Radiation Safety Training Module: Diagnostic Radiology

Radiation Safety and Patient Protection in Interventional Radiology

Radiological Safety Division

Atomic Energy Regulatory Board
 WHY RADIATION SAFETY & PROTECTION

Myths or Facts!! Guess…

• We live all our lives surrounded by radiation.
• All types of Radiation can cause serious injuries.
• Radiation effects are impossible during medical radiological X-ray procedures.
• Dose limits are prescribed for occupational exposures. There are no limits for Medical exposures.
• Radiation dose received by Medical practitioners during IR procedures needs to be monitored.
• Understanding YOUR equipment specific parameters can reduce patient and staff doses.
• Good work practice by operating physician is vital in reducing radiation doses due to medical
exposures.

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 What is RADIATION…..

Is there Radiation in your room?

Yes, but not all forms of
radiation are harmful!
 Radiation and its Types
Radiation: Radiation is nothing but Energy in motion
We live in a sea of radiation. This includes;
 Non-Ionizing Radiation: Radiation that does not have sufficient energy to
remove an electron (ionize) from an atom. e.g.: radio waves, microwaves,
infrared radiation, visible light, lasers, ultraviolet light and radar.
 Ionizing Radiation: Radiation that has sufficient energy to eject electrons from
atoms (i.e ionize atoms). e.g
Radiation and its Types
Ionizing Radiation Is Omnipresent.. Extra Cosmic Rays
from Air Travel
Natural Sources of Radiation
Dental X Rays
Man-made Sources of Radiation

Fallout from Nuclear Power

Weapon Testing Plants
Radon &
Daughters
Medical X Cosmic
Rays Rays
On an average, We all
receive dose of
~3mSv/year due to
natural radiation
Terrestrial Buried
Radiation from RadioActive
rocks and soil Waste
SOURCES OF IONIZING RADIATION
Natural Radiation: Cosmic rays, radiation within our body, in food we eat, in water we drink,
house we live in, lawn, in building material.
We cannot prevent exposures due to Natural Sources!!!

Man Made Radiation: Manmade sources include fall out from nuclear weapons testing and
nuclear explosions, extra cosmic radiation during air travel, exposure for medical diagnostic (X-
ray , nuclear medicine) and therapeutic (radiotherapy) purposes;
Among manmade sources, medical diagnostic X-rays are the largest contributors to radiation
dose
But, radiation doses to patients and operators due to medical diagnostic X-ray
investigations can be minimized
 RADIATION IN MEDICINE

• Machine produced radiation from X-ray

tubes used in medical imaging.
• Linear accelerators and equipment
containing radioactive sources used in
cancer therapy.
• Radioactive materials used in nuclear
medicine imaging and in some cancer
therapy applications.

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 WHY TO ADDRESS RADIATION SAFETY IN USE OF X-RAYS

ANNUAL GLOBAL X-RAY EXPOSURES

• Diagnostic X-ray Examinations : 3.1 billion
• Dental X-ray Examinations : 0.5 billion
• Collective effective dose : 4X106 man-Sv
• Effective dose per person : 0.62 mSv
• Contribution due to CT scans : 43% of collective dose
• Contribution due to IR procedures : 8 % (during last 10 years)

Diagnostic X-ray examinations in 1996 : 2.4 billion Data Source: Unscear Report 2008
 WHAT HARM CAN X-RAYS CAUSE
• X-rays are ionizing radiation and can cause biological effects in the
exposed person.
• The nature of biological effect depends on the dose delivered and the
chronic or acute nature of exposure.
• In routine general diagnostic radiology procedures, radiation doses dealt
with are very low and these effects are not normally observed.
• What about high dose imaging modalities like Interventional Radiology
and Cardiology??
BIOLOGICAL EFFECTS OF
RADIATION
UNDERSTANDING THE QUANTITIES FOR MEASUREMENT OF RADIATION EXPOSURES

• Charge produced in unit mass of air from ionization by gamma and x-rays.
Exposure • SI Unit is Coloumb/kg; special unit Roentgen (R)

• Energy deposited by any form of ionizing radiation in a unit mass of material.

