AIR KRMA RATS MASURMNT IN AN INTRVNTIONAL ARIOLOGY SUIT anevaro, L.V. 1 ; Gamarra Sanchez, M..; Pereira, L.S.; Maurício,.L.P. Instituto de Radioproteção e osimetria. omissão Nacional de nergia Nuclear. Av. Salvador Allende s/n. P 2278-16. Rio de Janeiro. Brazil. email: canevaro@ird.gov.br. Abstract. In Interventional ardiology (I), the assessment of the radiaton that the physicians are exposed to is extremely important because the irradiation is not uniform and the received doses are substantially high. uring the procedure, the radiation control is complex and there are several reasons for the high exposure levels. It is necessary to perform dosimetric assessments in different parts of the physicians body and in different specific points of the examination room. By analyzing this information it is possible to determine the probable causes and to provide recommendations, aiming at optimizing the radiological protection. This work had the following objetives: to assess the exposition levels at representative points of critical anatomical regions of the physicians body who perform I examinations; to provide means to implement personal monitoring procedures; and to make them aware of the radiation risks. Measurements of air kerma rates were performed in 45 points around the examination table, along the room. Such measurements were made in the conditions frequently used in coronary angiography and coronary angioplasties procedures: adult patient phantom; RAO, LAO and AP incidences; fluoro and digital modes; 13cm and 17cm magnification modes; frequencies of 3f/s (fluoro) and 15 f/s (digital); typical field size used during examinations. ata were obtained at the lenses, chest, hands, gonads and knees levels. For AP incidence, the lowest contributions for scattered radiation and a more homogeneous distribution of radiation were observed. The highest air kerma rates were obtained during digital acquisition mode and for LAO incidence on interventional radiologists, anaesthesists and nurses. The most critical anatomical regions were the knees and gonads. Air kerma rates of about 7,8mGy/h were registered in some places. At physicians hands position, rates of about 5mGy/h were reached. In several points and levels measured (workload 6 examinations/day), this air kerma rates would produce a higher dose than the annual limits. This work shows the need to implement additional protection devices; to elaborate safety guidelines; to train staff on radiological protection, and to implement the use of additional dosemeters attached to critical points. KYWORS: Interventional cardiology, fluoroscopy, radiation protection, air kerma rates, occupational exposure, workplace analysis. 1. Introduction The interventional doctors' radiation exposure in hemodynamics is an issue of great concern, once the received doses are greater than those received in conventional radiology [1]. ue to the expected high levels of such exposure, it is necessary to perform dosimetric evaluations, monitoring different parts of the body (usually, the worker's exposure is not even), as well as specific points in the examination room. By analyzing this information it will be possible to identify its probable causes and implement the recommendations and practice codes. Some of the reasons for the high level of radiology on the interventional doctors are: faults in an X ray equipment component, inappropriate use of the equipment and technology, acquisition of too many images, being exposed too long. ue to the scattering of the radiation beam through the different thickness of the patient, to the different modes of operation and to the angulations of the -arm, different rates of scattered radiation are generated [2]. Not wearing the appropriate protection accessories can also increase the doses received by the staff. In addition to that, the interventional techniques have been applied by radiology non-specialized physicians who, most of the times, have not had proper training in radiation protection [3, 4, 5]. This work aimed at evaluating the air kerma rates in critical parts of the bodies of the radiologists who perform coronary angiography (A) and coronary angioplasties (PTA) procedures, when its incidences were most significant. 1 Presenting Author; mail: canevaro@ird.gov.br 1
