An investigation of operator exposure in interventional radiology

A VR neurointerventional setup for catheter-based interventions focusing on visualizing the risk of radiation

Interventional neuroradiologists carry out their minimally-invasive procedure by using X-rays within the setup of a Bi-plane Digital Subtraction Angiography. This work provides an immersive virtual reality (VR) environment where the physicians can perform an simulated catheter-based intervention. Since radiation is invisible, the risk of radiation exposure can be enhanced virtually. Our goal is to see whether radiation visualization influences medical professionals such that they take a more mindful approach towards interactions on the operating table then without one. We tested our scenario within an expert study where ten neuroradiologists participated and solved intervention-related tasks. Our expert study found that while visualization does not affect the placement of the radiation shield by the physician, the overall radiation exposure using visualization does decrease as users standing very close move to a greater distance from the table. Furthermore, our System Usability Scale evaluation revealed a high score for this approach's usability.

Technical note: A comparison of physician doses in C-Arm and CT fluoroscopy procedures

PURPOSE

We address the misconception that the typical physician dose is higher for CT fluoroscopy (CTF) procedures compared to C-Arm procedures.

METHODS

We compare physician scatter doses using two methods: a literature review of reported doses and a model based on a modified form of the dose area product (DAP). We define this modified form of DAP, "cumulative absorbed DAP," as the product of the area of the x-ray beam striking the patient, the dose rate per unit area, and the exposure time.

RESULTS

The patient entrance dose rate for C-Arm fluoroscopy (0.2 mGy/s) was found to be 15 times lower than for CT fluoroscopy (3 mGy/s). A typical beam entrance area for C-Arm fluoroscopy reported in the literature was found to be 10.6 × 10.6 cm (112 cm2), whereas for CTF was 0.75 × 32 cm (24 cm2). The absorbed DAP rate for C-Arm fluoroscopy (22 mGy*cm2/s) was found to be 3.3 times lower than for CTF (72 mGy*cm2/s). The mean fluoroscopy time for C-Arm procedures (710 s) was found to be 21 times higher than for CT fluoroscopy procedures (23 s). The cumulative absorbed DAP for C-Arm procedures was found to be 9.4 times higher when compared to CT procedures (1.59 mGy*m2 vs. 0.17 mGy*m2).

CONCLUSIONS

The higher fluoroscopy time in C-Arm procedures leads to a much lower cumulative DAP (i.e., physician scatter dose) in CTF procedures. This result can inform interventional physicians deciding on whether to perform inter-procedural imaging inside the room as opposed to retreating from the room.

Femoral Neck Fractures Treated by Closed Reduction and Internal Fixation with the Double Fluoroscope Technique: A Preliminary Study

Background: Fractures of the femur require significant radiation exposure during operations using fluoroscopy (C-arm), posing a high risk of radiation exposure to the medical staff and patients. To address this concern, in this study, we investigated the efficacy of using two fluoroscopy machines simultaneously. Methods: We categorized 30 patients with femoral neck fracture (FNF) into single and double C-arm groups. The operation and radiation exposure times during a closed reduction and internal fixation operation were investigated to evaluate whether the operation and radiation exposure times were effectively audited when the operation was performed using a double C-arm. Results: The total operation times were 93.21 ± 20.70 min and 66.69 ± 13.97 min for the single and double C-arm groups, respectively. Additionally, the total radiation times were 100.43 ± 24.59 s and 83.06 ± 19.53 s for the single and double C-arm groups, respectively. Operation and radiation exposure times in the two groups showed statistically significant differences (p < 0.05). Conclusion: The use of double C-arm in FNF can reduce operation and radiation exposure times. Hence, using the double C-arm in surgical treatment could reduce the risk of radiation exposure to medical staff and patients.

Performance of elastic x-ray shield made by embedding Bi2 O3 particles in porous polyurethane

BACKGROUND

Many healthcare institutions have guidelines concerning the usage of protective procedures, and various x-ray shields have been used to reduce unwanted radiation exposure to medical staff and patients when using x-rays. Most x-ray shields are in the form of sheets and lack elasticity, which limits their effectiveness in shielding areas with movement, such as the thyroid. To overcome this limitation, we have developed an innovative elastic x-ray shield.

PURPOSE

The purpose of this study is to explain the methodology for developing and evaluating a novel elastic x-ray shield with sufficient x-ray shielding ability. Furthermore, valuable knowledge and evaluation indices are derived to assess our shield's performance.

METHODS

Our x-ray shield was developed through a process of embedding Bi2 O3 particles into porous polyurethane. Porous polyurethane with a thickness of 10 mm was dipped into a solution of water, metal particles, and chemical agents. Then, it was air-dried to fix the metal particles in the porous polyurethane. Thirteen investigational x-ray shields were fabricated, in which Bi2 O3 particles at various mass thicknesses (ranging from 585 to 2493 g/m2 ) were embedded. To determine the performance of the shielding material, three criteria were evaluated: (1) Dose Reduction Factor (D R F $DRF$ ), measured using inverse broad beam geometry; (2) uniformity, evaluated from the standard deviation (S D $SD$ ) of the x-ray image obtained using a clinical x-ray imaging detector; and (3) elasticity, evaluated by a compression test.

RESULTS

The elastic shield with small pores, containing 1200 g/m2 of the metal element (Bi), exhibited a well-balanced performance. TheD R F $DRF$ was approximately 80% for 70 kV diagnostic x-rays. This shield's elasticity was -0.62 N/mm, a loss of only 30% when compared to porous polyurethane without metal. Although the non-uniformity of the x-ray shield leads to poor shielding ability, it was found that the decrease in the shielding ability can be limited to a maximum of 6% when the shield is manufactured so that theS D $SD$ of the x-ray image of the shield is less than 10%.

CONCLUSIONS

It was verified that an elastic x-ray shield that offers an appropriate reduction in radiation exposure can be produced by embedding Bi2 O3 particles into porous polyurethane. Our findings can lead to the development of novel x-ray shielding products that can reduce the physical and mental stress on users.

