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Fluoroscopy Safety. New Wisconsin Regulations. In 2010, WI enacted new training regulations for clinicians who use fluoroscopy. Unless certified by the American Board of Radiology (or board eligible), clinicians are required to be trained in:

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New wisconsin regulations
New Wisconsin Regulations

In 2010, WI enacted new training regulations for clinicians who use fluoroscopy. Unless certified by the American Board of Radiology (or board eligible), clinicians are required to be trained in:

Principles of operation of the fluoroscopic x-ray system

Biological effects of x-rays

Principles of radiation protection

Fluoroscopic outputs

High Level control options

Dose reduction techniques

Applicable state and federal regulations


What is fluoroscopy
What is Fluoroscopy?

Fluoroscopy is an imaging procedure that uses a continuous x-ray beam to create real-time images viewed on a monitor.

It enables physicians to view internal organs and vessels in motion.

Fluoroscopy is used in both diagnostic and therapeutic procedures.


Medical uses of fluoroscopy began shortly after roentgen s discovery of x rays in 1895
Medical uses of fluoroscopybegan shortly after Roentgen’sdiscovery of x-rays in 1895.

Fluoroscopy Today

Fluoroscopy for tuberculosis (1940)


1990 s injuries reported to fda
1990’s: Injuries Reported to FDA

From 1992 through 1995, the FDA received more than 100 reports of patients with radiation injuries from fluoroscopy.

Since 1992, reports of injuries to patients and physicians have appeared in radiology, cardiology, and medical physics journals.



Skin injury and time to onset listed in order of time of initial onset
Skin Injury and Time to OnsetListed in order of time of initial onset



Skin injury and time to onset1
Skin Injury and Time to Onset

Source: Centers for Disease Control and Prevention. Cutaneous radiation injury: fact sheet for physicians.


Example 1
Example 1

A 40-year-old male underwent coronary angiography, coronary angioplasty and a second angiography procedure due to complications, followed by a coronary artery by-pass graft, all on March 29, 1990.

Example and images provided by Thomas Shope, U.S. FDA Center for Devices and Radiological Health


6 8 weeks post procedure
6-8 weeks post procedure

Note the erythema in the shape of the radiation collimation


16 21 weeks post procedure
16-21 weeks post procedure

Erythema reduced, Secondary Damage (not as well imaged)


18 21 months post procedure
18-21 months post procedure

Close-up view of lesion



Example 2

Note Epilation

Example 2

Injury following three procedures involving transjugularintrahepaticportosystemic shunt placement (TIPS), demonstrating disfigurement after surgical correction.

Koenig TR, Wolff D, Mettler FA et al. Skin injuries from fluoroscopically guided procedures: part 1, characteristics of radiation injury. AJR Am J Roentgenol 2001; 177(1):3-11.


Example 3
Example 3

Injury to arm of patient.

Patient was draped for

procedure and physicians

did not realize that she

had moved her arm so that

it was resting on the port of

the X-ray tube during the

procedure.

Wagner LK, Archer BR. Minimizing Risks from Fluoroscopic X Rays. 4th edition.

The Woodlands, Texas: Partners in Radiation Management, 2004.


Why are injuries occurring
Why Are Injuries Occurring?

One contributing factor is the growth in number and types of interventional procedures using fluoroscopy. But any procedure using fluoroscopy has the potential for patient injury.

Another factor may be more overweight and obese patients. Higher energy x-rays and higher radiation dose rates are required to penetrate through these patients.


Fda actions
FDA Actions

In 1994, the FDA issued a Public Health Advisory on avoidance of serious skin injuries to patients during fluoroscopy-guided procedures.

In 1995, the FDA issued a follow-up advisory on recording information in the patient’s record that identifies the potential for serious skin injury from fluoroscopy.


Joint commission action
Joint Commission Action

In 2006, the Joint Commission added a Sentinel Event category for radiation overdose involving prolonged fluoroscopy with a cumulative dose of more than 15 Gray to a single field.

Fluoroscopy machines manufactured after June 2006 measure and display a reference patient radiation dose. The reference dose can be monitored during the procedure, and the cumulative dose can be recorded in the patient’s medical record.


