08. Optimization of medical exposure: Therapy (1,774 KB)

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  • This is just an example of a method to calculate the relation between the prescribed dose and the resulting administered activity. There are several other methods. The image can be used to start a discussion about what should be prescribed by the physician: activity or dose?
  • An uptake measurement should be used in order to calculate the administered activity
  • A gammacamera examination of the thyroid will give an estimate of the sixe of the organ
  • This is an example of an application programme that calculate the size of the organ and the uptake of Tc99m-pertechnetate.
  • The image describes the safety equipment and precautions for safe dispensing of iodine-131. Note the extra thick shielding necessary because of the high energy photons from the radionuclide
  • This image shows the uptake of pertechnetate in the breast of a lactating women scheduled for a thyroid scan. The activity in the breasts is about 50% of the administered. The thyroid has an uptake of 1-2%.
  • Discuss with the students why all this information is necessary
  • Well illuminated, shielded container, table covered with absorbing paper, no hands on the table, patient clothes are protected.
  • Should a radioactive patient (diagnostics, therapy) be placed together with other patients?
  • This is one example of behaviour restrictions
  • And another one
  • This is the result of measurements of the effective dose to members of the family of therapy patients. They were all given restrictions according to previous images. Note that all values are lower than the given dose constraints and that there was no correlation between the administered activity and the dose. Social factors are more important.
  • This is an illustration of how a flexible system can be introduced for patients undergoing a iodine therapy
    If the activity is >1100 MBq, the patient should always be hospitalized
    Between 600-1100MBq the patients condition and social life determines if he/she should be hospitalized or not.
    Between 150-600 MBq the patient is always released and is given personal advice and restrictions.
    Below 150 MBq the patient is given only general advice of behavior restrictions regarding contact with children and pregnant women.
  • This is an example of a form that should be filled in for every released patient giving the necessary information to the family members
  • In some hospitals visitors are not allowed at any time
  • The measurements should be documented
  • 08. Optimization of medical exposure: Therapy (1,774 KB)

    1. 1. Radiation Protection inRadiation Protection in Radionuclide TherapyRadionuclide Therapy Part 8 IAEA Training Material on Radiation Protection in Nuclear Medicine
    2. 2. Part 8. Therapy 2Nuclear Medicine OBJECTIVEOBJECTIVE To be able to apply the principle of optimization of radiation protection to therapeutic procedures including design, operational consideration, quality control and clinical dosimetry..
    3. 3. Part 8. Therapy 3Nuclear Medicine ContentContent Basic requirements Administration of therapy The radioactive patient. Dose constraints The hospitalized patient Emergency procedures
    4. 4. Module 8.1 Basic requirementsModule 8.1 Basic requirements Part 8 Optimization of Protection inOptimization of Protection in Medical ExposureMedical Exposure IAEA Training Material on Radiation Protection in Nuclear Medicine
    5. 5. Part 8. Therapy 5Nuclear Medicine JUSTIFICATION OF MEDICALJUSTIFICATION OF MEDICAL EXPOSURES (BSS)EXPOSURES (BSS) Weigh diagnostic and therapeutic benefits against radiation detriment, and benefits and risks of alternative techniques. Use WHO guidelines
    6. 6. Part 8. Therapy 6Nuclear Medicine JUSTIFICATION (BSS)JUSTIFICATION (BSS) Decision on administration of therapy must be taken by a physician who has proper training and sufficient knowledge of radionuclide therapy.
