Informative and direct how to minimize the radiation dose in Cath Lab with mentioning most technologies

1. P R E PA R E D B Y:
A H M A D M . A B U Q O R A H , R T
RADIATION SAFETY IN CATH.
LAB.
HOW TO PRACTICE ALARA?

2. OBJECTIVES
• Best practice of ALARA principle
• Learn more about radiation safety.
• Take a look on the new technologies.

3. ALARA PRINCIPLE
As
Low
As
Reasonably
Achievable

4. STOCHASTIC EFFECT
• Can occur by chance
• No threshold
• Can cause cancer
• May appear after
years or decades.
Incidence
of
effect
Dose
Stochastic effect
THERE IS NO
SAFE DOSE

5. DOSE ON TEAM, WHERE DOES IT COME
FROM?

6. DOSE FACTORS
All factors that minimizing the dose to the patient will
minimize the dose to the worker.
• Beam on time.
• Field size.
• Radiation beam intensity: Exposure control parameters,
Patient size, SID, X-ray mode (fluoroscopy or cine),
Magnification.
• Angulation.

7. HOW TO MINIMIZE THE DOSE?
• Beam-on-time:
It is very important to keep
exposure duration as short
as possible, and when exam
prolonged consider
changing projection to
change the entrance site.

8. HOW TO MINIMIZE THE DOSE?
• Distance:
Depends on inverse square
low:
• On patient:
Maximize distance between
the X ray tube and the patient
(SSD) as much as possible,
and minimize the distance
between x ray tube and image
receptor (SID) as much as
possible.

9. HOW TO MINIMIZE THE DOSE?
• Distance
• Minimizing air gap:

10. HOW TO MINIMIZE THE DOSE?
• Distance
• On team:
Stand back and maximize
distance as much as clinically
possible.

11. HOW TO MINIMIZE THE DOSE?
• Field size :
Reducing field size using
collimation will reduce dose
for both patient and the
team.

12. HOW TO MINIMIZE THE DOSE?
• Magnification:
• Magnification increases the
dose to both patient and
team by increasing the x-ray
output.
• Use post processing mag.
when possible.

13. HOW TO MINIMIZE THE DOSE?
• Fluoroscopy and
cine:
Cine produces six times more
dose than fluoroscopy.

14. HOW TO MINIMIZE THE DOSE?
• Angulation:
• Cranial and caudal views
increase dose by increasing
the distance which x ray
beam has to travel, also
more tissue attenuation will
result in increasing dose.

15. HOW TO MINIMIZE THE DOSE?
• Angulation:
• LAO views give higher dose
than RAO views when the
operator stand on the right
side of the patient.

16. HOW TO MINIMIZE THE DOSE?
• Angulation:
• LAO-Cranial considered the
highest dose view, so try to
avoid using it as possible.
• Avoid using deep views as
possible.

17. HOW TO MINIMIZE THE DOSE?
• Isocenter:
Putting the target (lesion) in
the isocenter will reduce the
dose by minimizing the need
to repositioning the patient
under fluoroscopy.

18. HOW TO MINIMIZE THE DOSE?
• Using filters: (X Ray
beam hardening)
Added filtration will eliminate
low energy photons from the
primary beam.

19. HOW TO MINIMIZE THE DOSE?
• Using system
options:
• Pulsed fluoroscopy:
Because of the human eye
nature no need to use a
continues fluoroscopy or a
high pulse rate fluoroscopy,
actually 15 p/s should be
enough for your eye to see
fluoroscopy just like
continuous.

20. HOW TO MINIMIZE THE DOSE?
• Using system
options:
• Radiation free positioning:
Based on last image hold (LIH)
; radiation free positioning
option gives you the ability to
move your fields center point,
collimate, and put the wedge
filters all radiation free.

21. HOW TO MINIMIZE THE DOSE?
• Using system
options:
• Removable grid:
As children are more
sensitive to radiation and
there tiny and thin bodies do
not produce much scattered
radiation, then grid may be
removed which will reduce
the dose.