Radiation exposure in augmented fluoroscopic bronchoscopy procedures: a comprehensive analysis for patients and physicians

Cancer is a major health challenge and causes millions of deaths worldwide each year, and the incidence of lung cancer has increased. Augmented fluoroscopic bronchoscopy (AFB) procedures, which combine bronchoscopy and fluoroscopy, are crucial for diagnosing and treating lung cancer. However, fluoroscopy exposes patients and physicians to radiation, and therefore, the procedure requires careful monitoring. The National Council on Radiation Protection and Measurement and the International Commission on Radiological Protection have emphasised the importance of monitoring patient doses and ensuring occupational radiation safety. The present study evaluated radiation doses during AFB procedures, focusing on patient skin doses, the effective dose, and the personal dose equivalent to the eye lens for physicians. Skin doses were measured using thermoluminescent dosimeters. Peak skin doses were observed on the sides of the patients' arms, particularly on the side closest to the x-ray tube. Differences in the procedures and experience of physicians between the two hospitals involved in this study were investigated. AFB procedures were conducted more efficiently at Hospital A than at Hospital B, resulting in lower effective doses. Cone-beam computed tomography (CT) contributes significantly to patient effective doses because it has higher radiographic parameters. Despite their higher radiographic parameters, AFB procedures resulted in smaller skin doses than did image-guided interventional and CT fluoroscopy procedures. The effective doses differed between the two hospitals of this study due to workflow differences, with cone-beam CT playing a dominant role. No significant differences in left and right eyeHp(3) values were observed between the hospitals. For both hospitals, theHp(3) values were below the recommended limits, indicating that radiation monitoring may not be required for AFB procedures. This study provides insights into radiation exposure during AFB procedures, concerning radiation dosimetry, and safety for patients and physicians.

Better safe than so ray: national survey of radiation protection amongst interventional radiology trainees in the United Kingdom

OBJECTIVE

To establish the provision and use of radiation personal protective equipment (PPE) and dosimetry amongst UK interventional radiology (IR) trainees and highlight areas of improvement in order to enhance the radiation safety.

METHODS

A survey questionnaire was designed by members of the British Society of Interventional Radiology (BSIR) trainee committee via survey monkey and distributed to UK IR trainees via the BSIR membership mailing list, local representatives and Twitter. The survey was open from 04/01/2021 to 20/02/2021. Only IR trainees in years ST4 and above were included.

RESULTS

Of the 73 respondents, 62 qualified for analysis. Respondents (81% male) spent a median of 5.5 sessions (half day list) per week in the angiography suite and 58% (n=36) had difficulty finding appropriately sized lead aprons at least once a week. Overall 53% (n=33) had concerns about their radiation PPE. Furthermore 56% of trainees (n=35) experienced back pain among other symptoms attributed to wearing the lead aprons available to them. 77% (n=48) regularly wore lead glasses. For trainees requiring prescription glasses (n=22) overfit goggles were provided however 17 (77%) of these trainees felt the goggles compromised their ability to perform the procedure. Eye and finger dosimeters were used by 50% and 52% of respondents respectively. Compliance with body dosimetry was 99%.

CONCLUSION

Provision of radiation PPE and dose monitoring for IR trainees is suboptimal, particularly access to adequate eye protection or suitably fitting leads. Based on the findings of this survey, recommendations have been made to promote the safety and radiation awareness of IR trainees.

ADVANCES IN KNOWLEDGE

Radiation protection practices for IR trainees nationally are poor. Provision of suitable eye protection and well fitting lead body protection is low.

Modified design of x-ray protective clothing to enhance radiation protection for interventional radiologists

BACKGROUND

In interventional radiology procedures, the operator typically stands on the right side of the patient's right thigh to manipulate devices through the femoral sheath. Because the standard x-ray protective clothing is designed as sleeveless and scatter radiations from the patient are mainly incident from the left-anterior direction to the operator, the arm hole of the clothing may be a significant unprotected area, contributing to an increase in the operator's organ doses and effective dose.

PURPOSE

This study aimed to compare the organ doses and effective dose received by the interventional radiologist when wearing the standard x-ray protective clothing and when wearing the modified clothing with an additional shoulder guard.

METHODS

The experimental setup aimed to simulate actual clinical practice in interventional radiology. The patient phantom was located at the beam center to generate scatter radiation. An adult female anthropomorphic phantom loaded with 126 nanoDots (Landauer Inc., Glenwood, IL) was used to measure organ and effective doses to the operator. The standard wrap-around type x-ray protective clothing offered 0.25-mm lead-equivalent protection, and the frontal overlap area offered 0.50-mm lead-equivalent protection. The shoulder guard was custom-made with a material providing x-ray protection equivalent to lead of 0.50 mm thickness. The organ and effective doses were compared between the operator wearing the standard protective clothing and the one wearing the modified clothing with a shoulder guard.

RESULTS

After adding the shoulder guard, doses to the lungs, bone marrow, and esophagus decreased by 81.9%, 58.6%, and 58.7%, respectively, and the effective dose to the operator decreased by 47.7%.

CONCLUSIONS

Widespread use of modified x-ray protective clothing with shoulder guards can significantly decrease the overall occupational radiation risk in interventional radiology.

Reducing stray radiation with a novel detachable lead arm support in percutaneous coronary intervention

BACKGROUND

Placing radioprotective devices near patients reduces stray radiation during percutaneous coronary intervention (PCI), a promising technique for treating coronary artery disease. Therefore, lead arm support may effectively reduce occupational radiation dose to cardiologists.

PURPOSE

We aimed to estimate the reduction of stray radiation using a novel detachable lead arm support (DLAS) in PCI.

MATERIALS AND METHODS

A dedicated cardiovascular angiography system was equipped with the conventional 0.5-mm lead curtain suspended from the table side rail. The DLAS was developed using an L-shaped acrylic board and detachable water-resistant covers encasing the 0.5-, 0.75-, or 1.0-mm lead. The DLAS was placed adjacent to a female anthropomorphic phantom lying on the examination tabletop at the patient entrance reference point. An ionization chamber survey meter was placed 100 cm away from the isocenter to emulate the cardiologist's position. Dose reduction using the L-shaped acrylic board, DLAS, lead curtain, and their combination each was measured at five heights (80-160 cm in 20-cm increments) when acquiring cardiac images of the patient phantom with 10 gantry angulations, typical for PCI.

RESULTS

Median dose reductions of stray radiation using the L-shaped acrylic board were 9.0%, 8.8%, 12.4%, 12.3%, and 6.4% at 80-, 100-, 120-, 140-, and 160-cm heights, respectively. Dose reduction using DLAS with a 0.5-mm lead was almost identical to that using DLAS with 0.75- and 1.0-mm leads; mean dose reductions using these three DLASs increased to 16.2%, 45.1%, 66.0%, 64.2%, and 43.0%, respectively. Similarly, dose reductions using the conventional lead curtain were 95.9%, 95.5%, 83.7%, 26.0%, and 19.6%, respectively. The combination of DLAS with 0.5-mm lead and lead curtain could increase dose reductions to 96.0%, 95.8%, 93.8%, 71.1%, and 47.1%, respectively.

