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Radiation
- 1. Justin McWilliams, MD AssistantProfessor Interventional Radiology
- 2.  You need a lateral view. Is it better to rotate the image intensifier toward you or away from you?  Why is fluoro time a poor indicator of radiation exposure ?  How many Grays of radiation puts the patient at risk for skin injury?  A 5-second DSA run uses how much more radiation than 5 seconds of fluoro?  A typical embolization procedure exposes the patient to how many CXRs worth of radiation?  What is the increased cancer risk of such a procedure?  What is the cancer risk to the operator if he does 1 embo procedure per working day for 30 years?
- 3.  Radiation exposure  Radiation effects  Minimizing radiation to the patient  Minimizing radiation to you
- 5.  X-rays are produced by accelerating electrons through high voltage (50- 150 kVp) applied to a tungsten target in an X-ray tube  Amount of X-rays produced are determined by tube current (mA) and the tube voltage (kVp)
- 6.  Dose is not administered uniformly throughout the patient’s body  Radiation field is moved, angled, collimated  Both fluoro and DSA are used  Four metrics are used to estimate patient radiation dose  Fluoro time  Peak skin dose (not yet measured by equipment)  Reference dose (air kerma)  Dose-area product (DAP)
- 7.  Also called “cumulative dose”  The Air Kerma for the entire procedure, measured in Gy at a fixed reference point near the isocenter of the tube  Does not account that the radiation field is moved to different areas of the patient during the procedure  Conservative, generally overstates risk  Measurement is likely accurate to within +/- 50%
- 8.  Measure of total X-ray energy absorbed by the patient  Basically the air kerma (dose) multiplied by the area of body exposed (area)
- 9.  Fluoro time is only a very rough indicator of radiation dose, affected by:  Patient size  Beam location  Beam angle  Normal vs. high dose rate  Distance of tube from the patient  These can all add up to 10-fold difference in dose for the same fluoro time!
- 10. DOSE-AREA PRODUCT (DAP) CUMULATIVE AIR KERMA  Product of the air kerma and the  Air kerma = Kinetic Energy exposed area (in cm2) Released per unit Mass of Air; basically, how much radiation dose  Good measure of stochastic risk is being delivered at a specific (cancer risk) because it estimates point (about where the patient’s total radiation energy delivered to skin is) a patient  Also known as reference dose or  Poor estimator of skin dose and cumulative dose deterministic effects  large dose over small area or small  Easy to measure, expressed in Gy dose over large area?  Absorbed dose in tissue will be  Unit of measurement (Gy-cm2) about equal to the air kerma at does not translate into standard that point units of dose (hard to use)  Notification threshold = 3 Gy
- 12.  Patients and staff are exposed to radiation, but only a portion is absorbed into the body  Absorbed dose is measured in Gray or rads  1 Gray = 100 rads  Approximate radiation doses:  Fluoro = 2-10 rads/min  CXR = 0.02 rads  CT abdomen = about 2-10 rads  Natural background radiation = 0.3 rads/year
- 13.  Different forms of radiation (X-rays, alpha particles, etc) produce different biologic effects for same absorbed dose  Dose equivalent (rem or Sievert) is used to measure biologic “harmfulness” of a radiation dose  For diagnostic X-rays, 1 rem = 1 rad and 1 Gy = 1 Sv
- 14.  Effective dose is the dose equivalent to the whole body caused by irradiating just a localized area  This is calculated by multiplying the dose to each irradiated organ by a weighting factor based on the radiosensitivity of that organ  Example effective doses:  CXR = ~0.1 mSv  PTA = 10-20 msV  Biliary drainage = 40 mSv  Transcatheter embolization or TIPS = 50-100 mSv  Additional cancer risk = ~5%/Sv  So, a long embolization procedure in a 30 year old increases risk of developing a fatal cancer by about 0.5%
- 15.  Fluoro machines operate in automatic brightness control  When brightness of picture is inadequate, the ABC automatically increases mA or kVp (or both) to increase X-ray penetration  Large patients = more dose than small patients (up to 4-10x higher!)  Abdominal fluoro = more dose than chest fluoro  Oblique fluoro = more dose than AP fluoro
- 16.  Direct exposure rate refers to entrance skin exposure where the X-ray beam enters the patient  2-10 rads/min for fluoro  ~50 rads/min for DSA  30 mins of fluoro = 60-300 rads = 0.6-3 Gy
- 17.  Indirect exposure rate refers to exposure to the staff from scattered radiation from the patient  ~1/1000 of the skin entrance exposure rate at a distance of 1 meter  Large patients increase scatter radiation  Larger field (not collimated) increases scatter  Scatter much higher on the X-ray tube side of the patient ▪ For lateral view, stand next to II, not next to tube!