Absorbed
Dose • Unit Joule/kg or gray (Gy) and 1 Gy = 100 rads

• Accounts for the hazard potential of different types of radiation through a factor called
Equivalent Dose Radiation Weighting Factor (wR) Unit is sievert (Sv) HT (Sv)= ∑wR DT,R,

• Accounts for the different types of tissues and their sensitivity. Takes into account
Effective Dose
the tissue weightage factor..a measure of stochastic risk factor
• Unit is Sv; E (Sv) = ∑wTHT = ∑wT ∑wR DT,R
 MECHANISM OF RADIATION DAMAGE
Damage occurs due to the effect of radiation on the DNA of the Cells. Cells are capable of
repairing the damage but in a few the damage progresses to cause mutations, translocations or
cell death. There are two mechanisms by which radiation damages the DNA
1. DIRECT DAMAGE:
 Direct deposition of energy in the DNA.
 Predominant when exposed to alpha particles, protons, neutrons etc.
2. INDIRECT DAMAGE:
 Deposition of energy in the surrounding water & damage is caused due to reaction of free
radical formed in the water with the DNA.
 Predominant in case of X-rays and gamma rays.
 OUTCOMES AFTER CELL EXPOSURES

Mutation Viable Cell

repaired

Unviable Cell
Cell death

DNA Mutation Cancer?

Cell survives but
mutated
 What can these effects lead to?
Genetic effects
Skin Burns
Infertility
Cataract
Cancer
Death
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 Biological effects of ionizing radiation

• Tissue Reactions (also called as Deterministic Effects)

• There exists a threshold dose below which the effect is not observed (eg. Radiation
dermatitis, epilation, infertility etc.).
• Severity of the effect increases with dose.
• A large number of cells are involved.
• Stochastic Effects
• Stochastic Effects have no threshold dose (There is no safe dose for stochastic effects)
eg. Cancer, genetic effects.
• Probability of the effect increases with dose.
• Can occur with a single cell.
 Biological effects – A comparison
• Stochastic Effects • Deterministic Effects
• Due to cell changes (DNA) and • Due to cell killing
proliferation towards a
malignant disease
• Involve a large number of cells
• No dose threshold- applicable
also to very small doses • Have a dose threshold -
typically several Gy
• Probability of effect increases
with dose • Specific to particular tissues

• Severity (example cancer) • Severity increases with dose

independent of the dose eg. Skin injuries
 Factors Influencing Biological Effects

• Type of Radiation : alpha, beta, gamma or x-rays

• Type of Exposure : Acute or Chronic (prolonged)
• Type of cells exposed : Somatic Cells or Germ Cells
• Type of tissue involved; eg. Stomach is more sensitive than brain
• Area of exposure: Whole body or localized exposure
• Individual specific Radio Sensitivity
Deterministic Effects for Whole body Exposure (Acute)

Dose Range Immediate Effect

Less than 0.1 Gy No detectable effect

Above 0.1 Gy Chromosome aberrations detectable

Above 0.5 Gy Transient reduction in WBC count

Above 1 Gy Nausea, vomiting, diarrhea (NVD)

3 – 5 Gy Lethal Dose (LD50/60) (lethal in 60 days to 50% of

exposed population)
5 – 10 Gy Increase in severity of above effects
Almost 100% death (at higher dose)
Deterministic Effects for Local Irradiation (Acute)
Dose Range Region Effect
0.15 Gy Testes Temporary Sterility
3.5 - 6.0 Gy Testes Permanent Sterility

1.5 - 2 Gy Ovaries Temporary Sterility

2.5 - 6 Gy Ovaries Permanent Sterility

3 Gy Hair follicles Temporary Epilation

5 Gy Eye Cataract (after 5-10 yrs)

6 Gy Skin Skin Erythema

10 -20 Gy Skin Burns, Blisters, Wounds,

Necrosis, Permanent hair loss
CONCERN: INTERVENTIONIAL RADIOLOGY &
CARDIAC STUDIES
 Typical Doses in X-ray Procedures
Procedure Mean Effective Dose (mSv) Typical Organ doses (mGy)
to patient
10-40 (stomach) 27 (bone surface) 88.5 (breast
CT Abdomen & pelvis 13.6
dose in Cardiac CT)

CT Chest 7.9 9-20 (Lung)

CT Head 1.8 60 mGy (head) ACR AAPM reference value)

Radiography 0.02 -1 0.11 (lung in chest X-ray)* 7.8
mGy (Bone surface in Lumbar spine X-ray )