    7. 7. Part 8. Therapy 7Nuclear Medicine RESPONSIBILITIESRESPONSIBILITIES With regard to responsibilities for medical exposure, registrants and licensees shall ensure that (BSS II.1–3): • no patient is administered a diagnostic medical exposure unless the exposure is prescribed by a medical practitioner; • medical practitioners are assigned the primary task and obligation of ensuring overall patient protection and safety in the prescription of, and during the delivery of, medical exposure; • medical and paramedical personnel are available as needed, and are either health professionals or have appropriate training to discharge their assigned tasks in the conduct of the diagnostic or therapeutic procedure that the medical practitioner prescribes; • the exposure of individuals incurred knowingly while voluntarily helping (other than in their occupation) in the care, support or comfort of patients undergoing medical diagnosis or treatment is constrained as specified in Appendix C; and • training criteria are specified or subject to approval, as appropriate, by the Regulatory Authority in consultation with relevant professional bodies.
    8. 8. Part 8. Therapy 8Nuclear Medicine RESPONSIBILITIESRESPONSIBILITIES The licensee shall ensure that workers (medical practitioner, medical physicist, technologist): • follow any applicable rules and procedures for the protection and safety of patients, as established by the licensee; • are competent in the operation and use of the equipment and sources employed in nuclear medicine, of the equipment for radiation detection and measurement, and of the safety systems and devices, commensurate with the significance of the workers’ functions and responsibilities; and • know their expected response in the case of patient emergencies.
    9. 9. Part 8. Therapy 9Nuclear Medicine CLINICAL DOSIMETRY (BSS)CLINICAL DOSIMETRY (BSS) Registrants and licensees shall ensure that the following items be determined and documented: in diagnosis and treatment with unsealed sources, representative absorbed doses to relevant organs
    10. 10. Part 8. Therapy 10Nuclear Medicine Medical physicistMedical physicist A qualified medical physicist should be responsible for measurement of radionuclide activity, identification of radionuclides and internal radiation dosimetry
    11. 11. Part 8. Therapy 11Nuclear Medicine ABSORBED DOSE-ADMINISTERED ACTIVITYABSORBED DOSE-ADMINISTERED ACTIVITY I-131I-131 Thyroid mass (g) 30 Prescibed dose (Gy) 100 Uptake measurements Time Standard Patient Bg Uptake (h) (cpm) (cpm) (cpm) (%) 0 - - - 73,5 2 21736 5521 100 25,1 24 18286 12338 100 67,3 48 17165 10565 100 61,3 144 13171 5754 100 43,3 Effective half-life (d): 4,0 Activity to administer (MBq): 240 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 Example of method to calculate administered activity from Prescribed absorbed dose to the thyroid
    12. 12. Part 8. Therapy 12Nuclear Medicine UPTAKE MEASUREMENTUPTAKE MEASUREMENT
    13. 13. Part 8. Therapy 13Nuclear Medicine GAMMA CAMERA EXAMINATIONGAMMA CAMERA EXAMINATION
    14. 14. Part 8. Therapy 14Nuclear Medicine GAMMA CAMERAGAMMA CAMERA EXAMINATIONEXAMINATION Used to determine the size of the organ
    15. 15. Part 8. Therapy 15Nuclear Medicine Safe handling of radionuclides • ordering • receipt and unpacking • storage • dispensing • internal transports • radioactive waste Safe administration • Identification • pregnancy • breastfeeding Factors affecting safety inFactors affecting safety in radionuclide therapyradionuclide therapy 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
    16. 16. Part 8. Therapy 16Nuclear Medicine •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. ORDERING, RECEIPT &ORDERING, RECEIPT & UNPACKINGUNPACKING
    17. 17. Part 8. Therapy 17Nuclear Medicine •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. Storage of I-131
    18. 18. Part 8. Therapy 18Nuclear Medicine • 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 DISPENSING
    19. 19. Part 8. Therapy 19Nuclear Medicine Internal transportInternal 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
    20. 20. Part 8. Therapy 20Nuclear Medicine RADIOACTIVE WASTERADIOACTIVE WASTE Shall be collected, segregated and disposed of according to national regulations and local rules.
