Fluoroscopy Safety Awareness: High Dose Operator Management

Physicians, nurses, technologists and others involved in medicine constitute the largest single group of workers occupationally exposed to manmade sources of radiation and medical staff exposures have increased substantially over time [1,2], especially in the last decade or so. Medical staff doses generally track upward as the number of patient cases increases.

According to worldwide estimates, staff involved in fluoroscopy procedures (e.g., interventional radiology or interventional cardiology) receive about two times higher whole body doses than the mean measurable doses in all medical uses [1]. In high volume hospital settings, whole body and lens of eye doses for staff involved in fluoroscopy procedures are significantly higher than the hospital average doses [3].

Staff doses vary by procedure, training, methodology, complexity, patient factors and equipment. Medical practitioners performing fluoroscopically-guided interventional procedures are often required to wear protective aprons and thyroid collars to reduce whole body effective doses. However, they are typically exposed to a relatively high ocular dose, especially when protection tools are not used because in some cases lens doses could be as high as about 1 mSv per procedure [4,5,6,7,8,9]. Increased lens doses may result in increased risk of lens opacification and ultimately cataracts over a working lifetime [9,10].

The use of adequate eye protection is clearly a necessity, especially for high-volume practices [8,10]. Leaded glasses have been shown to reduce lens doses by a factor of about three (or higher), shielded sterile drapes by a factor of ~25 and suspended ceiling shields by a factor of roughly over 100 [11]. Protection controls for staff are outlined well in NCRP Report No. 168 [10] and include engineering, safe work practices, administrative controls, and personal protective equipment and monitoring.

Several guidelines for training in radiation protection and management have been developed by professional societies and should be fully implemented [12,13,14,15]. Managing patient doses ALARA can help to reduce staff doses overall. Several strategies have been developed for both patient and staff safety in fluoroscopy and should be considered when setting up a new program or auditing and existing practice [16,9,17,18,19,20].

