Radiation Safety: How Can We Reduce Risk? Rya n K o hlb re nne r, - - PDF document

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Radiation Safety: How Can We Reduce Risk? Rya n K o hlb re nne r, - - PDF document

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4/17/2018 Radiation Safety: How Can We Reduce Risk? Rya n K o hlb re nne r, MD Assista nt Pro fe sso r o f Clinic a l Ra dio lo g y Unive rsity o f Ca lifo rnia , Sa n F ra nc isc o Financial Disclosures No ne 1 4/17/2018 Outline

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SLIDE 1

4/17/2018 1

Radiation Safety: How Can We Reduce Risk?

Rya n K

  • hlb re nne r, MD

Assista nt Pro fe sso r o f Clinic a l Ra dio lo g y Unive rsity o f Ca lifo rnia , Sa n F ra nc isc o

Financial Disclosures

  • No ne
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SLIDE 2

4/17/2018 2

Outline

  • A. I

ntro duc tio n

  • B. Wa ys to Re duc e Ra dia tio n Do se
  • F

re e

  • Che a p
  • E

xpe nsive

Outline

  • A. Intr
  • duc tion
  • B. Wa ys to Re duc e Ra dia tio n Do se
  • F

re e

  • Che a p
  • E

xpe nsive

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SLIDE 3

4/17/2018 3

Types of Radiation Risks

  • Sto c ha stic risks/ e ffe c ts
  • Re sult fro m c e ll muta tio n
  • Pro bability inc re a se s with do se
  • E

xa mple s: Ca nc e r, he rita b le g e ne tic de fe c ts (? )

  • De te rministic risks/ e ffe c ts
  • Re sult fro m c e ll de a th
  • S

e ve rity inc re a se s with do se

  • E

xa mple s: Skin b urns (pa tie nts), c a ta ra c ts (o pe ra to rs)

Stochastic effects Deterministic effects

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SLIDE 4

4/17/2018 4

Deterministic Effects

Cataracts: Deterministic Effect Relevant to Proceduralists

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SLIDE 5

4/17/2018 5

Stochastic Risks by the Linear No‐Threshold Model

Stochastic Risks ‐ Cancer

  • E

stima te d la te nt pe rio ds

  • 2-12 ye a rs fo r le uke mia
  • 20 ye a rs fo r so lid o rg a n tumo rs
  • Ca nc e rs a sso c ia te d with ra dia tio n e xpo sure
  • L

e uke mia

  • Bre a st
  • L

ung

  • GI
  • T

hyro id

  • Bra in
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SLIDE 6

4/17/2018 6

Outline

  • A. I

ntro duc tio n

  • B. Ways to R

e duc e Your R adiation Dose

  • F

re e

  • Che a p
  • E

xpe nsive

Free

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4/17/2018 7

Basics of Radiation Protection

  • Minimize Usa g e
  • Be ne fits bo th pa tie nt a nd o pe ra to r
  • T

wo wa ys to minimize usa g e

  • 1. Ste p o n the pe da l le ss
  • 2. Whe n yo u do ste p o n the pe da l, b e e ffic ie nt
  • Ma ximize Dista nc e
  • Be ne fits o pe ra to r
  • I

nve rse sq ua re la w

  • E

xpo sure de c re a se s with the sq ua re o f the dista nc e fo rm the ra dia tio n so urc e

  • E

.g . Mo ving fro m 1m to 3m fro m so urc e will de c re a se yo ur do se b y fa c to r o f 9

Optimizing Radiation Efficiency

  • 1. Minimize fluo ro sc o py fra me ra te
  • 2. Minimize DSA fra me ra te
  • 3. Use la st ima g e ho ld/ fluo ro c ine sa ve s ra the r tha n DSA
  • 4. Do n’ t b e la te ra l whe ne ve r po ssib le
  • 5. Co llima te tig htly
  • 6. Bring do wn de te c to r to pa tie nt
  • 7. Minimize ma g nific a tio n
  • 8. Use we ig ht-b a se d pro to c o ls
  • 9. Ra ise the ta b le
  • 10. Audit yo ur do se s
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SLIDE 8

4/17/2018 8

Cheap

Protective Aprons

  • Must b e wo rn a t a ll time s, inc lud ing thyro id

shie ld

  • T

ra de o ff

  • F

ull le a d (0.5mm Pb ) o ffe rs b e st pro te c tio n

  • Alte rna tive s to le a d o ffe r g re a te st c o mfo rt
  • Optio ns
  • L

e a d

  • L

e a d-lite

  • L

e a d-fre e

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4/17/2018 9

Protective Aprons

  • Sc e na rio
  • Yo ur ne w 0.5mm Pb -e q uiva le nt le a d-fre e a pro n is

se nt to yo ur institutio n a nd a tte nua te s 95% a t 75kV a t a c c e pta nc e te sting . Yo ur pa rtne r’ s 0.5mm Pb full-le a d a pro n a tte nua te s 95% a t 75kV.