    21. 21. Module 8.Module 8.22 Administration of therapyAdministration of therapy Part 8 Optimization of Protection inOptimization of Protection in Medical ExposureMedical Exposure IAEA Training Material on Radiation Protection in Nuclear Medicine
    22. 22. Part 8. Therapy 22Nuclear Medicine • 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. PRECAUTIONS BEFORE ADMINISTRATION
    23. 23. Part 8. Therapy 23Nuclear Medicine Registrants and licensees shall ensure for nuclear medicine that: Administration of radionuclides for diagnostic or radiotherapeutic procedures to women pregnant or likely to be pregnant be avoided unless there are strong clinical indications. PREGNANCY (BSS)PREGNANCY (BSS)
    24. 24. Part 8. Therapy 24Nuclear Medicine Radioiodine therapy andRadioiodine therapy and pregnancypregnancy Radioiodine easily crosses the placenta and therapeutic doses can pose significant problems for the fetus, particularly permanent hypothyroidism.
    25. 25. Part 8. Therapy 25Nuclear Medicine Radio-iodine therapyRadio-iodine 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.
    26. 26. Part 8. Therapy 26Nuclear Medicine Radio-iodine therapyRadio-iodine 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.
    27. 27. Part 8. Therapy 27Nuclear Medicine Inadvertent administration of therapy doseInadvertent 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 tubal ligation 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.
    28. 28. Part 8. Therapy 28Nuclear Medicine Becoming pregnant after irradiationBecoming pregnant after irradiation •ICRP has recommended that a woman not become pregnant until the potential fetal dose from remaining radionuclides is less than 1 mGy.
    29. 29. Part 8. Therapy 29Nuclear Medicine PREGNANCY AFTERPREGNANCY AFTER THERAPYTHERAPY Radiopharmaceutical All activities Avoid pregnancy up to (MBq) (months) Au-198 colloid 10000 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
    30. 30. Part 8. Therapy 30Nuclear Medicine Registrants and licensees shall ensure for nuclear medicine that: For mothers in lactation, discontinuation of nursing be recommended until the radiopharmaceutical is no longer secreted in an amount estimated to give an unacceptable effective dose to the nursling BREASTFEEDING (BSS)BREASTFEEDING (BSS)
    31. 31. Part 8. Therapy 31Nuclear Medicine BREASTFEEDINGBREASTFEEDING
    32. 32. Part 8. Therapy 32Nuclear Medicine 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?
    33. 33. Part 8. Therapy 33Nuclear Medicine ADMINISTRATION OF THERAPYADMINISTRATION OF THERAPY CALIBRATION OF SOURCES (BSS)CALIBRATION OF SOURCES (BSS) “Registrants and licensees shall ensure that: unsealed sources for nuclear medicine procedures be calibrated in terms of activity of the radiopharmaceutical to be administered, the activity being determined and recorded at the time of administration;”
    34. 34. Part 8. Therapy 34Nuclear Medicine • 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. SAFE ADMINISTRATION
    35. 35. Part 8. Therapy 35Nuclear Medicine SAFE ADMINISTRATIONSAFE ADMINISTRATION
    36. 36. Part 8. Therapy 36Nuclear Medicine 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 Safe administrationSafe administration
    37. 37. Module 8.Module 8.33 The radioactive patient.The radioactive patient. Dose constraintsDose constraints Part 8 Optimization of Protection inOptimization of Protection in Medical ExposureMedical Exposure IAEA Training Material on Radiation Protection in Nuclear Medicine
    38. 38. Part 8. Therapy 38Nuclear Medicine Shall the patient be hospitalized?Shall the patient be hospitalized? Can the patient leave?Can the patient leave? Any restrictions?Any restrictions?
