Good working practice in Cath lab and OT

procedure with fluoroscopy

Dr (Smt) REENA SHARMA

RADIOLOGICAL PHYSICS & ADVISORY DIVISION

BHABHA ATOMIC RESEARCH CENTRE

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 US NCRP Report 160
(Radiation Exposure to the US Population)
2

Occupational doses in
interventional
procedures are the
highest among medical
staff using X rays

To achieve ALARA,
protection tools and
good operational
measures are required
 Use of Fluoroscopy in various exams
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 Barium X-rays.
 Cardiac catheterization
 Electrophysiologic procedures
 Arthrography
 Placement of IV (intravenous) or arterial catheters
 Hysterosalpingogram
 Percutaneous vertebroplasty
 Retrograde urethrogram
 Fistulography
 Good working practice focuses on
optimization which involves
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 Knowledge of various factors contributing to

patient and staff radiation dose
patient factors
procedural factors
equipment factors

 Periodic update of clinical and technical

working protocols
 Two technologies:
Image intensifier and Flat panel detector
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 Video Signal

Video
Camera Readout Electronics

Electrons
2,400

Motorized CCD or PUT

Iris Light
400,000

Output screen Digital Data

Electrons
400
Read Out Electronics

Image Photo-cathode

Intensifier

DETECTOR
Light Electrons
3,000 Amorphous Silicon Panel
(Photodiode/Transistor Array)
Cesium Iodide (CsI)

1
Light
Cesium Iodide (CsI)
Photons Particles #

Photons
Image Intensifier
Flat-panel

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 Patient factors
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 Establish standard protocols

(Dose monitoring/Limits on fluoroscopic
exposure time)

 Know dose rates of equipment

 Assessment/modification of the procedure

protocol to avoid potential radiation injury
 Patient factors
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 Use of pulsed fluoroscopy (variable frame rate)

 Low tube current

 Less radiation, less exposure

 Higher kVp
–Higher voltage causes radiation to go through
patient; less absorption; less skin dose
–Balance contrast and distance
 Patient factors
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 Distance
 Keep image intensifier as close to patient as
possible
 Increase distance from x-ray tube to patient

 Field of view
 Collimate to reduce field of view to region of
interest
 Limit use of magnification techniques
 Magnification increases patient dose
 Collimation (FOV)
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 Intensifier Diameter

Intensifier diameter Relative patient entrance

dose mSv/h

12’ (32 cm) Dose 100

9” (22 cm) Dose 150

6” (16 cm) Dose 200

4.5” (11 cm) Dose 300

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The smaller the image intensifier diameter, the greater the patient entrance dose
Magnification mode and Entrance skin dose
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(23/11)2 = 4.4
(23/15)2 = 2.4
 Patient factors
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 Last image hold

◦ Displays last image captured on monitor
 Beam on-time
◦ Intermittent fluoroscopy
◦ 5 minute reset timer
 Rotate fluoroscope around a center (do obliques and
laterals)
 Keep other body parts (arms, breasts) out of the x-ray
field
 Maintain logs to track trends in exposure and analyze
problems
 Use of additional “Cu” filter
 Additional Cu filters can
reduce the skin dose by
more than 70%
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Some systems offer

variable extra filtration
(0.2 mm - 0.9 mm) that is
automatically set
according to patient
weight and angulation of
the C-arm

Automatic filter
insertion should keep the
dose as low as possible
without degrading image
quality
 Pediatric Patients (No grid)
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 Higher heart rates,

 Smaller cardiovascular structures,
 Smaller body size, and
 Relatively lengthy and complex studies
 An advanced exposure control system, a constant
image quality can be maintained for all patient sizes,
leading to dose savings for babies and children of
up to 30%.
 Short pulse widths down to 4 ms are important to
reduce motion blurring artifacts
Transmission chamber for patient dose monitoring
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 Radiation Protection for the Operator
(Time)
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 Reduce the time you are exposed to radiation

 Fluoroscopist should use intermittent fluoroscopy

 Minimize beam-on time

 5 minute audible timer

 High dose fluoroscopy requires audible signal

while on
 Use last image hold

 Use pulsed technique

 Distance and machine positioning
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 Scattered radiation-X-ray tube position
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Staff exposed to reduced

Staff exposed to
radiation
increased radiation
 Radiation Protection for the Operator (Distance)
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 Inverse square law

 The exposure is inversely proportional to the
square of the distance from the source of
radiation (scattered radiation from the patient).
 To minimize exposure, stand as far away from
the patient as practical

 Do not put any part of your body in the primary

beam
 Radiation Protection for the Operator
(Shielding)
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 Lead aprons (0.5mm Pb equivalent)

 Thyroid collars

 Lead gloves

 Leaded glasses
 Radiation: Protective clothing
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 Gloves: 60–64% protection at 52–58 KV

 Eye protection: 0.15 mm lead-equivalent goggles

provide 70% attenuation of radiographic beam

 Thyroid collar: 2.5-fold decrease in scattered

radiation

 Leaded apron: AP: 16-fold decrease in scattered

radiation

Lateral: 4-fold decrease in scattered radiation

Devalla KL, Guha A, Devadoss VG (2004)

 Zero-Gravity (No weight concept)

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Ceiling suspended gantry with apron suite

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 Conclusions
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 Minimize beam-on time, both for fluoroscopy and acquisition (cine)

 Use optimal beam collimation
 Position of the X ray source and image receptor optimally
 Use of the least degree of image magnification required for
accurate interpretation
 Understand and utilize the X ray dose-reduction features provided
by the X ray unit
 Vary the site of the radiation entrance port
 Record the estimated dose delivered to the patient
 Maintain X ray equipment
 Select X ray units with sophisticated dose-reduction and monitoring
features