- 19.  Radiation effects with a threshold dose; effect is not observed unless threshold is exceeded
- 22.  Early erythema – 3 Gy – 1-2 days – sunburn  Epilation – 3-7 Gy – 3 weeks – hair loss  Main erythema – 10 Gy - onset 1-4 weeks – burning, itching  If >14 Gy, progresses to dry desquamation 1 week later  If >18 Gy, progresses to moist desquamation (blistering, sloughing) 1 week later  Ulceration – 24 Gy – 2-12 months
- 23.  No threshold  Any dose increases the chance of the effect, with higher doses increasing the chances  Radiation-induced cancer
- 24.  Approximate additional risk of fatal cancer for an adult for an examination:  Extremity X-ray: <1/1,000,000  CXR: 1/100,000 to 1/1,000,000  Chest CT: 1/10,000 to 1/1,000  Multiphase abdominal CT: 1/1,000 to 1/500  These risks are additive to the ~25% background risk of dying of cancer
- 26.  Very small (<10 kg) or very large (>135 kg) patients  Age (3x risk for newborns, 1x risk at age 25, 0.2x risk for patients in 60s)  Pregnant patients  Prior radiation exposure within last 2 months  Diabetes, autoimmune diseases, connective tissue diseases increase risk of skin effects
- 27.  Ultrasound instead of fluoro when possible (biliary, arterial access)  Patient should be as far from tube, and as close to II, as possible (good to be tall!)  Don’t step on the pedal  Pulse fluoro mode (7.5 or 15 frames/sec instead of 30/sec)  View and save images with “last image hold”  Exclude bone from the image
- 28.  Collimate to smallest field of view possible  Avoid exposure to eyes, thyroid and gonads  Position and collimate without fluoro  5-8% of radiation exposure is delivered during preparation for imaging, positioning the table and adjusting collimators  Avoid magnification  ABC uses more radiation to brighten and sharpen the image in mag view  Avoid high-dose or detail modes  Use higher kVp (but can reduce contrast)  Minimize overlap of fields and repeated acquisitions
- 32.  Less time on the pedal  Use last image hold  Pulsed fluoro  Low dose fluoro
- 33.  Inverse square law  Double distance from patient = ¼ the radiation dose from scatter radiation  Nonessential personnel should be outside a 6-foot radius from the X-ray source  Step out of room for DSA runs
- 34.  Lead apron (0.5 mm Pb equivalent) blocks about 95% of scatter radiation  Thyroid shield, leaded glasses are essential  Most radiosensitive organs  Lead drapes and clear leaded glass barriers
- 36.  Record dose in the medical record  If dose exceeded deterministic thresholds  Discuss possible effects and management with patient  Have patient or family member notify IR if deterministic effects occur  Institute a clinical follow-up plan for the patient
- 37.  Necessary when large radiation dose was used  Telephone call at 2 weeks or so  Redness? Blistering? Hair loss?  Location of radiation field  May need follow up for >1 year
- 39.  You need a lateral view. Is it better to rotate the image intensifier toward you or away from you?
- 40.  You need a lateral view. Is it better to rotate the image intensifier toward you or away from you?  Toward you! Keep the beam away from you, because most of the scatter occurs at the point the beam enters the patient
- 41.  Why is fluoro time a poor indicator of radiation exposure ?
- 42.  Why is fluoro time a poor indicator of radiation exposure?  Does not include DSA runs  Dose varies greatly for the same fluoro time  Thin or obese patient  AP or oblique views  Magnification  Distance from X-ray source
- 43.  How many Grays of radiation puts the patient at risk for skin injury?
- 44.  How many Grays of radiation puts the patient at risk for skin injury?  3 Grays!
- 45.  A 5-second DSA run uses how much more radiation than 5 seconds of fluoro?
- 46.  A 5-second DSA run uses how much more radiation than 5 seconds of fluoro?  About 10x more radiation for DSA!
- 47.  A typical embolization procedure exposes the patient to how many CXRs worth of radiation?  What is the increased cancer risk of such a procedure?  What is the cancer risk to the operator if he does 1 embo procedure per working day for 30 years?
- 48.  A typical embolization procedure exposes the patient to how many CXRs worth of radiation? About 1000!  What is the increased cancer risk of such a procedure? About 0.5% for a 30 year old!  What is the cancer risk to the operator if he does 1 embo procedure per working day for 25 years? 100 mSv (patient equivalent dose) x 1/250 (scatter fraction at 18 inches) x 1/20 (fraction of radiation that gets through the lead) x 5000 (# of procedures) = 100 mSv A career in IR is probably equivalent to having an embolization procedure done on yourself (0.5% additional cancer risk)
- 49.  Mitchell E and Furey P. Prevention of radiation injury from medical imaging. J Vasc Surg 2011; 53:22S-27S.  Miller D, et al. Clinical radiation management for fluoroscopically guided interventional procedures. Radiology 2010;257:321-332.  Cousins C and Sharp C. Medical interventional procedures – reducing the radiation risks. Clin Radiol 2004;59:468-473.  Wagner L. Angiography radiation dose – limiting dose to the patient while maintaining effective image quality. http://www.uth.tmc.edu/radiology/RSNA/2008/RSNA_wa gner_2008.pdf