    39. 39. Part 8. Therapy 39Nuclear Medicine Dose constraintsDose constraints (BSS)(BSS) “Registrants and licensees shall constrain any dose to individuals incurred knowingly while voluntarily helping (other than in their occupation) in the care, support or comfort of patients undergoing medical diagnosis or treatment and to visitors to patients who have received therapeutic amounts of radionuclides or are being treated with brachytherapy sources”
    40. 40. Part 8. Therapy 40Nuclear Medicine Dose limitation for comfortersDose limitation for comforters and visitors of patientsand visitors of patients (BSS Schedule II.9)(BSS Schedule II.9) ..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
    41. 41. Part 8. Therapy 41Nuclear Medicine Exposures from patientExposures from patient 1000 MBq I-131 0 0.5 1 2 m 0.5 0.1 0.06 0.03 mSv/h Contamination External saliva perspiration breath urine
    42. 42. Part 8. Therapy 42Nuclear Medicine Biodistribution of I-131Biodistribution of I-131 (MIRD)
    43. 43. Part 8. Therapy 43Nuclear Medicine Excretion of I-131Excretion of I-131
    44. 44. Part 8. Therapy 44Nuclear Medicine CONTAMINATIONCONTAMINATION Excretion Concentration Contamination Saliva <2 MBq/g utensils 2 kBq Perspiration <20 Bq/cm2 surfaces 10 Bq/cm2 Breathing 100 Bq/l air 1 Bq/l Urine < 500 kBq/ml toilet 2 kBq/cm2 Administered activity: 1000 MBq I-131 Generally larger than the derived limits for contamination given by ICRP (publ 57)
    45. 45. Part 8. Therapy 45Nuclear Medicine Exposures fromExposures from PatientPatient 3 μSv /h* GBq , 0 m 0 0,5 1 m 26 9 3μSv/h* GBq 6 μSv /h* GBq , 0 m Sm-153 Activity concentration in urine: 0.3 MBq/ml*GBq
    46. 46. Part 8. Therapy 46Nuclear Medicine External Exposure fromExternal Exposure from PatientPatient Sm-153Sm-153 Dose rate at 0.5 m 0 2 4 6 8 10 0 1 2 3 4 5 Time after injection (h) Meandoserate(µSv/h*GBq)
    47. 47. Part 8. Therapy 47Nuclear Medicine RESTRICTIONSRESTRICTIONS Patient with iodine-131 Activity of I-131 administered (MBq) 30-200 200-400 400-600 600-800 Behaviour restriction Period of restrictions (d) Stay at least 1 metre away from all members of the household except for very brief periods (a few minutes every day) 5 9 12 14 Restrict close contact (“cuddling” with all members of the household to less than 15 minutes per day, and sleep separately from them 15 21 25 27 Sleep separately from “comforters and cares” - - 4 8 Avoid prolonged close contact (more than 3 hours at <1 metre) with other adults - - - 1 NOTE THAT: The restriction times in the first two rows run concurrently e.g. for 30-200MBq category, a child should only be cuddled for brief periods for 5 days, then cuddling must be restricted to 15 min per day for a further 10 days. The dose constraint for the third row is 5 mSv The fourth row only covers on single event whereas the other categories assume daily contact.