2. Material and Method The work has been developed in an Interventional ardiology Room in an important hospital of Rio de Janeiro, Brazil. The procedures were performed with a Siemens (oroskop HIP- T.O.P) X-ray equipment, the range of tube voltage was 5 125kVp. The system has an automatic exposure control, three fields of view, 13,17 and 23cm, fluoroscopic and digital image acquisition modes. The equipment filters.2mm copper permanently during fluoroscopy. In the digital image acquisition mode, if the image quality is not good enough, the filter is immediately withdrawn from the beam's path. The most frequent conditions of irradiation in the -arm projections during A and PTA procedures were simulated. A plastic box containing 2 l of water was used as a thorax phantom. It was placed on the exam table, with the center of the phantom at the X-ray equipment isocenter. The projections were: Right Anterior Oblique RAO (+35 o ): fluoroscopic and digital acquisition modes. Left Anterior Oblique LAO (-35 o ): fluoroscopic and digital acquisition modes. Antero- Posterior, AP (cranial o /caudal o ): fluoroscopic and digital acquisition modes. For all cases: intensifier-focus distance = 1, m; table position: vertical + 2; horizontal + 4; diagonal 3; field of view = 13cm; field of irradiation size on the surface of the simulator = 49,5 cm 2. The electrometer used to measure the exposure in the different points inside the procedure room was a Radcal 915 with a 1x5-18cc ionisation chamber. In order to identify the measurements points, a system of coordinates was defined, with points marked on the floor with a separation of 6cm between them. In the coordinate system, the lines parallel to the table's bigger axis were denominated A,B,, and and the lines perpendicular to the bigger axis were denominated 1,2,3,4 and 5 and -1,-2,-3 and - 4.(Fig.1). Point 1A corresponds to the position of the table command, where the interventional doctor stays during the procedure. In each point, air kerma rate was measured in different heights from the floor. The heights measured were: 1,6m, to simulate the eye height (lens); 1,3m (thorax);,85m (gonads);,5m (knees). Measurements were also taken at 1,m high, in the areas around the examination table to simulate the upper extremities. The total measurements were 134 for the RAO, 138 for the LAO and 156 for the AP. Figure 1: Sketch of the room, coordinates system definition and identification of the measurement points. -4-3 -2-1 1 2 3 4 5-4 - 3-2 -1 1 2 3 4-4 - 3-2 - 1 1 2 3 4 5-4 A - 3 A -2A - 1 A 1A 2A 3A 4A 5A A - 4 B - 3B - 2 B - 1 B 1B 2B 3B 4B 5B B - 2-1 1
In order to estimate the exposure of the interventional doctor in a part of their body during a real procedure, the equivalent dose in the lens and in the hands were calculated from the air kerma rates values measured in the 1,6m and 1,heights. It was simulated a case in which the interventional cardiologist performs 1 angiographies, working 5 days a week and 5 weeks a year. This was calculated using the most frequent projections, the number of images and the average values of fluoroscopic current and time. 3. Results The air kerma rate values (µgy/h) were classified in numbered bands, each of them being colored in shades of gray. As an example, the results of the measurements of the air kerma rates taken in the points shown in Figure 1 are presented in Figure 2 for the RAO (+35 o ) projection, as a plan of the room with the numerical values at each point. The values measured have an associated uncertainty of 16%. 3.1 Right Anterior Oblique Projection, RAO (+35 o ) The air kerma rates were lower in the fluoroscopic mode than in the acquisition mode due to the different currents used (fluoro 15mA, acquisition mode 6mA). The distribution of the air kerma rates in both modes follow the same pattern in all points of the room. The points with greater variation are those closer to the patient, due to the fact that the contribution of scattered radiation is more significant for the positions close to the X-ray tube. In the acquisition mode, the rates reached, in many cases, values 4 or 5 times higher than in the fluoroscopic mode, demonstrating the importance of the reasonable use of image acquisition. The rates were higher next to the X-ray tube, left of the patient. 3
758 1515 1813 164 363 214 96 1441 698 391 99 45 48 288 112 66 78 163 13 311 244 45 26 1,6 43 359 563 368 134 95 44 72 53 123 39 A 24 46 A B 61 55 46 16 19 28 B 51 43 44 324 38 43 5 134-4 -3-2 -1 1 2 3 4 5-4 -3-2 -1 1 2 3 4 5 698 2452 319 2488 35 215 86 431 998 344 11 57 1,3 88 482 986 554 232 126 46 32 923 176 36 89 234 577 542 236 11 64 A 64 194 41 A 64 349 36 712 184 33 2 B 54 93 126 27 98 B 43 57 54 528 41 59 71 153 1m 4891 163 23 1263 161 695 129 19 A 233 A -4-3 -2-1 1 2 3 4 5-4 -3-2 -1 1 2 3 4 5 888 265 4854 252 441 166 75 <15 R X 7181 1255 176 31.85 66 59 213 55 156 81 24 53 1943 145 I I I I 397 4 1732 247 A 94 461 32 A 82 654 874 85 285 B 78 132 194 337 143 B 6 79 76 523 49 73 92 196-4 -3-2 -1 1 2 3 4 5,5-4 -3-2 -1 1 2 3 4 5 868 2816 1541 2434 489 142 64 <15 781 1684 496 59 32 99 519 924 99 292 131 3 1882 359 37 579 695 2693 675 76 A 174 578 127 A 9 82 1163 1418 618 49 B 18 176 25 467 244 45 B 7 93 97 682 59 89 11 252 IGITAL AQUISITION MO FLUORO MO Figure 2: Air kerma rates distribution in the different heights of the points in the examination room (digital acquisition and fluoro modes) for the projection RAO (+35º).