22. HOW TO MINIMIZE THE DOSE?
• Using system
options:
• Store fluoroscopy:
Store fluoroscopy option can
save the last fluoroscopy run
without a need to extra dose
from acquisition.

23. HOW TO MINIMIZE THE DOSE?
• Using system
options:
• ECG triggered fluoroscopy:
This enables one image per
heartbeat to be displayed
because the image is triggered
by the R wave on the ECG.
• This option would be suited
for long fluoroscopy times
such as ablations.

24. HOW TO MINIMIZE THE DOSE?
• Using system
options:
• Dual axis rotational coronary
angiography (Swing):
This option gives the operator
the ability to get all desired
anatomical views in a single
run, which will reduce dose for
both patient and the team.

25. HOW TO MINIMIZE THE DOSE?
• Using system
options:
• Live zoom:
This option digitally magnify the
image without the need for
traditional electronic
magnification which depends
on FOV.

26. HOW TO MINIMIZE THE DOSE?
• Procedure strategy:
• Start procedure with
minimum mag. possible.
• When going with wire from
femoral or radial artery stay
in PA view until engagement.
• For L.V use RAO from the
beginning.
• Tightly collimate during
engagement procedure.
• Use lung filters.
• Use low contrast fluoroscopy
as possible

27. SHIELDING
• Lead aprons:
• Are the most effective
shielding.
• May reduce dose up to
90%.
• Wrap-around aprons with
0.25 lead equivalent that
overlaps on front to give 0.5
lead equivalent are the best.

28. SHIELDING
• Thyroid protection:
It is highly recommended to
wear it all the time in the
cath. lab.

29. SHIELDING
• Lead glasses:
• Lens of the eye is very
sensitive to x ray.
• The last recommendations
from ICRP on 2011 reduce
equivalent dose limit from
75 mSv to 20 mSv.

30. SHIELDING
• Sterile radiation
attenuation
gloves:
• Using such type of gloves
reduces skin dose
delivered to hands from
scattered radiation about
35% up to 58%.
• However, if hands get in
the primary beam field,
total dose will be
increased.

31. SHIELDING
• Modality built in
shielding:
Use ceiling suspended
screens, lateral shield, and
table curtains will provide
more than 90% protection
from scattered radiation in
fluoroscopy.
Ceiling
suspende
d screens
Table curtains

32. SHIELDING
• Mobile radiation
shield:
• This type of shield is
advised in prolonged
studies.
• It may give a protection up
to 99% protection from the
scattered radiation*.
*Manufacturer data.

33. SHIELDING
• Shield drapes:
• Shield drapes are a sterile
disposable drapes may be
used for further protection.
• It is supposed to reduce
dose for operator and team
from 50% to 95%*.
*Manufacturer data.

34. SHIELDING
• Star System

35. PERSONAL DOSIMETRY
• Use at least two
dosimeters:
• One inside the apron at
chest level.
• One outside the apron at
neck or eye level.
• Additional finger ring
dosimeter for procedures
requiring hands close to
primary beam.

36. RECOMMENDATIONS
• Use imaging techniques that maintain dose low.
• Use shielding.
• Use every available option on your system that can
reduce dose.
• Initiate a good radiation safety program in your lab
combined to a quality control program.
• Continues learning about radiation safety for all the team
is highly recommended.
• Periodically check on aprons and other protection
equipment.

37. CONCLUSION
• Radiation safety is a serious topic that should always
kept in mind.
• Time, distance, and shielding are the major factors in
respect minimizing dose.
• Any reduction in the amount of radiation is a benefit to
you.
• Cath. lab. modalities available in the market today have
many options in respect minimizing dose.

39. • Dose reduce technologies (Clarity, Care and clear,
Blue??)
• Dose map
• 3d mapping
• Radiation meter?
• Digital dosimeter