CONCLUSIONS

DLAS reduces stray radiation at 120-, 140-, and 160-cm heights, where the conventional lead curtain provides insufficient protection.

Prediction model using clinical factors for radiation exposure during endoscopic retrograde cholangiopancreatography

BACKGROUND AND AIM

Endoscopic retrograde cholangiopancreatography (ERCP) requires radiation. This study aimed to assess the clinical factors influencing radiation exposure and devise a scoring model for predicting high-dose radiation exposure.

METHODS

Endoscopic retrograde cholangiopancreatography cases recorded between 2016 and 2019 in a single tertiary teaching hospital were retrospectively reviewed. A scoring model was created by bootstrap method in a derivation cohort (2016-2018) and was assessed in a validation cohort (2019).

RESULTS

Out of 4223 ERCPs, 2983 and 1240 cases were included in the derivation and validation cohorts, respectively. In the derivation cohort, 746 cases (top 25%) comprised the high-dose exposure group, and 2237 cases (bottom 75%) comprised the low-dose exposure group. Nine clinical parameters associated with high-dose exposure were male, pancreatic sphincterotomy, balloon dilatation, biliary or pancreatic drainage, procedures with contrast dye, endoscopist, in-hospital ERCP, and spot image. Stone removal was included by bootstrap analysis. As presented in a nomogram, the weight score of each variable was as follows: male, 1; pancreatic sphincterotomy, 3; balloon dilatation, 7; stone removal, 3; biliary or pancreatic drainage, 5; procedures with contrast dye, 1; endoscopist B, 4; endoscopist C, 5; in-hospital procedure, 3; and spot image, 3. A total score ≥ 15 suggested a high-dose radiation exposure. The sensitivity and specificity of the model for high-dose exposure were 0.562 and 0.813, respectively. In the validation cohort, the model showed reasonable predictability.

CONCLUSIONS

Various factors were associated with radiation exposure. The simple scoring system in this study could guide endoscopists in predicting the risk of high-dose radiation exposure.

How should radiation exposure be handled in fluoroscopy-guided endoscopic procedures in the field of gastroenterology?

Fluoroscopy-guided endoscopic procedures (FGEPs) are rapidly gaining popularity in the field of gastroenterology. Radiation is a well-known health hazard. Gastroenterologists who perform FGEPs are required to protect themselves, patients, as well as nurses and radiologists engaged in examinations from radiation exposure. To achieve this, all gastroenterologists must first understand and adhere to the International Commission on Radiological Protection Publication. In particular, it is necessary to understand the three principles of radiation protection (Justification, Optimization, and Dose Limits), the As Low As Reasonably Achievable principle, and the Diagnostic Reference Levels (DRLs) according to them. This review will mainly explain the three principles of radiation exposure protection, DRLs, and occupational radiological protection in interventional procedures while introducing related findings. Gastroenterologists must gain knowledge of radiation exposure protection and keep it updated.

Clinical Efficacy of the Transradial Approach in Percutaneous Intervention for a Malfunctioning Arteriovenous Fistula

Purpose

To evaluate the effectiveness of the transradial artery approach (TRA) for treating malfunctioning arteriovenous fistulas (AVFs) in patients on hemodialysis.

Materials and Methods

A retrospective analysis was conducted in this single-center study of TRA endovascular procedures in 73 patients (43 male and 30 female; mean age of 67.4 years (range, 42–92 years) with malfunctioning AVFs, between January 2008 and April 2019. Patients’ baseline and lesion characteristics, technical and clinical success, and complications were evaluated, and functional patency was analyzed using the Kaplan-Meier method.

Results

Radial artery approaches were successful in all patients. Angioplasty performed using the TRA achieved technical and clinical success rates of 98.6%(72/73) and 91.7%(67/73), respectively. The median primary patency time was 18.8 ± 15.9 months. The primary functional patency rates at 3, 6, and 12 months were 82.1%, 68.6%, and 63.9%, respectively. There were no major complications or adverse events, such as hand ischemia, related to the radial artery approach.

Conclusion

In selected cases, the TRA can be used complementary to the transvenous approach to treat malfunctioning AVFs.

Effect of equalization filters on measurements with kerma-area product meter in a cardiovascular angiography system

PURPOSE

This study aimed to evaluate the effect of equalization filters (EFs) on the kerma-area product ( K A P Q K M ) and incident air-kerma ( K a , i , Q K M ) using a kerma-area product (KAP) meter. In addition, potential underestimations of the K a , i , Q K M values by EFs were identified.

MATERIALS AND METHODS

A portable flat-panel detector (FPD) was placed to measure the X-ray beam area (A) and EFs dimension at patient entrance reference point (PERP). Afterward, a 6-cm3 external ionization chamber was placed to measure incident air-kerma ( K a , i , Q e x t ) at PERP instead of the portable FPD. KAP reading and K a , i , Q e x t were simultaneously measured at several X-ray beam qualities with and without EFs. The X-ray beam quality correction factor by KAP meter ( k Q , Q 0 K M ) was calculated by A, K a , i , Q e x t and KAP reading to acquire the K A P Q K M and K a , i , Q K M . Upon completion of the measurements, K A P Q K M , K a , i , Q K M , and K a , i , Q e x t were plotted as functions of tube potential, spectral filter, and EFs dimension. Moreover,K a , i , Q K M / K a , i , Q e x t values were calculated to evaluate the K a , i , Q K M underestimation.

RESULTS

The k Q , Q 0 K M values increased with an increase in the X-ray tube potential and spectral filter, and the maximum k Q , Q 0 K M was 1.18. K A P Q K M and K a , i , Q K M decreased as functions of EFs dimension, whereas K a , i , Q e x t was almost constant.K a , i , Q K M / K a , i , Q e x t decreased with an increase in EFs dimension but increased with an increase in tube potential and spectral filter, and the range was 0.55-1.01.

CONCLUSIONS

K a , i , Q K M value was up to approximately two times lower than the K a , i , Q e x t values by EFs. When using the K a , i , Q K M value, the potential K a , i , Q K M underestimation with EFs should be considered.

Exposure of the eye lens and brain for interventional cardiology staff

INTRODUCTION

Occupational exposure to ionizing radiation for people working with an X-ray treatment unit is one of the highest in medicine. The epidemiological data analyzed by the International Commission on Radiological Protection (ICRP) indicate that the dose threshold for tissues located in the eye lens is or may be lower than previously thought. The new ICRP recommendations reduce the currently used threshold 7.5 times to the limit of 20 mSv per year.

AIM

To carry out measurements of equivalent doses for the lenses and scalps of cardiology interventional staff to determine the actual exposure.

