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Part 8. IAEA Training Material on Radiation Protection in Nuclear Medicine. Radiation Protection in Radionuclide Therapy. Objective.

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Part 8

Part 8

IAEA Training Material on Radiation Protection in Nuclear Medicine

Radiation Protection inRadionuclide Therapy


Objective

Objective

To be able to apply the principle ofoptimization of radiationprotection to therapeutic proceduresincluding design,operational consideration, quality control and clinical dosimetry.

Part 8. Therapy


Contents

Contents

  • Basic requirements

  • Administration of therapy

  • The radioactive patient. Dose constraints

  • The hospitalized patient

  • Emergency procedures

Part 8. Therapy


Part 8 optimization of protection in medical exposure

IAEA Training Material on Radiation Protection in Nuclear Medicine

Part 8Optimization of Protection in Medical Exposure

Module 8.1 Basic Requirements


Justification of medical exposure bss interim edition 2011

Justification of Medical Exposure (BSS: Interim Edition, 2011)

“3.154. Medical exposures shall be justified by weighing the expected diagnostic or therapeutic benefits that they yield against the radiation detriment that they might cause, with account taken of the benefits and the risks of available alternative techniques that do not involve medical exposure.”

Use WHO guidelines

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Responsibilities bss interim edition

Responsibilities (BSS: Interim Edition)

”3.164. For therapeutic radiological procedures in which radiopharmaceuticals are administered, the radiological medical practitioner, in cooperation with the medical physicist and the medical radiation technologist, and if appropriate with the radiopharmacist or radiochemist, shall ensure that for each patient the appropriate radiopharmaceutical with the appropriate activity is selected and administered so that the radioactivity is primarily localized in the organ(s) of interest, while the radioactivity in the rest of the body is kept as low as reasonably achievable.”

Part 8. Therapy


Dosimetry bss interim edition

Dosimetry (BSS: Interim Edition)

“3.167. Registrants and licensees shall ensure that dosimetry of patients is performed and documented by or under the supervision of a medical physicist, using calibrated dosimeters and following internationally accepted or nationally accepted protocols, including dosimetry to determine the following:

  • …..

  • (c) For therapeutic medical exposures, absorbed doses to the tissues or organs for individual patients, as determined to be relevant by the radiological medical practitioner.”

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Medical physicist

Medical Physicist

A qualified medical physicist should be responsible for

measurement of radionuclide activity, identification of

radionuclides and internal radiation dosimetry

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Absorbed dose administered activity i 131

Absorbed Dose-Administered ActivityI-131

Example of method to calculate administered activity from

Prescribed absorbed dose to the thyroid

Activity (MBq)=

23.4*mass(g)*dose (Gy)

uptake at t=0 (%)*Teff (d)

Berg GEB et al, J Nucl Med 1996; 37:228-232

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Uptake measurement

Uptake Measurement

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Gamma camera examination

Gamma Camera Examination

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Gamma camera examination1

Gamma Camera Examination

Used to determine the size of the organ

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Factors affecting safety in radionuclide therapy

Factors Affecting Safety in Radionuclide Therapy

Safe handling of

radionuclides

  • ordering

  • receipt and unpacking

  • storage

  • dispensing

  • internal transports

  • radioactive waste

    Safe administration

  • Identification

  • pregnancy

  • breastfeeding

  • Patient preparation

  • The radioactive patient and dose constraints

  • The hospitalized patient

    • instructions to nursing staff

    • visitors instructions

    • discharge of the patient

    • decommissioning of hospital ward

    • radioactive waste

  • Emergency procedures

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Ordering receipt unpacking

Ordering, Receipt & Unpacking

  • The hospital routines for ordering radionuclides should

  • be followed.

  • When ordering, be sure the delivery service knows where

  • in the hospital to deliver the material.

  • Make sure that the package is expected and that no un-

  • authorized person will open it upon arrival.

  • Before unpacking, check the package. In case of damage,

  • contact your RPO.

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Storage of i 131

Storage of I-131

  • The radionuclide should be stored in a controlled

  • area, according to national regulations and local

  • rules.

  • The radionuclide should always be stored in a lead

  • container and preferably in a fridge to prevent evaporation

  • To reach an acceptable external dose rate,

  • a thickness of 1-4 cm lead is generally required.

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Dispensing

Dispensing

  • Protective clothing

  • Lead shields (bench top shield,

  • vial shield, syringe shield)

  • Keep the vial in the fume hood

  • and on a tray with lips, lined with

  • plastic backed absorbent pads.

  • Handle the vial with forceps or

  • similar long handled instruments.