  • Will the y g ive yo u the sa me pro te c tio n?
  • Usua lly no t…so me time s it’ s no t e ve n c lo se
  • Ac c e pta nc e te sting o nly a t o ne x-ra y e ne rg y
  • Do e s no t a c c o unt fo r x-ra ys pa rtia lly sc a tte re d in the

a pro n b ut ultima te ly ma ke it thro ug h a t a lo we r e ne rg y

Protective Aprons

  • E

vide nc e

  • Me d Physic s (2013); 40(6): 063902
  • T

e ste d le a d a nd le a d-fre e a pro ns a c ro ss diffe re nt e ne rg ie s

  • “0.5mm Pb e q uiva le nt” le a d fre e a pro ns pe rfo rme d a s if it

we re 0.37-0.46mm Pb e q uiva le nt

  • Pe ne tra b ility o f o ne le a d-fre e a pro n a t 60kV wa s 478% hig he r

tha n le a d

  • Me d Physic s (2007); 34(11): 4270-80
  • T

e ste d le a d a g a inst tin a nd tin+b ismuth, a ll with e q ua l “le a d- e q uiva le nc e ” a t 75 kV

  • T

in+b ismuth a tte nua te d 26-42% le ss tha n le a d, de pe nding o n e ne rg y

  • T

in a lo ne a tte nua te d 41-74% le ss tha n le a d, de pe nding o n e ne rg y

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SLIDE 10

4/17/2018 10

Protective Aprons

  • E

vide nc e

  • E

urRadio l(2005); 15(7): 1477-84

  • T

e ste d le a d c o mpo site a nd le a d-fre e a pro ns in use a t inve stig a ting institutio n

  • “Out o f the 41 pro te c tive a pro ns e xa mine d fo r a c tua l le a d

e q uiva le nc e , 73% we re o utside to le ra nc e le ve ls, with a c tua l le ve ls in so me a pro ns de mo nstra ting le ss tha n ha lf o f the no mina l va lue s.”

Leaded Glasses

  • T

ypic a lly 0.5mm Pb e q uiva le nc e

  • Ca n b e o rde re d with pre sc riptio n
  • L

ike ly re duc e risk o f c a ta ra c ts o ve r c a re e r

  • Do wnside s
  • He a vy
  • L

imite d b y po sitio ning o f he a d

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SLIDE 11

4/17/2018 11

Leaded Glasses

  • E

vide nc e

  • CVI

R (2014); 37(5): 1149-55

  • 7.9-10.0x re duc tio n fo r fro nta l e xpo sure
  • 2.1x re duc tio n unde r c linic a l c o nditio ns (le ft e ye )
  • J I

nte rv Cardio l(2009); 22(3): 299-307

  • 3.0x re duc tio n to le ft e ye unde r c linic a l c o nditio ns
  • 1.9x re duc tio n to rig ht e ye unde r c linic a l c o nditio ns
  • Me d Physic s (1980); 7(1): 8-12
  • 1.8-2.7x fo r sta nda rd mo de ls
  • 5.3x fo r wra p-a ro und mo de l

Suspended Shields

  • T

ypic a lly 0.5mm Pb e q uiva le nc e

  • Ce iling -mo unte d with

b a ll a nd so c ke t jo int

  • Po sitio ne d b e twe e n

pa tie nt a nd o pe ra to r

  • Do wnside s:
  • Ce iling ma y a lre a dy b e

c ro wde d (surg ic a l lig hts, mo nito rs)

  • Ma y b e diffic ult to po sitio n

during c e rta in pro c e dure s

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SLIDE 12

4/17/2018 12

Suspended Shields

  • E

vide nc e

  • CVI

R (2014); 37(5): 1149-55

  • 5.7x re duc tio n to le ft e ye do se unde r c linic a l

c o nditio ns

  • Cath Cardio vasc I

nte rv (2006); 67(1): 18-23

  • 19.0x re duc tio n to e ye do se unde r c linic a l

c o nditio ns

  • Minima l e ffe c t o n do se to ha nds

Protective Drapes

  • Ste rile , surg ic a l dra pe s

impre g na te d with no n- le a d he a vy me ta l

  • I

ne xpe nsive

  • Dispo sa b le
  • Diffe re nt mo de ls fo r use

with diffe re nt a c c e ss site s

  • Disa dva nta g e s
  • Adhe sive b a c king ma y fa il
  • Va ria b le b e ne fit
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4/17/2018 13

Protective Drapes

  • E

vide nc e

  • Cath Cardio vasc I

nte rv (2012); 79(1): 97-102

  • RCT

– c o ro na ry a ng io g ra ms via tra nsra dia l a c c e ss

  • 30 c a se s with RADPAD, 30 witho ut RADPAD
  • 23% o ve ra ll re duc tio n in o pe ra to r do se
  • E