MATERIAL AND METHODS

Personnel performing interventional cardiology procedures participated in the measurements. The measurements were performed using thermoluminescence dosimetry in two measurement periods. The operational quantities used in individual dosimetry were determined (dose equivalent for the scalp, dose equivalent for the eye lens). In both measurement periods, 69 operators and 12 nurses took part.

RESULTS

The maximum value of eye doses for cardiologists was 18.80 mSv per year, with a mean of 9.83 ±6.47 mSv/year (for all cases), 5.70 ±4.26 mSv/year (with safety glasses/headgear), 13.14 ±6.28 mSv/year (without safety glasses/headgear), and 6.28 ±1.76 mSv per year for the nurses. The values of brain doses fluctuate around 1 mSv per quarter.

CONCLUSIONS

Dose equivalents for the lenses of the eyes obtained by cardiologists may be close to or exceed the current dose limits.

A Roadmap for Navigating Occupational Exposures for Surgeons: A Special Consideration for the Pregnant Surgeon

SUMMARY

Surgeons are exposed to occupational hazards daily. Risks include chemical, biological, and physical hazards that place providers at risk of serious harm. Departmental policies or written guides to help pregnant surgeons navigate the hospital are lacking. In response to the scarcity in the literature, the authors have summarized current guidelines and recommendations to aid surgeons in making an informed decision. In addition, the authors present a brief narrative of the impact of these exposures during pregnancy and methods of transmission and, where relevant, include specialties that are at risk of these exposures.

RADIATION EXPOSURE TO THE BACK WITH DIFFERENT TYPES OF APRONS

Physicians and nurses stand with their back towards the C-arm fluoroscope when using the computer, taking things out of closets and preparing drugs for injection or instruments for intervention. This study was conducted to investigate the relationship between the type of lead apron and radiation exposure to the backs of physicians and nurses while using C-arm fluoroscopy. We compared radiation exposure to the back in the three groups: no lead apron (group C), front coverage type (group F) and wrap-around type (group W). The other wrap-around type apron was put on the bed instead of on a patient. We ran C-arm fluoroscopy 40 times for each measurement. We collected the air kerma (AK), exposure time (ET) and effective dose (ED) of the bedside table, upper part and lower part of apron. We measured these variables 30 times for each location. In group F, ED of the upper part was the highest (p < 0.001). ED of the lower part in group C and F was higher than that in group W (p = 0.012). The radiation exposure with a front coverage type apron is higher than that of the wrap-around type and even no apron at the neck or thyroid. For reducing radiation exposure to the back of physician or nurse, the wrap-around type apron is recommended. This type of apron can reduce radiation to the back when the physician turns away from the patient or C-arm fluoroscopy.

Is It Safe to Use a Lead Screen During Hip Arthroscopy?

Purpose

To assess the radiation attenuation of lead screens in comparison to lead gowns in a simulated hip arthroscopy setting.

Methods

In this quantitative laboratory study, a phantom pelvis was used to simulate the scatter produced by patients during hip arthroscopy. Radiation measurements were taken using a handheld radiation detector positioned perpendicular to the phantom pelvis at 1.5 m and 2 m. Measurements were taken without shielding as a control, behind a lead gown (0.4-mm lead equivalent), and behind a lead screen (0.5-mm lead equivalent).

Results

With the detector at 1.5 m perpendicular to the hip, equivalent radiation was attenuated by the lead screen (94%) and the lead gown (94%). With the detector at 2 m perpendicular to the hip, the lead screen at 1.7 m attenuated 95% of radiation.

Conclusions

In hip arthroscopy, using lead screens is a safe and more comfortable alternative to wearing lead gowns. The lead screen should be at least 1.2 m from the radiation source, with the surgeon standing closely behind the screen, fully covered.

Clinical Relevance

Lead screens can be safely used in hip arthroscopy.

CT Fluoroscopy for Image-Guided Procedures: Physician Radiation Dose During Full-Rotation and Partial-Angle CT Scanning

PURPOSE

To determine physician radiation exposure when using partial-angle computed tomography (CT) fluoroscopy (PACT) vs conventional full-rotation CT and whether there is an optimal tube/detector position at which physician dose is minimized.

MATERIALS AND METHODS

Physician radiation dose (entrance air kerma) was measured for full-rotation CT (360°) and PACT (240°) at all tube/detector positions using a human-mimicking phantom placed in a 64-channel multidetector CT. Parameters included 120 kV, 20- and 40-mm collimation, and 100 mA. The mean, standard deviation, and increase/decrease in physician dose compared with a full-rotation scan were reported.

RESULTS

Physician radiation exposure during CT fluoroscopy with PACT was highly dependent on the position of the tube/detector during scanning. The lowest PACT physician dose was when the physician was on the detector side (center view angle 116°; -35% decreased dose vs full-angle CT). The highest PACT physician dose was with the physician on the tube side (center view angle 298°; +34% increased dose vs full-angle CT), all doses P <.05 vs full-rotation CT.

CONCLUSIONS

Partial-angle CT has the potential to both significantly increase or decrease physician radiation dose during CT fluoroscopy-guided procedures. The detector/tube position has a profound effect on physician dose. The lowest dose during PACT was achieved when the physician was located on the detector side (ie, distant from the tube). This data could be used to optimize CT fluoroscopy parameters to reduce physician radiation exposure for PACT-capable scanners.

Radiation Concerns for the Neuroanesthesiologists

With the advent of minimally invasive neurosurgical techniques and rapid innovations in the field of neurointervention, there has been a sharp rise in diagnostic and therapeutic modalities requiring radiation exposure. Neuroanesthesiologists are currently involved in various procedures inside as well as outside the operating room (OR) like intensive care units, interventional suites, and gamma knife units. The ambit expands from short-lasting diagnostic scans to lengthy therapeutic procedures performed under fluoroscopic guidance. Hence, a modern-day neuroanesthesiologist has to bear the brunt of the radiation exposure in both inside and outside the OR. However, obliviousness and nonadherence to the relevant radiation safety measures are still prevalent. Radiation protection and safety are topics that need to be discussed with new vigor in the light of current practice.

High filtration in interventional practices reduces patient radiation doses but not always scatter radiation doses

OBJECTIVES

In fluoroscopy-guided interventional practices, new dose reduction systems have proved to be efficient in the reduction of patient doses. However, it is not clear whether this reduction in patient dose is proportionally transferred to operators' doses. This work investigates the secondary radiation fields produced by two kinds of interventional cardiology units from the same manufacturer with and without dose reduction systems.Methods:Data collected from a large sample of clinical procedures over a 2-year period (more than 5000 procedures and 340,000 radiation events) and the DICOM radiation dose structured reports were analysed.