The air kerma rates in the fluoroscopic mode reached values of 1943µGy/h (point 1) and 213µGy/h (point -1), at gonad height. At 1,6m (eye lens), the greater air kerma rates were measured in points - 1, 1 and -1A, points near the X- ray tube and the area where the anesthetist and the nurses usually walk around. In the digital acquisition mode, due to the geometry, the areas with the greatest rates are the ones where the anesthetist and the nurses stay (points 1, 2, -1, -2, -3). Values such as 7181µGy/h at point 1 (gonad height) and 781mGy/h at the same point (knee height) were registered. The relation between the values of air kerma rates measured in opposite points (e.g. right and left of the patient, points 1A and 1), might reach up to a factor 4. In Figure 3 it is shown the profiles for the points where the medical staff is more likely to be working, for instance, 1A, 2A, 3A, 1, 2 and 3. Figure 3: Air kerma rates profile for points 1A (interventional cardiologist), 2A (assistent cardiologist), 3A and 1 (anesthetist), 2 (nurses) and 3, for RAO (+35º), digital acquisition mode. 2 2 1A 2A 3A 1 2 3 1.5 1.5 1 Altura (m) Altura (m) 1.5.5 8 6 4 2 2 4 6 8 Taxa de kerma no ar (ugy/h) Taxa de kerma no ar (ugy/h) 3.2 Left Anterior Oblique Projection, LAO (-35 o ) The air kerma rates measured in the fluoroscopic mode were almost homogeneous and lower than the air kerma rates in the acquisition mode. This values reached 124μGy/h (point 1A) at knee height, and 1848μGy/h (point 1), knee height. At 1,6m (lens), thew higher aire kerma rates were measured at points 1 and 1A. In the digital acquisition mode, values such as 362μGy/h (hands), 569μGy/h (gonads) and 5677 Sv/h (knee) at the point 1A, were measured. The air kerma rates reached, again, values 4 or 5 times higher than in the fluoroscopic mode. 3.3 Antero- Posterior Projection, AP (cranial o /caudal o ): The scattered radiation follows the same pattern in both sides of the examination table; that is, the interventional doctor and the anesthetist, who are in symmetric position in relation to the X-rays tube, are exposed to similar intensity of air kerma rates. This happens because the X-ray beam is underneath the examination table, without any angulation. Among the three projections studied, the AP geometry is the one that presented the smallest air kerma rate measured. This can be explained by the fact that the path made by the primary beam in the phantom is shorter than in the other projections, as a result there is less scattering. In the fluoroscopic mode, the maximum values measured were 861µGy/h (hands), 685µGy/h (gonads) and 574µGy/h (knee), at point -1 (close to the anesthetist). In the same mode, at point -1A, close to 5
the interventional doctor when the access is brachial, the corresponding values were 254µGy/h, 368µGy/h e 391µGy/h. These values are reasonably low, if compared with the ones measured in digital acquisition mode, which were of 5µGy/h at some points. 3.4 Additional onsiderations It was clear that the exposure of the body of the ones who operate the equipments is not even; it varies in intensity and distribution according to the person's position in relation to the patient, to the techniques used, to the time of exposure, to the fields of view used, etc. Therefore, the air kerma rates measured at each point are an attempt to estimate the doses received by the medical staff. Individual exact values of the levels of exposure are not possible to be determined. A comparison of the air kerma rates for the different access modes was made. For the femoral access, the interventional doctor stands at point 1A, and for the brachial access, at point 2A. In Figure 4, it is shown a comparison of the rates measured at point 1A and 2A, for all the heights and for