    48. 48. Part 8. Therapy 48Nuclear Medicine RESTRICTIONSRESTRICTIONS Public travel Sleep apart Restricted close contact allowed per day Off from partner with children Activity 1:st w 2:nd w work pregn. no <2 y 2-5 y 5-11 y (MBq) (h) (h) (d) (d) (d) (d) (d) (d) 200 3,5 24 0 15 1 15 11 5 400 1,5 14 3 20 8 21 16 11 600 1 9 6 24 11 25 20 14 800 0,5 7 8 26 13 27 22 16 Patient with iodine-131
    49. 49. Part 8. Therapy 49Nuclear Medicine 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 THERAPY PATIENTTHERAPY PATIENT
    50. 50. Part 8. Therapy 50Nuclear Medicine MEASUREMENTSMEASUREMENTS Husband/wife 220-3100 μSv Children 110- 700 μSv No correlation between administered activity and doses to members of the family. 25 patients who received 220-600 MBq I-131 University Hospital, Gothenburg, Sweden
    51. 51. Part 8. Therapy 51Nuclear Medicine The patient should be kept at least 2h, and if possible one day in the hospital. In the case of cancer treatment, the patient should generally be hospitalized for several days. In all cases, the dose rate at 1 m from the patient should be down to an acceptable level established by the RPC. TherapyTherapy PatientPatient I-131I-131
    52. 52. Part 8. Therapy 52Nuclear Medicine PATIENT SURVEYPATIENT SURVEY Typical Graph of the Exposure Rate at 1 m from the Patient Administered with of 5.5 GBq I-131 0 2 4 6 8 10 12 14 1 2 3 4 5 Days of Isolation ExposureRate(mR/hr) Abdalla Al-Haj
    53. 53. Part 8. Therapy 53Nuclear Medicine Guidance level for maximum activity for patients in therapy on discharge from hospital
    54. 54. Part 8. Therapy 54Nuclear Medicine HOSPITALIZATION OR NOTHOSPITALIZATION 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
    55. 55. Part 8. Therapy 55Nuclear Medicine • 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: ………… INSTRUCTIONS TO OUT-PATIENTS
    56. 56. Part 8. Therapy 56Nuclear Medicine • 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. AVOIDING SOLID WASTE Sensitive detectors at sanitary landfills and solid waste transfer and processing sites have identified contaminated articles from nuclear medicine patients.
    57. 57. Part 8. Therapy 57Nuclear Medicine
    58. 58. Module 8.Module 8.44 TheThe hospitalizedhospitalized patientpatient Part 8 Optimization of Protection inOptimization of Protection in Medical ExposureMedical Exposure IAEA Training Material on Radiation Protection in Nuclear Medicine
    59. 59. Part 8. Therapy 59Nuclear Medicine • 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 Hospitalized patientHospitalized patient
    60. 60. Part 8. Therapy 60Nuclear Medicine Room for iodine therapyRoom for iodine therapy (controlled area(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
    61. 61. Part 8. Therapy 61Nuclear Medicine ISOLATION WARDISOLATION WARD Areas are covered with plastic backed absorbent material. Areas are covered with plastic backed absorbent material. Bed shield is positionedBed shield is positioned King Faisal Specialist Hospital and Research Center, Riyadh
    62. 62. Part 8. Therapy 62Nuclear Medicine WARNING SIGNSWARNING SIGNS Radiation sign posted on door and on Patient Chart King Faisal Specialist Hospital and Research Center, Riyadh
    63. 63. Part 8. Therapy 63Nuclear Medicine • 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 after using toilet. • Wear footwear when leaving the bed. • In event of vomiting or incontinence notify the nurse immediately. PATIENT INSTRUCTIONSPATIENT INSTRUCTIONS
    64. 64. Part 8. Therapy 64Nuclear Medicine • 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. INSTRUCTIONS TO NURSINGINSTRUCTIONS TO NURSING STAFFSTAFF
    65. 65. Part 8. Therapy 65Nuclear Medicine 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. VISITORS WARNING CARD
    66. 66. Part 8. Therapy 66Nuclear Medicine The patient may leave the hospital when his/her radiation level has dropped below the equivalent activity level specified by the Regulatory Authority or 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 general precautions for out-patients DISCHARGE OF PATIENTDISCHARGE OF PATIENT
    67. 67. Part 8. Therapy 67Nuclear Medicine DISCHARGE OF PATIENTDISCHARGE OF PATIENT Typical Graph Showing the Percentage of I-131that is Retained in the Body of a Patient Administered with 5.5 GBq 0 10 20 30 40 50 60 70 80 90 100 1 2 3 4 5 Day of Isolation PercentageofI-131inBody Abdalla Al-Haj
    68. 68. Part 8. Therapy 68Nuclear Medicine DISCHARGE OF PATIENTDISCHARGE OF PATIENT Graph Showing the Number of Patients (5GBq) and the Number of Days of Isolation (Year 2000 Statistics) 0 142 10 31 8 0 20 40 60 80 100 120 140 160 1 2 3 4 5 Number of Days of Isolation NumberofPatients (4%) (75%) (16%) (5%) Abdalla Al-Haj
    69. 69. Part 8. Therapy 69Nuclear Medicine DECONTAMINATIONDECONTAMINATION 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.