Summary
Summary

All of the following injuries can be

caused by radiation:

  • Skin erythema and desquamation

  • Epilation

  • Skin ulceration


What about personnel safety
What About Personnel Safety?

Physicians and staff using fluoroscopy are exposed to:

- Scattered radiation from the patient

  • Leakage radiation from

    the x-ray tube

  • Primary radiation from the

    x-ray beam if their hands

    are in the radiation field

Detector/image intensifier

x-ray tube


Personnel safety
Personnel Safety

Although clinician radiation dose is much lower than the patient dose, it is proportional to patient dose.

Higher patient doses will usually lead to higher operator and staff doses.


Radiation risks
Radiation Risks

High doses of radiation (>1 Gray in a single exposure), such as those received by patients injured by fluoroscopy, are linked to skin injury and increased risk of cancer.

Low doses of radiation over long periods of time, such as those received by medical personnel, may result in an increased risk of cancer, although this has not been conclusively proven.


Alara as low as reasonably achievable
ALARA (As Low As Reasonably Achievable)

Because we know that large doses of radiation can cause long term health effects, such as increasing the risk of developing cancer, we assume that all radiation exposure entails some risk.

Therefore, we should try to limit the radiation exposure to patients and staff, consistent with obtaining the necessary clinical information.


In fluoroscopy, there are three practical techniques to reduce radiation exposure to patients and personnel.

  • Reduce Fluoro Time

  • Increase Distance

  • Provide Shielding

    The following slides demonstrate how to use these techniques to reduce radiation exposure.


Time identify if the patient has had other recent long fluoro procedures
Time: Identify if the patient has had other recent long reduce radiation exposure to patients and personnel.fluoro procedures

Check the patient’s medical record to see if they have had a recent long fluoroscopy procedure in the same location.

If yes, try to change the C-Arm angle so that you are not irradiating the same area of skin again.


Time recognize the fluoroscopy beam on controls
Time: Recognize the Fluoroscopy “Beam-On” Controls reduce radiation exposure to patients and personnel.

Typical x-ray “beam-on” foot pedal.

Most units also have a beam-on button or switch the user can operate by hand.


Time minimize beam on time
Time: Minimize “Beam-On” time reduce radiation exposure to patients and personnel.

Use short taps of the fluoroscopy beam-on control. Don’t use a “lead foot” on the

fluoroscopy pedal.

Reducing beam-on

time is the most

effective way to

reduce dose.


Time lih and lf h
Time: LIH and LF reduce radiation exposure to patients and personnel.H

Use Last Image Hold (LIH) or

Last Fluoroscopy Hold (LFH)

when possible instead of re-

exposing the patient.

Last Image Hold saves the last fluoroscopy image and displays it on the monitor.

Last Fluoroscopy Hold saves the last video sequence of fluoroscopy images for instant replay.


Time fluoroscopy dose modes
Time: Fluoroscopy Dose Modes reduce radiation exposure to patients and personnel.

Different dose mode selections may be available

  • Low Dose (↓patient dose, ↑ image noise)

  • High Dose (↑patient dose, ↓ image noise)

  • Low Frame Rate (↓patient dose,↓ frame rate)

    When Image Quality allows, use low dose mode and/or a lower frame rate.


Time minimize use of high dose mode
Time: Minimize Use of High Dose Mode reduce radiation exposure to patients and personnel.

High dose rate mode may be needed for large patients or for seeing greater detail.

High dose mode selection is usually denoted by a “+” sign.

Do not routinely use high dose mode.


Time digital acquisition mode
Time: Digital Acquisition Mode reduce radiation exposure to patients and personnel.

X-Ray machines used for

interventional procedures have a

digital acquisition or “cine” mode.

A high radiation dose rate is used to obtain a series of high resolution images with reduced image noise.

The radiation dose per frame for digital acquisitions can be 15 times greater than for fluoroscopy.


Time use digital acquisition cine mode appropriately
Time: Use Digital Acquisition/Cine Mode Appropriately reduce radiation exposure to patients and personnel.