RESULTS

The average cumulative H_p(10) per procedure measured at the C-arm was similar for the standard and the dose reduction systems (452 vs 476 μSv respectively). The events analysis showed that the ratio H_p(10)/KAP at the C-arm was (mean ± SD) 5 ± 2, 10 ± 4, 14 ± 4 and 14 ± 6 μSv·Gy^-1·cm^-2 for the beams with no added filtration, 0.1, 0.4 and 0.9 mm Cu respectively and suggested that the main cause for the increment of the ratio H_p(10)/KAP vs the "standard system" is the use of higher beam filtration in the "dose reduction" system.

CONCLUSION

Dose reduction systems are beneficial to reduce KAP in patients and their use should be encouraged, but they may not be equally effective to reduce occupational doses. Interventionalists should not overlook their own personal protection when using new technologies with dose reduction systems.

ADVANCES IN KNOWLEDGE

Dose reduction technology in interventional systems may increase scatter dose for operators. Personal protection should not be overlooked with dose reduction systems.

Feasibility of dosimetric measurements using Al2O3:C OSL dosimeter during fluoroscopy-guided procedures

This study investigated the feasibility of dosimetric measurements using Al2O3:C optically stimulated luminescence (OSL) dosimeters during fluoroscopy-guided procedures. The linearity and energy dependence of Al2O3:C OSL dosimeters were evaluated, and the air kerma rate at the operator's position was measured. The response of Al2O3:C OSL dosimeters to short, repetitive irradiations was compared to that of long uninterrupted irradiation. The change in response of the Al2O3:C OSL dosimeter under automatic exposure rate control (AERC) was evaluated with the use of various thicknesses of polymethyl-methacrylate (PMMA) plates (15-30 cm). The Al2O3:C OSL dosimeters could detect 5µGy and showed good linearity in doses of ≥10µGy (R²: 0.997-0.999,p< 0.001). The relative response of the Al2O3:C OSL dosimeter normalised to that of 36.8 keV was 0.828-1.101 at the energies investigated (30.6-46.0 keV). The air kerma rate at the operator's position was estimated to be 2.61-7.17µGy min^-1depending on the heights representing different body parts. Repetitive short irradiations had no significant impact on the relative response of the Al2O3:C OSL dosimeters (p> 0.05). Despite a high energy dependence on the low energy beam used in fluoroscopy, the change in relative response of the Al2O3:C OSL dosimeter under AERC was within 5.7% depending on the thickness of the PMMA plates. Dosimetric measurement using Al2O3:C OSL dosimeters for patients and operators is feasible. However, one should be cautious about high standard deviations when measuring small doses of ≤20µGy using Al2O3:C OSL dosimeters. It is essential to perform intensive bleaching before measuring very small doses to minimise pre-irradiation counts.

Does reducing radiation levels for procedures affect image quality and radiation to proceduralists? A double-blinded randomised study of two protocols

AIM

To evaluate the ultra-lose dose imaging protocol (ULDP), compared to the standard low-dose imaging protocol (LDP), which are used for haemodialysis access, in terms of radiation exposure and image quality.

MATERIAL AND METHODS

This was a single-centre, institutional review board-approved, prospective, double-blinded randomised controlled study to compare radiation exposure and image quality of the ULDP and LDP. Ten proceduralists, two radiographers, and 11 nurses were enrolled. Radiation exposure during 80 procedures (40 angioplasties and 40 thrombolysis) was recorded (direct radiation to patients from protocol report and scattered radiation to participants from the RaySafe i2 real-time dosimetry system). Baseline characteristics of procedure were recorded. Image quality was assessed subjectively using questionnaires based on the five-point Likert scale after each procedure.

RESULTS

Compared with LDP, the use of ULDP was associated with a significantly lower rate of radiation exposure to proceduralists, patients, and scrub nurses (0.506±0.430 versus 0.847±0.965 μSv/s, p=0.044; 0.571±1.284 versus 1.284±1.007 mGy/s, p<0.001; and 0.052±0.071 versus 0.141±0.185 μSv/s, p=0.005, respectively). No significant difference in image quality or duration of procedure was observed (all p values >0.05).

CONCLUSION

Compared with LDP, the use of ULDP was associated with a significantly lower rate of radiation exposure to proceduralists, patients, and scrub nurses without compromising the image quality or duration of procedure.

A parametric study of occupational radiation dose in interventional radiology by Monte-Carlo simulations

This paper presents the results of a parametric study on the occupational exposure in interventional radiology to explore the influence of various variables on the staff doses. These variables include the angiography beam settings: x-ray peak voltage (kVp), added copper filtration, field diameter, beam projection and source to detector distance. The study was performed using Monte-Carlo simulations with MCNPX for more than 5600 combinations of parameters that account for different clinical situations. Additionally, the analysis of the results was performed using both multiple and random forest regression to build a predictive model and to quantify the importance of each variable when the variables simultaneously change. Primary and secondary projections were found to have the most effect on the scatter fraction that reaches the operator followed by the effect of changing the x-ray beam quality. The effect of changing the source to image intensifier distance had the lowest effect.

Novel diagnostic and imaging techniques in endovascular iliac artery procedures

INTRODUCTION

Endovascular revascularization has become the preferred treatment for most patients with iliac artery obstructions, with a high rate of clinical and technical success.

AREAS COVERED

This review will describe novel developments in the diagnosis and treatment of iliac artery obstructions including the augmentation of preprocedural imaging with advanced flow models, image fusion techniques, and state-of-the-art device-tracking capabilities.

EXPERT OPINION

The combination of these developments will change the endovascular field within the next 5 years, allowing targeted iliac treatment without the need for radiographic imaging or iodinated contrast media.

EVALUATION OF RADIATION DOSE IN DIFFERENT POSITIONS AROUND THE PATIENT TABLE DURING INTERVENTIONAL CARDIOLOGY PROJECTIONS

The aim of the present study was to evaluate the radiation exposure around the patient table as relative to the cardiologist position dose value. The dose rates at eight points presuming staff positions were measured for PA, LAO 30° and RAO 30° radiographic projections, and then normalized to the cardiologist's position dose-rate value. The results show that in PA and RAO 30° projections, the normalized dose rate was higher by 9-22% at the right side of the table at a distance of 50 cm, while it was higher up to 31% at the left side for the same measured points in the LAO 30°. The differences of normalized dose rates for the both table sides were lower and decreased at farther positions. The obtained results correspond to the recommendations of staff radiation protection in Cath-labs with regards to X-ray tube and detector positions.