    70. 70. Part 8. Therapy 70Nuclear Medicine MONITORINGMONITORING Furniture and telephone sets are surveyed. Areas suspected to be contaminated are surveyed. King Faisal Specialist Hospital and Research Center, Riyadh
    71. 71. Part 8. Therapy 71Nuclear Medicine MONITORINGMONITORING Area or item Initial (Bq/cm2 ) After cleaning (Bq/cm2 ) Toilet Washroom floor Sink and Faucets Shower Bed Armchair Bedroom floor TV/Telephone Bedside table Doorknobs Lamp switches Derived limit: 3 Bq/cm2 METHODS • wipe testing • direct surveying
    72. 72. Part 8. Therapy 72Nuclear Medicine READY FOR A NEW PATIENTREADY 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
    73. 73. Part 8. Therapy 73Nuclear Medicine • 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. • Cutlery and dishes should be washed in the patient’s room and reused by the patient. RADIOACTIVE WASTE
    74. 74. Part 8. Therapy 74Nuclear Medicine RADIOACTIVE WASTERADIOACTIVE WASTE All patient radioactive wastes are placed in a plastic bag and the bag is properly tagged. King Faisal Specialist Hospital and Research Center, Riyadh
    75. 75. Module 8.Module 8.5 Emergency procedures5 Emergency procedures Death of patientDeath of patient Part 8 Optimization of Protection inOptimization of Protection in Medical ExposureMedical Exposure IAEA Training Material on Radiation Protection in Nuclear Medicine
    76. 76. Part 8. Therapy 76Nuclear Medicine HELP!
    77. 77. Part 8. Therapy 77Nuclear Medicine SAFETY ASSESSMENTSAFETY ASSESSMENT CONTINGENCY PLANCONTINGENCY 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.
    78. 78. Part 8. Therapy 78Nuclear Medicine 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. Radionuclide Burial Cremation I-131 400 400 Y-90 colloid 2000 70 Au-198 colloid 400 100 P-32 2000 30 Sr-89 2000 200 DEATH OF PATIENTDEATH OF PATIENT Activity (MBq) (UK)
    79. 79. Part 8. Therapy 79Nuclear Medicine 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 DEATH OF PATIENT
    80. 80. Part 8. Therapy 80Nuclear Medicine Questions?
    81. 81. Part 8. Therapy 81Nuclear Medicine DISCUSSIONDISCUSSION Discuss the advantages/disadvantages of giving the patient a standard activity of I-131 in a capsule or giving a carefully calculated activity based on a prescribed dose to the thyroid.
    82. 82. Part 8. Therapy 82Nuclear Medicine DISCUSSIONDISCUSSION 1. Who should prescribe a thyroid treatment with I-131? 2. Who should perform the treatment?
    83. 83. Part 8. Therapy 83Nuclear Medicine DISCUSSIONDISCUSSION Define some emergency situations or other hazardous events that can occur in an isolation ward and how to handle the situations.
    84. 84. Part 8. Therapy 84Nuclear Medicine Where to Get MoreWhere to Get More InformationInformation 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, (1996) IPEM, Medical and Dental Guidance Notes. A good practice guide to implement ionising radiation protection legislation in the clinical environment (draft) IAEA/WHO Manual on Radiation Protection in Hospitals and General Practice, Volume 4, Nuclear Medicine (draft) IAEA, Manual on therapeutic use of iodine-131. Practical Radiation Safety Guide

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