The number and length of digital

acquisition or cine “runs” may be

the greatest source of patient

radiation dose in interventional

radiology procedures.

Be aware of the increased dose rate and do not use digital acquisition/cine mode as a substitute for fluoroscopy.


Using time to reduce exposure summary
Using Time to Reduce Exposure: reduce radiation exposure to patients and personnel.Summary

When image quality allows, choosing to use low dose fluoro modes and last image hold, while limiting the use of “boost” fluoro and high dose digital acquisitions, will reduce patient and staff radiation exposure.


Distance scattered radiation
Distance: Scattered Radiation reduce radiation exposure to patients and personnel.

During fluoroscopy, radiation is scattered from the surface of the patient where the x-ray beam enters.

Scattered radiation is the main source of radiation dose to staff. It also decreases image contrast and degrades image quality.

Detector/Image Intensifier

x-ray tube


Distance c arm position
Distance: C-Arm Position reduce radiation exposure to patients and personnel.

Position the X-ray tube underneath the patient, not above the patient.

The greatest amount of scatter radiation is produced where the x-ray beam enters the patient.

By positioning the x-ray tube below the patient, you receive less scatter radiation.

Image Intensifier

X-ray Tube


Distance c arm position1
Distance: C-Arm Position reduce radiation exposure to patients and personnel.

Always stand closer to the detector/image intensifier.

For lateral and oblique projections, position the C-arm so that the x-ray tube is on the opposite side of the patient from where you are working.

This will reduce the scatter radiation reaching you.

Always stand farther from the X-Ray Tube.


Distance c arm position2
Distance: C-Arm Position reduce radiation exposure to patients and personnel.

Position the x-ray tube and image intensifier so you are working on the image intensifier side of the patient.

Position the x-ray tube as far from the patient as possible.

Position the Image intensifier as close to the patient as possible.

X-ray tube

Image intensifier


Distance proximity to the x ray tube
Distance: Proximity to the X-Ray Tube reduce radiation exposure to patients and personnel.

The patient’s skin should never touch or be near the x-ray tube port (where the x-rays come out).

Staff should also never touch or be near the x-ray tube port.

Burns can occur in seconds if skin is touching or near the x-ray tube port.

X-ray tube port


Distance minimize the air gap
Distance: Minimize the Air Gap reduce radiation exposure to patients and personnel.

Move the detector or image intensifier as close to the patient as possible.

A smaller air gap reduces radiation dose to the patient and staff and improves image quality.


Distance when possible increase your distance from the patient when the x ray beam is on
Distance: When possible increase your distance from the patient when the x-ray beam is on

When possible, simply taking a step back from the radiation source whenever possible will greatly reduce your radiation dose.

Moving from 30cm to 60 cm from the patient will reduce your exposure by a factor of 4.


Distance stay out of the fluoroscopy beam
Distance: Stay Out of the Fluoroscopy Beam patient when the x-ray beam is on

Don’t put your hands in the fluoroscopy beam unless absolutely necessary for the procedure.

This is the hand of a physician who was exposed to repeated small doses of x-ray radiation for 15 years. The skin cancer appeared several years after his work with x-rays had ceased.

Meissner, William A. and Warren, Shields: Neoplasms, In Anderson W.A.D. editor; Pathology, edition 6, St. Louis, 1971, The C.V. Mosby Co


Using distance to reduce exposure summary
Using Distance to Reduce Exposure: patient when the x-ray beam is onSummary

  • When possible, always position the image intensifier over the patient.

  • Maximize the distance from the x-ray tube to the patient.

  • Move the image intensifier as close to the patient as you can.

  • Maximize the distance between you and the patient during the x-ray exposure.

  • Do not put your hands in the primary beam.


Shielding collimate appropriately
Shielding: Collimate Appropriately patient when the x-ray beam is on

Collimate tightly to the area of clinical interest to reduce patient and staff dose, reduce scatter, and improve image contrast.

uncollimated

collimated


Shielding magnification modes
Shielding: Magnification Modes patient when the x-ray beam is on

Magnification enlarges the anatomy being viewed, but it also increases the radiation dose to the patient.