Radiation exposure in the treatment of pediatric supracondylar humerus fractures

PURPOSE

To determine the factors that influence radiation exposure during repair of supracondylar humerus fractures.

METHODS

Medical records of almost 200 children with supracondylar fractures were retrospectively analyzed for variables correlated with fluoroscopy time and radiation dose as measures of radiation exposure.

RESULTS

There was no statistically significant difference in fluoroscopy time (27 vs. 22 s p = 0.345) or direct radiation dose (0.394 vs. 0.318 mSv p = 0.290) between uniplanar and biplanar C-arm use. No statistically significant differences in fluoroscopy time or radiation dose were found for surgical technique, comorbid ipsilateral fractures, preoperative neurovascular compromise, or resident participation. There was a significant 8.3 s increase in fluoroscopy time (p = 0.022) and 0.249 mSv increase in radiation dose (p = 0.020) as the fracture type increased from II to III. An increase in one pin during CRPP resulted in a statistically significant 10.4 s increase in fluoroscopy time and a 0.205 mSv increase in radiation dose. There were significant differences between the physician with the lowest fluoroscopy time and radiation dose compared with the physicians with the two highest values for both fluoroscopy time and radiation dose (p < 0.01).

CONCLUSIONS

We found no significant difference in direct radiation exposure or fluoroscopy time when comparing biplanar to uniplanar C-arm use, resident participation, preoperative neurovascular compromise, or for comorbid ipsilateral fractures. Both outcomes increased significantly as fracture type increased from II to III and as the number of pins used during CRPP increased. Both outcomes were significantly different between the surgeons performing CRPP.

ESTIMATION OF Hp(3) TO THE EYE LENS OF INTERVENTIONAL RADIOLOGISTS-RELATION BETWEEN THE EYE LENS DOSE AND RADIOLOGIST'S HEIGHT

The aim of the study was to estimate occupational radiation dose to the eye lens of radiologists and the dose reduction ratio of lead glasses during interventional radiology. Three interventional radiologists monitored Hp(3) using small-type optically stimulated luminescence dosemeters attached to the left inside and outside of the lead glasses with 0.07-mmPb [Hp(3)eye]. Hp(10) and Hp(0.07) were monitored, respectively, by attaching the personal dosemeter to the lead neck collar above the lead apron. The median Hp(3)eye with lead glasses and the median dose reduction ratio of lead glasses for the three radiologists were 8.02 mSv/y and 57.7%, respectively. The median Hp(3)eye without lead glasses [Hp(3)eye-w/o] for the three radiologists was 18.6 mSv/y, but Hp(3)eye-w/o for one of the radiologists was 24.1 mSv/y. Monitoring occupational radiation dose to the eye lens is important because interventional radiologists are at risk of exceeding the new dose limit.

Don't be Caught Half-dressed When Working with Radiation

A typical 2-piece personal protective equipment apron covers only half the body. However, with radiation exposure there is evidence of the following: (1) Left-sided head exposure estimates equal to 100,000 chest X-rays over a 20-year career, (2) direct linear relationship between stroke and concentration of dose, (3) increases in ischemic heart disease and myocardial infarction, (4) accelerated aging processes, and (5) increased double-stranded DNA breaks in circulating lymphocytes when lower legs are exposed. Every exposure to ionizing radiation involves a health risk that accumulates. Interventionalists are treating more patients, more complex patients, using new complicated devices. Juxtaposed with the global obesity epidemic, the result is an unprecedented level of radiation exposure for those who use radiation in their daily work. By implementing a simple system of shields, we can dramatically reduce our radiation dose. This would give us a better chance to live a longer, healthier life, and pass quality DNA to our children. This narrative review examines the efficacy of protective barriers to reduce medical occupational radiation exposure and risk.

Optimizing Staff Dose in Fluoroscopy-Guided Interventions by Comparing Clinical Data with Phantom Experiments

PURPOSE

To evaluate conditions for minimizing staff dose in interventional radiology, and to provide an achievable level for radiation exposure reduction.

MATERIALS AND METHODS

Comprehensive phantom experiments were performed in an angiography suite to evaluate the effects of several parameters on operator dose, such as patient body part, radiation shielding, x-ray tube angulation, and acquisition type. Phantom data were compared with operator dose data from clinical procedures (n = 281), which were prospectively acquired with the use of electronic real-time personal dosimeters (PDMs) combined with an automatic dose-tracking system (DoseWise Portal; Philips, Best, The Netherlands). A reference PDM was installed on the C-arm to measure scattered radiation. Operator exposure was calculated relative to this scatter dose.

RESULTS

In phantom experiments and clinical procedures, median operator dose relative to the dose-area product (DAP) was reduced by 81% and 79% in cerebral procedures and abdominal procedures, respectively. The use of radiation shielding decreased operator exposure up to 97% in phantom experiments; however, operator dose data show that this reduction was not fully achieved in clinical practice. Both phantom experiments and clinical procedures showed that the largest contribution to relative operator dose originated from left-anterior-oblique C-arm angulations (59%-75% of clinical operator exposure). Of the various x-ray acquisition types used, fluoroscopy was the main contributor to procedural DAP (49%) and operator dose in clinical procedures (82%).

CONCLUSIONS

Achievable levels for radiation exposure reduction were determined and compared with real-life clinical practice. This generated evidence-based advice on the conditions required for optimal radiation safety.

Peripherally inserted central catheters: dependency of radiation exposure from puncture site and level of training

Background Several interventional procedures show a dependency on fluoroscopy times (FT) and level of training. Furthermore, FT and dose area products (DAP) vary depending on access site and target vessel for chest port implantations, but not for other thoracic interventions such as percutaneous coronary interventions. Purpose To evaluate the influence of the combination of venous access site and level of training on FTs and DAPs during peripherally inserted central catheters (PICC) implantations in a large cohort of patients. Material and Methods In this retrospective study, PICC implantations of 681 consecutive patients (385 women, 296 men; mean age = 55.0 ± 16.7 years) were analyzed. Two groups of junior (< 50 interventions) and senior (≥ 50 implantations) radiologists were investigated in respect to FT and DAP during PICC placement procedures. Statistical analysis included the Mann-Whitney U test and the Kruskal-Wallis test. P values < 0.05 were considered significant. Results Senior radiologists required significantly less FT (senior = 0.43 s, junior = 0.53 s, P = 0.041), but there was no significant difference in DAPs (senior = 56.3 µGy*m², junior = 60.6 µGy*m², P = 0.151). PICC implantations through the left side resulted in a significant reduction of the median FT by 60.9% (left = 0.45 s, right = 1.15 s, P = 0.010). Conclusion Due to considerable dose reduction, the left-sided puncture, especially via the basilic and brachial veins, performed by well-trained interventional radiologists seem to be the preferable approach for PICCs.