  • Cover the vial with lead after use.

  • Check the activity

  • Fill in the necessary records

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Internal transport

Internal Transport

If the administration of radiopharmaceutical to the patient takes

place far from the dispensing room, use a transport container with

absorbent pads.

Make sure that a warning sign is on the container together

with patient name, activity and date.

Travel by the most direct route avoiding more heavily

occupied areas

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Radioactive waste

Radioactive Waste

Shall be collected, segregated and disposedof according to national regulations and localrules.

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Part 8 optimization of protection in medical exposure1

IAEA Training Material on Radiation Protection in Nuclear Medicine

Part 8Optimization of Protection in Medical Exposure

Module 8.2Administration of Therapy


Precautions before administration

Precautions Before Administration

  • Be prepared for an emergency situation.

  • Careful identification of the patient (hospital routines shall be followed).

  • Questions to the patient:

    -Pregnant?

    -Breastfeeding?

    -Incontinent?

    -Nausea?

    -Living conditions?

    -Type of work?

    -Public transportation back home?

  • Verbal and written individual instructions to the patient.

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Pregnancy bss interim edition

Pregnancy (BSS: Interim Edition)

  • “3.175. Registrants and licensees shall ensure that there are procedures in place for ascertaining the pregnancy status of a female patient of reproductive capacity before the performance of any radiological procedure that could result in a significant dose to the embryo or fetus, so that this information can be considered in the justification for the radiological procedure (para. 3.154 and 3.156) and in the optimization of protection and safety (para. 3.165).”

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Radioiodine therapy and pregnancy

Radioiodine Therapy and Pregnancy

Radioiodine easily crosses the placenta and therapeutic doses can pose significant problems for the fetus, particularly permanent hypothyroidism.

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Radioiodine therapy

Radioiodine Therapy

As a rule, a pregnant woman should not be treated with a radioactive substance unless the therapy is required to save her life: in that extremely rare event, the potential absorbed dose and risk to the fetus should be estimated and conveyed to the patient and the referring physician. Considerations may include terminating the pregnancy.

Part 8. Therapy


Radioiodine therapy1

Radioiodine Therapy

In women, thyroid carcinoma comprises over 80% of cancer of the head and neck diagnosed between the ages of 15-45 years. Thyroid cancers are relatively unaggressive compared to most other cancers. As a result both surgical and radio-iodine treatment are often delayed until after pregnancy. In general, if any therapy is to be performed during pregnancy, it will be surgery during the second or third trimester.

Part 8. Therapy


Inadvertent administration of therapy dose

Inadvertent Administration of Therapy Dose

Menstrual history is often not adequate to ensure that a patient is not pregnant. In most developed countries, it is common practice to obtain a pregnancy test prior to high-dose 131 I scanning or therapy for women of childbearing age unless there is a clear history of prior tuballigation or hysterectomy precluding pregnancy.

In spite of the above, it still happens that pregnant women are treated, either because of false histories or because the pregnancy is at such an early stage that the pregnancy test is not yet positive.

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Part 8

Becoming Pregnant after Irradiation

  • ICRP has recommended that a woman not become pregnant until the potential fetal dose fromremaining radionuclides is less than 1 mGy.

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Pregnancy after therapy

Pregnancy after Therapy

Radiopharmaceutical All activities Avoid pregnancy

up to (MBq) (months)

Au-198 colloid10000 2

I-131 iodide (thyroid ca)5000 4

I-131 iodide (thyrotoxicosis) 800 4

I-131 MIBG 5000 4

P-32 phosphate 200 3

Sr-89 chloride 150 24

Y-90 colloid (arthritic joints)400 0

Y-90 colloid (malignancy) 4000 1

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Breast feeding bss interim edition

Breast Feeding (BSS: Interim Edition)

  • “3.176. Registrants and licensees shall ensure that there are arrangements in place for establishing that a female patient is not breast-feeding before the performance of any radiological procedure involving the administration of a radiopharmaceutical that could result in a significant dose to an infant being breast-fed, so that this information can be considered in the justification for the radiological procedure (para. 3.154 and 3.156) and in the optimization of protection and safety (para. 3.165).”

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Breast feeding

Breast Feeding

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Patient information needed

Patient Information Needed:

  • Nausea-intravenous administration to

  • be considered?

  • Living conditions-number of people in house?-children?-separate room?

  • Type of work-working close to other people?-working with children?

  • -pregnant coworkers?

  • Public transport-time?