Multiple electronic magnification modes may be available.


Use shielding
Use Shielding patient when the x-ray beam is on

Wisconsin DHS regulations require anyone within 6 feet of a fluoroscopy machine to wear a lead apron.

You may also wear a lead thyroid shield or leaded eyeglasses, depending on the type and amount of work you do.


Shielding mini c arms
Shielding: Mini C-Arms patient when the x-ray beam is on

Although Mini C-Arms produce less scatter Radiation than full C-Arms, Aspirus Wausau Hospital radiation safety procedures require the use of lead aprons when performing any fluoroscopy procedure.

GE OEC Mini-C


Shielding hang lead aprons properly
Shielding: Hang Lead Aprons Properly patient when the x-ray beam is on

Hanging lead aprons on hangers/hooks prevents the lead from cracking and tearing.

This is for your safety, so please be sure to take care of your lead.


Using shielding to reduce exposure summary
Using Shielding to Reduce Exposure: patient when the x-ray beam is onSummary

  • Collimate the radiation to the area of interest.

  • Minimize the use of high magnification modes.

  • Always wear radiation protection devices.


Pediatric patients
Pediatric Patients patient when the x-ray beam is on

Children are estimated to be two to seven times more sensitive to radiation than adults.

They have more dividing and differentiating cells and have a longer time over which radiation effects such as cancer can appear.

Use techniques taught in this course to minimize the dose to pediatric patients as well.


To reduce pediatric radiation exposure
To Reduce Pediatric Radiation Exposure patient when the x-ray beam is on

  • Use low dose or low pulse rate mode.

  • Collimate the beam to only show the area of interest.

  • Maximize the distance from the x-ray tube to the patient.

  • Minimize the distance from the image intensifier to the patient.

  • Use the minimum electronic magnification necessary.

  • Use the minimum amount of “beam-on” time necessary.


Radiation dose limits
Radiation Dose Limits patient when the x-ray beam is on

Occupational radiation exposure to radiation workers is regulated by the federal government and the states.

Annual occupational radiation exposure limits are set to levels at which there is believed to be negligible risk of biological effects.

Whole Body: 50 mSv/yr

Lens of the Eye: 150 mSv/yr

Extremities, Skin: 500 mSv/yr


Dosimetry badges
Dosimetry patient when the x-ray beam is on Badges

Workers likely to receive an occupational radiation dose greater than 5 mSv/year must be monitored.

Radiation exposure reviews determine which categories of workers are required to be monitored.

Workers with particular concern regarding radiation, such as pregnant workers, may also be monitored even if they are not likely to exceed 5 mSv/yr.

Dosimetry Badge


Dosimetry badges1
Dosimetry patient when the x-ray beam is on Badges

If you have been issued a single dosimetry badge, wear it outside your lead apron at collar level.

If you have been issued two badges, wear the “collar badge” outside your lead apron, and wear the “body badge” underneath your lead apron.


For more information
For More Information patient when the x-ray beam is on

These and other policies regarding radiation safety are available in the Aspirus Wausau Hospital Radiation Safety Plan which is available on the hospital network at:

S:\Radiation Safety Plan

or by contacting the Aspirus Wausau Hospital Radiation Safety Officer.


Questions
Questions patient when the x-ray beam is on

For questions about fluoroscopy safety, contact the Aspirus Wausau Hospital Radiation Safety Officer.

Raymond Wery, M.S., DABR

phone: 715-847-2031

[email protected]


Fluoroscopy safety certificate
Fluoroscopy Safety Certificate patient when the x-ray beam is on

A test will follow this presentation, to validate your understanding of these safety principles.

If you would like a certificate documenting that you have received training in Fluoroscopy Safety, call or e-mail the Aspirus Wausau Hospital Provider Support Services Department.

The certificate can satisfy other organizations’ requirements for fluoroscopy training, if needed.


Contributors patient when the x-ray beam is on

Mary Ellen Jafari, M.S., DABR

Alan M. Daus., M.S., DABR

Diagnostic Medical Physics Section

Imaging Department

Gundersen Lutheran Medical Center

La Crosse, Wisconsin


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