Impact of the Ceiling-Mounted Radiation Shielding Position on the Physician's Dose from Scatter Radiation during Interventional Procedures

The effect of the ceiling-mounted radiation shielding on the amount of the scatter radiation was assessed under conditions simulating obese patients for clinically relevant exposure parameters. Measurements were performed in different projections and with different positions of the ceiling-mounted shielding: without shielding; shielding closest to the patient; and shielding closest to the physician performing the procedure. The protection provided by the shielding was assessed for cardiology when the femoral access is used and for radiology when the physician performs the procedure in the abdominal area. The results show that the use of the ceiling-mounted shielding can decrease the dose from the scatter radiation by 95% at the position of the performing physician. In cardiology, the impact is more pronounced when the left oblique projection is used. In radiology, a large decrease was observed for right oblique projections, compared to cardiology. The ceiling-mounted shielding should be placed as close to the physician as possible. The idea of creating the largest radiation shadow by placing the radiation shielding as close to the patient as possible does not provide as effective radiation protection of the operator as it might be thought.

Totally Implantable Central Venous Port Catheters: Radiation Exposure as a Function of Puncture Site and Operator Experience

BACKGROUND

Totally implantable central venous port systems provide a safe and effective, long-term means of access for administration of hyperosmolar, local irritant medication, such as chemotherapy, antibiotics and parenteral nutrition.

AIM

To evaluate the combination of access site and level of experience on fluoroscopy times (FT) and dose area products (DAP) during implantation of port catheters in a large patient population.

MATERIALS AND METHODS

A total of 1,870 patients (992 women, 878 men; age: 61±13.14 years) were reviewed investigating two groups of junior (≤50 implantations) and senior (>50) radiologists.

RESULTS

Senior radiologists required less FT/DAP (0.24 s/57.3 μGy m2 versus 0.43 s/68.2 μGy m2, respectively; p<0.001). Right jugular vein access required the least FT/DAP (0.25 s/56.15 μGy m2) and right-sided implantation lower FT/DAP (right: 0.26 s/56.4 μGy m2, left: 0.40 s/85.10 μGy m2, p<0.001).

CONCLUSION

Due to DAP/FT reductions, the right jugular vein seems to be the most favorable implantation side for port systems. For further dose reduction, residents should be well-trained.

Should We Keep the Lead in the Aprons?

Medical staff should not be exposed to the primary X-ray beam during fluoroscopy-guided interventional procedures (FGIP). The main source of staff exposure is scatter radiation from the patient, which can be significant. Although many aspects of X-ray exposure to the patient as well as occupational exposure to interventional radiologists and other staff are strongly regulated and monitored in most countries, it is surprising how loosely the labeling and testing of the protective aprons is regulated. Interventional radiologists (IRs) have to be experts in interventional radiology as well as in basic facts regarding ways to provide a satisfactory level of protection from occupational exposure. IRs, however, are not familiar with the apron testing methods. The accompanying documents provided with aprons by manufacturers may not be informative enough. Vendors often report apron effectiveness at a single beam quality and attenuation. The vendor reports repeatedly disagree with independent reports, which clearly show that the attenuation of these garments at other important unreported energies may be lower than expected. Better trust no one and check your protective garment yourself, or, better yet, consult a medical physicist when making purchasing decisions related to protective garments. Each interventionist should choose garments that are appropriately protective for that individual's practice. Review of past personal dosimetry results and consultation with a medical physicist can help the IR make the best decision. This article will help the reader to understand why all protective garments are not created equally, and provides some practical tools that will allow safe and healthy practice in FGIP.

Personalized Feedback on Staff Dose in Fluoroscopy-Guided Interventions: A New Era in Radiation Dose Monitoring

PURPOSE

Radiation safety and protection are a key component of fluoroscopy-guided interventions. We hypothesize that providing weekly personal dose feedback will increase radiation awareness and ultimately will lead to optimized behavior. Therefore, we designed and implemented a personalized feedback of procedure and personal doses for medical staff involved in fluoroscopy-guided interventions.

MATERIALS AND METHODS

Medical staff (physicians and technicians, n = 27) involved in fluoroscopy-guided interventions were equipped with electronic personal dose meters (PDMs). Procedure dose data including the dose area product and effective doses from PDMs were prospectively monitored for each consecutive procedure over an 8-month period (n = 1082). A personalized feedback form was designed displaying for each staff individually the personal dose per procedure, as well as relative and cumulative doses. This study consisted of two phases: (1) 1-5th months: Staff did not receive feedback (n = 701) and (2) 6-8th months: Staff received weekly individual dose feedback (n = 381). An anonymous evaluation was performed on the feedback and occupational dose.

RESULTS

Personalized feedback was scored valuable by 76% of the staff and increased radiation dose awareness for 71%. 57 and 52% reported an increased feeling of occupational safety and changing their behavior because of personalized feedback, respectively. For technicians, the normalized dose was significantly lower in the feedback phase compared to the prefeedback phase: [median (IQR) normalized dose (phase 1) 0.12 (0.04-0.50) µSv/Gy cm2 versus (phase 2) 0.08 (0.02-0.24) µSv/Gy cm2, p = 0.002].

CONCLUSION

Personalized dose feedback increases radiation awareness and safety and can be provided to staff involved in fluoroscopy-guided interventions.

Impact of Allura Clarity Technology on Radiation Dose Exposure During Left Atrial Appendage Closure

BACKGROUND

To evaluate the impact of the Clarity IQ technology on reducing radiation risk in patients undergoing cardiac interventional radiology (IR) procedures.

MATERIAL/METHODS

Phantom studies were performed with two angiographic systems, FD10 Allura Xper and FD10 Allura Clarity. In the study, we performed left atrial appendage closure. Dosimetric measurements were performed with thermoluminescent dosimeters (TLD) placed inside a CIRS anthropomorphic phantom. Radiation risk was estimated based on the TLD readings and expressed as the dose absorbed by particular organs. The Mann-Whitney U test was carried out to test for significance of differences in the absorbed radiation doses between the techniques.

RESULTS

During left atrial appendage closure, the estimated dose absorbed by particular organs was lower in the case of the FD10 Allura Clarity system in comparison to the Allura Xper. In this procedure, dose reduction for particular organs ranged between 49-86%.