JVE S (2014); 47(3): 268-272

  • RCT

– E VAR via fe mo ra l a c c e ss

  • 18 c a se s with RADPAD, 18 witho ut RADPAD
  • 49 a nd 55% re duc tio n in do se to o pe ra to r ha nds a nd c he st,

re spe c tive ly

  • Am J Cardio l (2011); 108(10): 1408-1410
  • RCT

– c o mple x c o ro na ry inte rve ntio ns via tra nsra dia l o r fe mo ra l a c c e ss

  • 30 c a se s with RADPAD, 30 witho ut RADPAD
  • 41% o ve ra ll re duc tio n in o pe ra to r do se

Expensive

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SLIDE 14

4/17/2018 14

Proprietary Imaging Platforms

  • Ha rdwa re a nd so ftwa re upg ra de s, ta ilo re d

to c o mmo n ima g e ta sks, de sig ne d to re d uc e ra d ia tio n d o se while ma inta ining ima g e q ua lity

  • I

nc re a se d c o ppe r b e a m filtra tio n to re duc e use le ss lo w e ne rg y x-ra ys

  • E

dg e sha rpe ning a lg o rithms

  • T

e mpo ra l a ve ra g ing

  • Mo tio n c o rre c tio n

Siemens: CARE+CLEAR

  • “Sta nda rd” o n e a c h Artis syste m
  • …b ut yo u will like ly pa y to upg ra de yo ur syste m if ne w do se re duc tio n

pa c ka g e is re le a se d

  • F

e a ture s:

  • Co ntro l o f fluo ro sc o py ra te 0.5-30 fps
  • Dyna mic filtra tio n o f x-ra y b e a m de pe nding o n pa tie nt

thic kne ss a nd C-a rm a ng ula tio n

  • I

mpro ve me nts in c o ne -b e a m CT

  • Ma pping o f pa tie nt skin do se
  • T

ra c ks c umula tive do se to diffe re nt a re a s o f b o dy a s pro c e dure pro g re sse s

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SLIDE 15

4/17/2018 15

Philips: AlluraClarity IQ

  • Add-o n pa c ka g e
  • F

e a ture s:

  • T

a sk-spe c ific ima g e pro c e ssing

  • Dyna mic filtra tio n
  • Mo st e xte nsive ly studie d ne w pla tfo rm
  • E

vide nc e

  • JVI

R (2017); 28(8): 1129-1135

  • 60% re duc tio n in DAP during ute rine a rte ry e mb o liza tio n
  • JVI

R (2015); 26(9): 1331-1338

  • 46% re duc tio n in DAP during T

ACE

  • E

JVE S (2015); 50(4): 480-86

  • 57-73% re duc tio n during E

VAR a nd a o rto ilia c o c c lusive c a se s

GE: Blueprint

  • Add-o n pa c ka g e
  • F

e a ture s:

  • Custo mize do se se tting s fo r diffe re nt use rs fo r diffe re nt

pro c e dure s

  • De te c to r tha t a uto ma tic a lly po sitio ns de te c to r o ptima lly

with re spe c t to the pa tie nt

  • 15-60 se c o nd fluo ro sc o py pla yb a c k
  • Co ppe r filtra tio n to e limina te lo w e ne rg y x-ra ys
  • Do se ma p (simila r to Sie me ns) to de te rmine e xpo sure to

diffe re nt a re a s o f the pa tie nt

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SLIDE 16

4/17/2018 16

EVAR Imaging Packages

  • Ava ila b le fro m e ve ry ma jo r ve ndo r

Potential Benefits: ‐Optimized C‐arm angulations ‐Vessel navigation ‐3D dynamic overlay

Suspended Shielding System

www.biotronik.com

  • 1mm thic k le a d a pro n

suspe nde d fro m c e iling (Ze ro -Gra vity syste m)

  • L

e a d-a c rylic fa c e shie ld to re duc e e ye e xpo sure

  • Do se re duc tio n

c o mpa re d with sta nda rd le a d

  • L

e ft a xilla : 78x lo we r

  • L

e ft e ye : 45x lo we r

  • Rig ht e ye : 56x lo we r
  • Go na d: 16x lo we r

JVIR 2011; 22(4): 437‐442

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SLIDE 17

4/17/2018 17

Conclusion

  • Pla n b e fo re yo u ste p
  • K

e e p yo ur dista nc e

  • Ge t so me re a l le a d
  • …o r a t le a st kno w ho w yo ur le a d-fre e a pro n b e ha ve s a t

diffe re nt e ne rg ie s

  • Co nside r pro te c tive dra pe s a nd c e iling shie lds
  • Upg ra de yo ur x-ra y e q uipme nt if yo u ha ve the

mo ne y

Thank you!

rya n.ko hlb re nne r@ uc sf.e du

Figure references: ‐Bushberg, et al. The Essential Physics of Medical Imaging. Lippincott, 2nd and 3rd ed (2001, 2011). ‐Wolbarst, et al. Physics of Radiology. MPPC, 2nd ed (2005).