentialing For the Use of Fluoroscopy Kim James RT-R, CV,CT, QA Coordinator CaroMont Imaging Services Edited by Jennifer Helton, RT-R, 2013 1 Preface • The following guidelines will aid physicians in minimizing the use of ionizing radiation in fluoroscopically guided procedures. • Physicians should be aware of the potential for serious radiation induced skin injury. • The following tutorial will advise you in the techniques to optimize the use of the C-arm and radiation protection practices thereby reducing the radiation dose to the patient, staff and yourself. • It is the physician’s obligation to protect the staff and the patient from over exposure to radiation. 2 Preface The North Carolina Radiation Protection Commission statue .0603 General Requirements (B) states ”Individuals who will be operating the x-ray equipment shall be instructed on the safe operating procedures and use of equipment and demonstrate an understanding there of.” 3 Definitions • ABC: (Automatic brightness control); The ABC compensates brightness loss caused by decreased image intensifier radiation reception by generating more X-rays (increasing mA) and/or producing more penetrating X-rays (increasing kVp). Conversely, when the image is too bright, the ABC compensates by reducing mA and decreasing kVp. • Interpolation: Sometimes called re-sampling is an imaging method to increase (or decrease) the number of pixels in a digital image. • Air Kerma: Is another radiation quantity that is sometimes used to express the radiation concentration delivered to a point, such as the entrance surface of a patient's body. • DAP: (Dose Area Product); The dose-area product is a measurement of the amount of radiation that the patient absorbs. 4 Definitions Inverse square law: The intensity or dose of the radiation emitted from the source of the X-ray beam diminishes with the square of its distance from the source. If you double the distance, the dose decreases to a factor of ¼. For example, if you received 8rads of radiation at 2ft., you would only receive 2rads of radiation at 4ft. MPD: Maximum Permissible Dose 5 ALARA • ALARA concept: – ALARA stands for As Low As Reasonably Achievable. – Because some risk, however small, exists from any radiation dose, all doses should be kept ALARA. – Includes reducing both internal and external radiation dose. – ALARA is the responsibility of all personnel involved in radiographic procedures. 6 Equipment Quality Control When new equipment is installed it must be tested by a medical physicist. The equipment must meet FDA and state regulatory requirements, manufacturers specifications, and lowest radiation dose level settings to produce image quality. • Fluoroscopic equipment must be maintained in good working order with all electrical and radiation safety features within regulatory compliance. Annual inspections are performed by a medical physicist to ensure radiation safety and image quality. •Preventive maintenance is performed on an annual basis by a qualified service engineer. Tests will include proper calibration of the x-ray tube and the x-ray generator. 7 Units of Radiation Radiation is measured in units: • Roentgen - unit of radiation exposure in air • Rad - energy absorbed per gram of tissue • Rem - biological effect of a rad 8 Known Biological Effects of Radiation 1. Marrow depression 100 Rads 2. Cataracts 200 Rads 3. Erythema 200 Rads 4. Temporary reduced fertility 250 Rads in males 150 Rads in females 5. Permanent sterility 500 Rads in males 600 Rads in females 6. Birth defects in human fetus 10 Rads in first trimester 9 Exposure Limits • All persons who are associated with the operation of an x-ray system are subject to the occupational exposure limits. • The annual limit is the total effective dose equivalent, which is equal to 5 rems . 10 Exposure Limits MPD (mrem/yr) ALARA Whole Body 5,000 500 (head,trunk, arms above elbows, legs above knees) Extremeties 50,000 5,000 (arms below elbow, legs below knee) Individual organs; skin 50,000 5,000 Lens of the eye 15,000 1,500 Embryo / Fetus: 500 mrem over ≯ 50 mrem/month 9 months; 11 Protective Clothing, Equipment and Monitoring • Lead Aprons: Must be worn by physicians and ancillary staff in a room where fluoroscopy is performed. The myth that a lead apron is worn to stop radiation is false, the truth being that it can only reduce the amount of radiation exposure to an acceptable level. Radiation loses energy and intensity as it passes through lead and will most likely be absorbed in the body tissue. • Thyroid shields and leaded glasses: added protection against cataracts and thyroid problems. • Personal dosimeters: collar and waist badges must be worn during fluoroscopic procedures to measure occupational exposure • Control badges 12 Protective Clothing and Equipment • RADPADS may be placed on the patient before creating a sterile field. RADPAD shields and drapes reduce harmful scatter radiation by as much as 95%. Sterile