the three projections, in the digital acquisition mode. The staff that performed the work through the brachial access were more exposed to radiation than those who performed the procedures through femoral access, due to their proximity to the X-ray tube in all the angulations of the -arm. Figure 4 omparison of the air kerma rates for the different access modes (interventional cardiologist position). Interventional ardiologist Position: 1A(Braquial) 2A(Femoral) 8 1,6 m ye Lens 1,3 m Thorax 1 m Hand,85 m Gonads,5 m Knees 6 4 2 1A 2A 1A 2A 1A 2A OA - IN OA - IN AP - IN Points/Angulations The calculated values for the equivalent doses were: lens = 293mSv/year and hands = 4mSv/year. The estimated value for the lens is higher than the annual limit of 15mSv/year [6]. It is recommended that the interventional doctor wears lead glasses to perform the procedure. Although the estimated value for the upper extremities in this simulation is not higher than the annual limit (5 msv/year), it is still considered high. So, it is recommended that the interventional doctors wear protective gloves and keep their hands away from the primary X-ray beam. Although the air kerma rates ( Gy/h) measured in the digital acquisition mode are higher than those in the fluoroscopic mode ( Gy/h), the calculated equivalent doses are significantly higher when projected for the annual limits (msv/year), due to the long fluoroscopy times involved in the procedures.
4. onclusion From the air kerma rates values obtained in the points inside the room, it is possible to identify the places with the highest levels of exposure, where it is not desirable for the staff to stay during the procedures. In some cases, as in the LAO for the hands and lens, the air kerma rates measured could be higher than the equivalent dose limits. It can happen when the projection for the obtained values in air kerma for the annual equivalent doses is made. The oblique incidences are considered the most critical to the irradiation of the staff. The work allows the staff to be aware of the expected levels of exposure in some parts of the body, as well as it suggests means of protection against radiation for the different geometries of the equipment. In points identified as critical, it is important to implement additional protection devices and dosimeters. The doctor that performs the procedures must wear protection for the face and lens. It is important to call the attention of the protective clothes manufacturers to the size and length of the lead aprons, due to the measured values of air kerma rates in the knee area. Aknowledgments The authors wish to thanks to r. Paulo Sérgio Oliveira, nurses and technicians who colaborated to the developing of this work. RFRNS [1] OUSINS,. Medical interventional procedures-reducing the radiation risks. linical Radiology, lsevier Science Ltd., v. 59, pp. 468-473. (23). [2] GIS, RA.; UBIG,.;et al. Managing the Use of Fluoroscopy in Medical Institutions. AAPM Report nº 58. Task group VI. American Association of Physicists in Medicine Madison. (1998). [3] ARHR, BR.; WAGNR, LK. Protecting Patients by Training Physicians in Fluoroscopic Radiation Management. Journal of Applied linical Medical Physics. American ollege of Medical Physics. (2). [4] International ommission on Radiological Protection (IRP). Publication 85. Avoidance of radiation injuries from medical interventional procedures. Oxford, Pergamon Press. (2). [5] UROPAN OMMISSION, (). Guidelines on education and training in radiation protection for medical exposures. Radiation Protection 119. Project 98/B4-34/F-9. uropean ommission. Luxembourg. (2). [6] MINISTÉRIO A SAÚ, BRASIL. iretrizes Básicas de Proteção Radiológica em Radiodiagnóstico Médico e Odontológico, Portaria 453/98. (1998). 7