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Administration of therapy calibration of sources bss

Administration of Therapy:Calibration of Sources (BSS)

“3.166. In accordance with para. 3.153(d) and (e), the medical physicist shall ensure that:

  • (a) All sources giving rise to medical exposure are calibrated in terms of appropriate quantities using internationally accepted or nationally accepted protocols;

    3.164. For therapeutic radiological procedures in which radiopharmaceuticals are administered, the radiological medical practitioner, in cooperation with the medical physicist and the medical radiation technologist, and if appropriate with the radiopharmacist or radiochemist, shall ensure that for each patient the appropriate radiopharmaceutical with the appropriate activity is selected and administered so that the radioactivity is primarily localized in the organ(s) of interest, while the radioactivity in the rest of the body is kept as low as reasonably achievable.”

Part 8. Therapy


Safe administration

Safe Administration

  • I-131 should be administered in a controlled area (hot lab or the patient’s hospital bedroom).

  • A plastic bag for contaminated items should be available as well as paper tissues.

  • The patient is asked to sit at a table covered with adsorbent pads and the floor beneath the patient should also be covered by adsorbent pads.

  • If the I-131 is administered in capsules they should be transferred to the patient mouth by tipping from a small shielded (>1 cm Pb) container.

  • I-131 administered in an oral solution (50 ml) should be sucked up through a straw from the shielded vial by the patient. The vial should be flushed with water several times. The patient should drink several glasses of water to clean the mouth.

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Safe administration1

Safe Administration

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Safe administration2

Safe Administration

Procedure for intravenous administration:

  • Dispense the radionuclide into a shielded syringe

  • Put the radionuclide in an infusion bottle

  • Line the bottle to the patient using an intravenous catheter

  • Keep the patient in bed until the bottle is empty

  • Remove the bottle and the catheter and dispose of them as radioactive waste

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Part 8 optimization of protection in medical exposure2

IAEA Training Material on Radiation Protection in Nuclear Medicine

Part 8Optimization of Protection in Medical Exposure

Module 8.3 The Radioactive Patient: Dose Constraints


Shall the patient be hospitalized

Shall the Patient be Hospitalized?

Can the patient leave?

Any restrictions?

Part 8. Therapy


Dose constraints bss interim edition

Dose Constraints(BSS: Interim Edition)

“3.172. Registrants and licensees shall ensure that relevant dose constraints (para. 3.148(a)(i)) are used in the optimization of protection and safety in any procedure in which an individual acts as a carer or comforter.”

Part 8. Therapy


Dose limitation for comforters and visitors of patients

Dose Limitation for Comforters and Visitors of Patients

..The dose shall be constrained so that it is unlikely that his or

her dose will exceed 5 mSv during the period of a patient’s

diagnostic examination or treatment. The dose to children

visiting patients who have ingested radioactive materials should

be similarly constrained to less than 1 mSv

Part 8. Therapy


Exposures from patient

Exposures From Patient

Contamination External

saliva

perspiration

breath

urine

0.5 0.1 0.06 0.03 mSv/h

1000 MBq

I-131

0 0.5 1 2 m

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Biodistribution of i 131

Biodistribution of I-131

(MIRD)

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Excretion of i 131

Excretion of I-131

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Contamination

Contamination

Administered activity: 1000 MBq I-131

Excretion Concentration Contamination

Saliva <2 MBq/gutensils 2 kBq

Perspiration <20 Bq/cm2surfaces 10 Bq/cm2

Breathing 100 Bq/lair 1 Bq/l

Urine < 500 kBq/mltoilet 2 kBq/cm2

Generally larger than the derived limits for contamination

given by ICRP (publ 57)

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Exposures from patient1

Exposures from Patient

Sm-153

Activity concentration in urine: 0.3 MBq/ml*GBq

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External exposure from patient sm 153

External Exposure from PatientSm-153

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Restrictions

Restrictions

Patient with Iodine-131

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Restrictions1

Restrictions

Patient with Iodine-131

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Therapy patient

Therapy Patient

The dose to a family member staying at a distance of 0.5 meters from the patient until the radioactivity totally decays (about 10 weeks) is about 1.3 mGy from a hyperthyroid patient and 6.8 mGy from a thyroid cancer patient.

These patients must also be careful not to transfer radio-iodine contamination to family members by direct contact or through indirect means

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Measurements

Measurements

25 patients who received 220-600 MBq I-131

Husband/wife220-3100 μSv

Children110- 700 μSv

No correlation between administered activity and

doses to members of the family.

University Hospital, Gothenburg, Sweden

Part 8. Therapy


Therapy patient i 131

Therapy PatientI-131

The patient should be kept at least 2h,and if possible one day in the hospital.

In the case of cancer treatment, thepatientshould generally be hospitalized forseveral days.