and disposable RADPAD Shields are effective in reducing scatter radiation in medical intervention utilizing x-radiation. • Sterile, lead-free and repositionable, RADPAD shields are placed directly on the patient to provide the physician or technologist with moveable protective device in which to work. 13 Cardinal Principles of Radiation Safety • Time The less time spent near the radiation source, the less radiation received. • Distance Inverse Square Law = double the distance, 1/4 the dose • Shielding -Aprons: 0.25 – 0.5 mm lead equivalent, -Thyroid collar, lead glasses, lead eye protection -Ceiling mounted, rollaway shields, and RADPADS 14 The Most Common Sense Principle DISTANCE - One step back from tableside: cuts exposure by factor of 4 - Lateral fluoroscopy: 5x less dose on Image Intensifier side - Moving Image Intensifier closer to patient: the patient skin exposure is lessened there is less scatter radiation creating a sharper image - Source to Skin Distance (SSD): 38 cm for stationary fluoroscopes 30 cm for C-arm fluoroscopes - Distance is the most effective means of radiation protection. 15 Radiation Exposure Reduction Patient dose is directly proportional to the time your foot remains pressed on the fluoro pedal. 16 Best Radiation Exposure Reduction Practices 1. Distance from source 2. Collimation 3. Automatic Brightness control 4. Pulse Rate Reduction 5. Tube Angulation 6. Last Image Hold 7. Skin Entrance Dose Monitoring 17 The inverse square law The Xray tube should be as far away from the patient as possible and the image intensifier as close to the patient as possible. Patient moved closer to x-ray 30cm tube. 2 R/min 60cm 8 R/min 60cm 30cm Exposure rate quadruples “Ideal” setup when the patient to focal spot distance is halved! 18 Collimation Restrict the x-ray field of view by using collimation. “Cone down” to the area of interest. Avoid irradiation of irrelevant anatomy, this reduces the volume of tissue irradiated, and reduces x-ray scatter, it also improves image quality by reducing scatter. reduced x-ray field size typical collimator control buttons on collimators the control panel uncollimated collimated x-ray beam x-ray beam 19 Automatic Brightness Control •Use the settings which give the lowest patient entrance exposure rates consistent with acceptable image quality. •Choose high kV / low mA options when available •“Record” modes such as cine, DA, and DSA produce the highest quality (lowest noise) images. .**CAUTION!: Use high dose rate or “boost” fluoro modes as infrequently as possible. These double patient entrance exposure rates and are designed for situations when normal fluoro images are too noisy to properly carry out a procedure. They are almost never needed. It is a legal requirement that a continuous audible beeping signal be heard whenever the fluoro pedal is depressed in high dose or boost mode. 20 Magnification Modes Use electronic magnification (MAG) modes sparingly. • MAG modes allow for the magnification of small areas for better visualization. Although a smaller volume of tissue is irradiated in MAG mode, the radiation intensity roughly doubles with each step up in magnification. MAG mode Relative Exposure Rates Normal 1 MAG1 2 x normal MAG2 4 x normal 21 Pulse rate reduction For pulsed fluoro units, use the lowest pulse rate consistent with the resolution requirements of the procedure during cine and DSA applications. mA mA Lower Pt Dose time time Insertion of guide wires and similar procedures can usually be performed at low pulse rates - 15 or 7.5 pps (pulses per second). Even lower rates can be used if fluoro image interpolation is available or the physician has a high tolerance for jerky images and flicker. 22 Last image hold C-arms at Caromont Regional come with a last image hold feature. The last image that was taken will remain on the TV monitor after the release of the fluoro pedal. This allows the fluoroscopist to view the image so that decisions and discussions about the image can occur with the radiation off. Image still present Foot off pedal 23 Variation of x-ray tube angulation When long fluoro times are anticipated (greater than approximately 15 min of actual x-ray beam “on” time) the tube angle should be changed so that the same area of skin is not under constant irradiation. Even small changes in tube angle can spread the dose over a wider area due to the curvature of the body. Always bear in mind that larger patients always receive higher dose rates. 24 Patient and Tube Positioning To reduce the chance of the patient receiving a significant skin dose, the patient should be placed as close to the image intensifier as possible. The x-ray tube should be as far away as possible from the patient. Ideal Can be dangerous due as a result of the inverse square law. 25 Dose-area product The dose-area product is a measurement of the amount of radiation that the patient absorbs.
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