References

1. UNSCEAR 2006 report to the general assembly with scientific annexes. Volume 1. United Nations Scientific Committee on the Effects of Atomic Radiation; 2008. Available at: http://www.unscear.org/docs/reports/2006/07-82087_Report_2006_Web.pdf. Accessed October 13, 2014.
2. NCRP Report No. 160. Ionizing radiation exposure of the population of the United States. National Council on Radiation Protection and Measurements; 2009. Available at: http://www.ncrponline.org/Publications/Press_Releases/160press.html. Accessed October 13, 2014.
3. Dauer LT. Exposed medical staff: challenges, available tools, and opportunities for improvement. Health Physics, 2014. 106(2):217-224. Available at: http://journals.lww.com/health-physics/Fulltext/2014/02000/Exposed_Medical_Staff__Challenges,_Available.11.aspx. Accessed October 13, 2014.
4. Vano E, Gonzalez L, Fernandez JM, Alfonso F, Macaya C. Occupational radiation doses in interventional cardiology: a 15-year follow-up. Br J Radiol, 2006. 79:383-388. Available at: http://www.birpublications.org/doi/abs/10.1259/bjr/26829723?journalCode=bjr. Accessed October 13, 2014.
5. Vano E. Reduction of exposure of patients and staff to radiation during fluoroscopically guided interventional procedures. Curr Radiol Rep, 2013;1:11-22. Available at: http://link.springer.com/article/10.1007/s40134-012-0001-9. Accessed October 13, 2014.
6. Kim KP, Miller DL, Balter S, Kleinerman RA, Linet MS, Kwon D, Simon SL. Occupational radiation doses to operators performing cardiac catheterization procedures. Health Phys 94:211-227; 2008. Available at: http://journals.lww.com/health-physics/Abstract/2008/03000/Occupational_Radiation_Doses_to_Operators.1.aspx. Accessed October 13, 2014.
7. Kim KP, Miller DL, Berrington de Gonzalez A, Balter S, Kleinerman RA, Ostroumova E, Simon SL, Linet MS. Occupational radiation doses to operators performing fluoroscopically guided procedures. Health Phys, 2012. 103:80-99. Available at: http://www.ncbi.nlm.nih.gov/pubmed/22647920. Accessed October 13, 2014.
8. Dauer LT, Thornton RH, Solomon SB, St Germain J. Unprotected operator eye lens doses in oncologic interventional radiology are clinically significant: estimation from patient kerma-areaproduct data. JVIR, 2010. 21:1859-1861. Available at: http://www.jvir.org/article/S1051-0443(10)00860-2/abstract. Accessed October 13, 2014.
9. NCRP Report No. 168. Radiation dose management for fluoroscopically-guided interventional medical procedures: National Council on Radiation Protection and Measurements; 2010. Available at: https://ncrponline.org/publications/reports/ncrp-report-168/. Accessed February 4, 2022.
10. ICRP Publication 118. ICRP statement on tissue reactions/early and late effects of radiation in normal tissues and organs - threshold doses for tissue reactions in a radiation protection context. International Commission on Radiological Protection. Ann ICRP 118; 2012. Available at: http://www.icrp.org/publication.asp?id=ICRP Publication 118. Accessed October 13, 2014.
11. Thornton RH, Dauer LT, Altamirano JP, Alvarado KJ, St Germain J, Solomon SB. Comparing strategies for operator eye protection in the interventional radiology suite. JVIR, 2010. 21:1703-1707. Available at: http://www.jvir.org/article/S1051-0443(10)00782-7/abstract. Accessed October 13, 2014.
12. Hirshfeld JW Jr, Balter S, Brinker JA, et al. ACCF/ AHA/HRS/SCAI clinical competence statement on physician knowledge to optimize patient safety and image quality in fluoroscopically guided invasive cardiovascular procedures: a report of the American College of Cardiology Foundation/ American Heart Association/American College of Physicians Task Force on Clinical Competence and Training. Circulation, 2005. 111:511-532. Available at: http://circ.ahajournals.org/content/111/4/511.full. Accessed October 13, 2014.
13. Stecker MS, Balter S, Towbin RB, et al. Guidelines for patient radiation dose management. JVIR 2009. 20:S263-S273. Available at: http://www.sirweb.org/clinical/cpg/Patient_Radiation_Dose_Management_Stecker.pdf. Accessed October 13, 2014.
14. Miller DL, Vano E, Bartal G, Balter S, Dixon R, Padovani R, Schueler B, Cardella JF, de Baere T. Occupational radiation protection in interventional radiology: a joint guideline of the Cardiovascular and Interventional Radiology Society of Europe and the Society of Interventional Radiology. JVIR 2010. 21:607-615. Available at: http://www.sirweb.org/clinical/cpg/safety6.pdf. Accessed October 13, 2014.
15. Chambers CE, Fetterly KA, Holzer R, Lin PJ, Blankenship JC, Balter S, Laskey WK. Radiation safety program for the cardiac catheterization laboratory. Catheter Cardiovasc Interv, 2011. 77:546-556. Available at: http://www.google.com/url?sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=1&sqi=2&ved=0CB4QFjAA&url=http://www.scai.org/asset.axd?id=9401c662-81a8-4589-b1f8-1c0c1647c059&t=634309820210970000&ei=LKBOVPScK8XjoATS1YCgDQ&usg=AFQjCNHS-Q6hodibIkH70WB6OVGtkmUNvw&bvm=bv.77880786,d.cGU. Accessed October 13, 2014.
16. NCRP Report No.122. Use of personal monitors to estimate effective dose equivalent and effective dose to workers for external exposure to low-LET radiation. National Council on Radiation Protection and Measurements; 1995. Available at: https://ncrponline.org/publications/reports/ncrp-reports-122/. Accessed February 4, 2022.
17. ICRP Publication 85. Avoidance of radiation injuries from medical interventional procedures. International Commission on Radiological Protection. Ann ICRP 30(2); 2000. Available at: http://www.icrp.org/publication.asp?id=ICRP Publication 85. Accessed October 13, 2014.
18. Rehani MM, Ciraj-Bjelac O, Vano E, Miller DL, Walsh S, Giordano BD, Persliden J. ICRP Publication 117. Radiological protection in fluoroscopically guided procedures performed outside the imaging department. International Commission on Radiological Protection. Ann ICRP 40:1-102; 2010. Available at: http://www.icrp.org/publication.asp?id=ICRP Publication 117. Accessed October 13, 2014.
19. IAEA. RELID (retrospective evaluation of lens injuries and dose) [online] 2012. Available at https://rpop.iaea.org/rpop/rpop/content/news/relid-cataract-study.htm. Accessed October 13, 2014.
20. Cousins C, Miller DL, Bernardi G, et al. ICRP Publication 120: Radiological protection in cardiology. International Commission on Radiological Protection. Ann ICRP 42; 2013. Available at: http://www.icrp.org/publication.asp?id=ICRP Publication 120. Accessed October 13, 2014.