In all cases, the dose rate at 1 m fromthepatient should be down to an acceptablelevelestablished by the RPC.

Part 8. Therapy


Patient survey

Patient Survey

Abdalla Al-Haj

Part 8. Therapy


Guidance level for maximum activity for patients in therapy on discharge from hospital

Guidance level for maximum activity for patients in therapy on discharge from hospital

Iodine-131 1100 MBq

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Hospitalization or not

Hospitalization or Not?

I-131

1100 MBq stay in hospital

stay in hospital or

discharged with individual restrictions

600 MBq

discharged with individual restrictions

150 MBq

discharged, general restrictions

Part 8. Therapy


Instructions to out patients

Instructions to Out-patients

  • No eating and drinking during the first hour after treatment.

  • During the following two days you should drink more than usual.

  • Use only a WC and flush 2-3 times. Keep the toilet and the floor clean.

  • Wash your hands frequently and take a shower every day.

  • Avoid close contact with members of the family, children and pregnant women according to the time table attached

  • Avoid solid waste

    Contact the Nuclear medicine department in case of problems

    or questions. Phone: …………

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Avoiding solid waste

Avoiding Solid Waste

Sensitive detectors at sanitary landfills and solid waste

transfer and processing sites have identified contaminated

articles from nuclear medicine patients.

  • Do not use paper plates or disposable cups or flatware.

  • Use regular dishes, glasses and utensils. Wash them in the sink or dishwasher.

  • Tissues and paper napkins should go in the toilet, not the garbage.

  • Food residues should be avoided during the first week (apple cores, chicken bones etc).

  • Articles contaminated with body fluids that cannot be washed clean or disposed of in the toilet should be stored for decay.

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Part 8

Part 8. Therapy


Part 8 optimization of protection in medical exposure3

IAEA Training Material on Radiation Protection in Nuclear Medicine

Part 8Optimization of Protection in Medical Exposure

Module 8.4

The Hospitalized Patient


Hospitalized patient

Hospitalized Patient

  • separate room with toilet and shower

  • patient instructions (verbal and written)

  • local rules for nursing the patient

  • local rules for visitors

  • local rules for decontamination

  • local rules for emergency situations

Part 8. Therapy


Room for iodine therapy controlled area

Room for Iodine Therapy(controlled area)

  • only one patient in the room

  • easily cleanable surfaces

  • and utensils

  • extra lead shields

  • door closed

  • warning sign outside

  • restrictions for visitors

  • decontamination equipment

Part 8. Therapy


Isolation ward

Isolation Ward

Bed shield is positioned

Areas are covered with plastic backed absorbentmaterial.

King Faisal Specialist Hospital and Research Center, Riyadh

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Warning signs

Warning Signs

Radiation sign posted on door

and on Patient Chart

King Faisal Specialist Hospital and Research Center, Riyadh

Part 8. Therapy


Patient instructions

Patient Instructions

  • Stay in the room.

  • Drink as much as possible.

  • Eat lemon slices.

  • Use only the private toilet and flush 3 times.(Men should sit down to avoid splashing.)

  • Wash hands well in soapy water afterusing toilet.

  • Wear footwear when leaving the bed.

  • In event of vomiting or incontinence notifythe nurse immediately.

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Instructions to nursing staff

Instructions to Nursing Staff

  • Reduce time spent with patient by planning ahead and working efficiently.

  • Work as far from patient as possible.

  • Practice preventative measures against contamination.

    -wear impermeable protection gloves

    -wear shoe covers

    -wear a protective gown

  • Remove protection clothing before leaving the room.

Part 8. Therapy


Visitors warning card

Visitors Warning Card

The patient you are about to visit has received a therapeutic dose

of radioactive iodine. It is in your own best interest to protect yourself

as much as possible from receiving more radiation than is necessary.

To assist you in meeting that end we offer the following recommendations:

  • Visitors are discouraged for a 48 hour period after the patient receives the treatment.

  • Pregnant women and children under the age of 18 are not permitted to visit.

  • You should keep your visit short (<30 min).

  • Keep a reasonable distance (e.g. 2 m) away from the patient.

  • Do not kiss the patient.

  • Do not eat, drink or smoke in the patient’s room

  • Do not touch the toilet or sink in the patient’s room

    If you have any questions, please ask the nursing staff.