CONCLUSIONS

Application of the FD10 Allura Clarity system resulted in a significant dose reduction, thereby leading to a significant decrease in radiation risk for patients undergoing IR procedures.

Radiation Risk to the Fluoroscopy Operator and Staff

OBJECTIVE

Recent articles discussing cases of brain cancer in interventionalists have raised concerns regarding the hazards of occupational exposure to ionizing radiation. We review the basics of radiation dose and the potential radiation effects, particularly as they pertain to the operator. Then we present the data regarding the risk of each type of radiation effect to the fluoroscopy operator and staff, with special attention on cancer induction, radiation-induced cataracts, and the pregnant operator.

CONCLUSION

Although the evidence overwhelmingly shows that exposure to higher doses of radiation carries a risk of cancer and tissue reactions, the risks of chronic exposure to low-level radiation are less clear. Many studies examining occupational exposure to radiation fail to show an increased risk of stochastic effects of radiation, but the positive results raise concern that the studies are underpowered to consistently detect the small risk. The lack of information in these studies about radiation doses and adherence to radiation protection further confound their interpretation. Large prospective studies of populations with occupational exposure to low-level radiation might clarify this issue. More clearly established are the risks of radiation to the fetus and the risk of cataracts in interventional cardiologists and interventional radiologists. Interventionalists can mitigate these risks by following established radiation safety practices.

LEAD COMPOSITE VS. NONLEAD PROTECTIVE GARMENTS: WHICH ARE BETTER? A MULTIVENDOR COMPARISON

This study aims to provide more insight in attenuation characteristics and corresponding lead (Pb) equivalences of a broad range of commercially available lead composite and nonlead protective garments. Thirty garments of five manufacturers (listed as 0.25-0.35-0.50 mm Pb equivalent) were tested. Transmission values were determined at 70, 90 and 110 kVp using an inverse broad beam geometry. Pb equivalence was determined using lead sheets as reference material. A substantial variability in photon transmission across garments was found. Differences between lead composite and nonlead garments were not statistically significant. Depending on tube voltage, between 9 and 12 out of 30 garments had a lower Pb equivalence than the indicated value. This work shows that lead equivalence as indicated on a garment's label may overestimate its protective performance. Depending on the application a more thorough verification of the effectiveness of protective garments at the desired kVp is warranted.

Real-Time Patient and Staff Radiation Dose Monitoring in IR Practice

PURPOSE

Knowledge of medical radiation exposure permits application of radiation protection principles. In our center, the first dedicated real-time, automated patient and staff dose monitoring system (DoseWise Portal, Philips Healthcare) was installed. Aim of this study was to obtain insight in the procedural and occupational doses.

MATERIALS AND METHODS

All interventional radiologists, vascular surgeons, and technicians wore personal dose meters (PDMs, DoseAware, Philips Healthcare). The dose monitoring system simultaneously registered for each procedure dose-related data as the dose area product (DAP) and effective staff dose (E) from PDMs. Use and type of shielding were recorded separately. All procedures were analyzed according to procedure type; these included among others cerebral interventions (n = 112), iliac and/or caval venous recanalization procedures (n = 68), endovascular aortic repair procedures (n = 63), biliary duct interventions (n = 58), and percutaneous gastrostomy procedure (n = 28).

RESULTS

Median (±IQR) DAP doses ranged from 2.0 (0.8-3.1) (percutaneous gastrostomy) to 84 (53-147) Gy cm² (aortic repair procedures). Median (±IQR) first operator doses ranged from 1.6 (1.1-5.0) μSv to 33.4 (12.1-125.0) for these procedures, respectively. The relative exposure, determined as first operator dose normalized to procedural DAP, ranged from 1.9 in biliary interventions to 0.1 μSv/Gy cm² in cerebral interventions, indicating large variation in staff dose per unit DAP among the procedure types.

CONCLUSION

Real-time dose monitoring was able to identify the types of interventions with either an absolute or relatively high staff dose, and may allow for specific optimization of radiation protection.

Radiation Protection for the Fluoroscopy Operator and Staff

OBJECTIVE

The purposes of this article are to review available data regarding the range of protection devices and garments with a focus on eye protection and to summarize techniques for reducing scatter radiation exposure.

CONCLUSION

Fluoroscopy operators and staff can greatly reduce their radiation exposure by wearing properly fitted protective garments, positioning protective devices to block scatter radiation, and adhering to good radiation practices. By understanding the essentials of radiation physics, protective equipment, and the features of each imaging system, operators and staff can capitalize on opportunities for radiation protection while minimizing ergonomic strain. Practicing and promoting a culture of radiation safety can help fluoroscopy operators and staff enjoy long, productive careers helping patients.

Ionizing Radiation Doses Detected at the Eye Level of the Primary Surgeon During Orthopaedic Procedures

OBJECTIVES

To evaluate the ionizing radiation dose received by the eyes of orthopaedic surgeons during various orthopaedic procedures. Secondary objective was to compare the ionizing radiation dose received between differing experience level.

DESIGN

Prospective comparative study between January 2013 and May 2014.

SETTING

Westmead Hospital, a Level 1 Trauma Centre for Greater Western Sydney.

PARTICIPANTS

A total of 26 surgeons volunteered to participate within the study.

INTERVENTION

Experience level, procedure performed, fluoroscopy time, dose area product, total air kerma, and eye dose received was recorded. Participants were evaluated on procedure and experience level.

MAIN OUTCOME MEASUREMENTS

Radiation dose received at eye level by the primary surgeon during an orthopaedic procedure.

RESULTS

Data from a total of 131 cases was recorded and included for analysis. The mean radiation dose detected at the eye level of the primary surgeon was 0.02 mSv (SD = 0.05 mSv) per procedure. Radiation at eye level was only detected in 31 of the 131 cases. The highest registered dose for a single procedure was 0.31 mSv. Femoral nails and pelvic fixation procedures had a significantly higher mean dose received than other procedure groups (0.04 mSv (SD = 0.07 mSv) and 0.04 mSv (SD = 0.06 mSv), respectively). Comparing the eye doses received by orthopaedic consultants and trainees, there was no significant difference between the 2 groups.

CONCLUSIONS

The risk of harmful levels of radiation exposure at eye level to orthopaedic surgeons is low. This risk is greatest during insertion of femoral intramedullary nails and pelvic fixation, and it is recommended that in these situations, surgeons take all reasonable precautions to minimize radiation dose. The orthopaedic trainees in this study were not subjected to higher doses of radiation than their consultant trainers. On the basis of these results, most of the orthopaedic surgeons remain well below the yearly radiation dose of 20 mSv as recommended by the International Commission on Radiological Protection.