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Discharge of patient

Discharge of Patient

The patient may leave the hospital when his/herradiation level has dropped below the equivalentactivity level specified by the Regulatory Authorityor the dose constraints specified by the local RPC. E.g. 20 μSv/h which corresponds to an activity of about 500 MBq

The patient should be instructed about the generalprecautions for out-patients

Part 8. Therapy


Discharge of patient1

Discharge of Patient

Abdalla Al-Haj

Part 8. Therapy


Discharge of patient2

Discharge of Patient

Abdalla Al-Haj

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Decontamination

Decontamination

The RPO should supervise the removal of contaminated waste, the decontamination of the room and equipment and should make a documented final survey of the room.

Monitoring and decontamination must be done prior to entry of nursing and housekeeping staff to prepare the room for the next patient.

When survey and decontamination procedures are complete, the RPO will remove the radiation warning sign and notify the nursing and housekeeping staff that the room is now clear for general use.

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Monitoring

Monitoring

Areas suspected to be

contaminated are surveyed.

Furniture and telephone sets

are surveyed.

King Faisal Specialist Hospital and Research Center, Riyadh

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Monitoring1

Monitoring

  • Derived limit: 3 Bq/cm2

  • METHODS

  • wipe testing

  • direct surveying

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Ready for a new patient

Ready for a New Patient

A “Radiation Safe” sign is posted at the door after decontamination and clearing of room

King Faisal Specialist Hospital and Research Center, Riyadh

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Radioactive waste1

Radioactive Waste

  • Faeces, urine and other liquids should be disposed of via the toilet.

  • Contaminated clothing, linen, food items etc which can not go into the toilet should be stored in a separate plastic bag labeled ’RADIOACTIVE’, and should be removed daily to the designated radioactive waste storage facility.

  • Disposable cutlery and dishes should be used. If not, they should be washed in the patient’s room and reused by the patient.

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Radioactive waste2

Radioactive Waste

All patient radioactive wastes are placed in a plastic bag and the bag is properly tagged.

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Part 8 optimization of protection in medical exposure4

IAEA Training Material on Radiation Protection in Nuclear Medicine

Part 8Optimization of Protection in Medical Exposure

Module 8.5 Emergency Procedures:

Death of Patient


Part 8

Emergencies

HELP!

Part 8. Therapy


Safety assessment contingency plan

Safety AssessmentContingency Plan

  • A safety assessment will reveal the possible

  • situations where emergency actions have to be taken:

  • Loss or damage of radioactive material

  • Spillage of radioactive material

  • Fire

  • Medical emergencies

  • ...

A detailed contingency plan covering actions to

be taken in any foreseeable accident should be

available.

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Death of patient

Death of Patient

In the event of death of a patient who has recently received

a therapeutic dose of a radionuclide care has to be taken to

ensure that personnel receive as low a dose as possible at all stages prior to the burial or cremation.

Activity (MBq)

(UK)

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Death of patient1

Death of Patient

  • Precautions that should be given are depending on the residual activity

  • and the expert advice provided by the RPO and may involve the following:

  • preparation for burial or cremation should be controlled by a

  • competent person,

  • relatives should be prevented from coming into close contact with the

  • body,

  • people should not be allowed to linger in the presence of the coffin,

  • all personnel involved in handling the corpse should be instructed by

  • the RPO and monitored if appropriate,

  • all objects, clothes, documents etc that might have been in contact

  • with the deceased must be tested for contamination,

  • it may be expedient to wrap the cadaver in waterproof material

  • immediately after death to prevent spread of contaminated body fluids,

  • embalming of cadavers should, if possible, be avoided,

  • autopsy of highly radioactive cadavers should be restricted to the

  • absolute minimum

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Questions

Questions?

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Discussion

Discussion

Discuss the advantages/disadvantages of givingthe patient a standard activity of I-131 in a capsule or givinga carefully calculated activity based on a prescribeddose to the thyroid.

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Discussion1

Discussion

  • Who should prescribe a thyroid treatment with I-131?

  • Who should perform the treatment?

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Discussion2

Discussion

Define some emergency situations or other hazardous events that can occur in an isolation ward and how to handle the situations.

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Where to get more information

Where to Get MoreInformation

  • Other sessions

    • Part 6 Medical exposure

    • Part 5 Occupational exposure

    • Part 4 Design

  • Further readings

    • IAEA, International Basic Safety Standards for Protection Against Ionizing Radiation and for the Safety of Radiation Sources Safety Series No.115, Interim Edition (2011)

    • IPEM, Medical and Dental Guidance Notes. A good practice guide to implement ionising radiation protection legislation in the clinical environment

    • IAEA/WHO Manual on Radiation Protection in Hospitals and General Practice, Volume 4, Nuclear Medicine

    • IAEA, Manual on therapeutic use of iodine-131. Practical Radiation Safety Guide

Part 8. Therapy


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