Interventional Radiology 10-70 80-758 (Interventional CT 1)

104-71600 (mean 2Gy for TIPS Creation2)
Fluoroscopy 1-20 65 mGy/min (GI fluoro ) ACR AAPM reference
value

Dental Radiography 0.001-0.03 0.06 (Thyroid in Intra Oral)

0.15 (in Bitewing)
*HPA Recommended national reference doses for individual radiographs on adultpatients, 2000
Organ dose measurement in x-ray CT and other diagnostic radiology by using novel photodiode dosimeters installed in an
anthropomorphic phantom: Takahiko Aoyama, Shuji Koyama and Chiyo Kawaura
 Ionizing Radiation

We live with Can kill

2-3 mSv/y 4000 mSv
(>30 mSv/y in
some places)

Is there a safe point?

If not, how to deal with the problem?
RADIATION PROTECTION
 OBJECTIVE OF RADIATION PROTECTION

• PREVENTION of deterministic effect.

• LIMITING the probability of stochastic effect.
HOW? Up to what point?
• Data from atomic bomb survivors and other sources show a correlation between radiation
exposure and increased cancer risk.

• Until proven false the linear-no-threshold model of radiation exposure versus risk is a
conservative approach for public policy - i.e we go with the assumption that there is a
direct co-relation between radiation exposure and risk of cancer.

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 BASIC PRINCIPLES OF RADIATION PROTECTION

1) JUSTIFICATION: No practice shall be adopted unless its introduction produced a net positive
benefit.

2) OPTIMIZATION OF EXPOSURES: All exposures shall be kept As Low As Reasonably Achievable

(ALARA), economic & social factors being taken into account.

3) DOSE LIMITS: Dose to individuals shall not exceed recommended limits (Applicable to
occupationally exposed personnel).

Exposure due to natural background radiation & medical exposure excluded in arriving at the dose
limits.
 OPTIMIZATION OF DOSES
• All Justified medical exposures
should ensure that the doses are
such that;

• Maximum information is
obtained through minimum
possible doses to the patient
i.e, Acceptable quality images
with minimum patient dose.

• Dose to the
operators/occupational
workers is As Low as
Reasonably Achievable
(ALARA).
Crisp Images = increased dose to
patients .. So, settle for acceptable
quality images
 OPTIMIZING DOSES
• Deliver only the dose needed to make the diagnosis and no more.
• Set X-ray control techniques that are unique to each patient based on size.
• Only image the body part needed to make the diagnosis by using collimation.
• An image that needs to be re-taken due to poor quality is a 100% wasted
radiation dose.
• An image taken with too low X-ray exposure risks a false-negative diagnosis
thereby put the patient at risk.
 Dose Limits prescribed by the National Authority of India i.e. AERB

Part of the body Occupational Worker Member of Public Trainee

Whole body 20 mSv/year averaged over 1 mSv/year 6mSv in a year

(Effective dose) 5 consecutive years;
30 mSv in any single year

Lens of eyes 150 mSv in a year 15 mSv/year 50 mSv in a year

(Equivalent dose)*

Skin 500 mSv in a year 50 mSv/year 150 mSv in a year

(Equivalent dose)

Extremities 500 mSv in a year ----- ----- 150 mSv in a year

(Hands and Feet)
Equivalent dose

For female workers , once pregnancy is declared the equivalent dose limit to embryo / fetus shall be 1 mSv for the
remainder of the pregnancy.

ICRP has recently revised the dose limit for lens of eyes as 20mSv in a year for occupational workers

(There is a probability of high lens doses in IR procedures, if protective accessories lead goggles and ceiling
suspended screens are not used)
 NEED FOR PATIENT PROTECTION
• Patient is irradiated by the direct beam.
• Medical personnel is irradiated by the scatter radiation (which is only
0.1% of direct beam).
• Patients may undergo repeated radiation procedures.
• A patient may receive in one procedure a dose equivalent to dose the staff
may receive in one (or several) years.
INTERVENTIONAL RADIOLOGY
AND TISSUE REACTIONS
(DETERMINISTIC EFFECTS)
If you take precautions while using Iodinated Contrasts ….Why
not for radiation
 DETERMINISTIC EFFECTS IN
DIAGNOSTIC RADIOLOGY- Probable?
• Radiation Doses in General Radiography procedures are too less to cause any Tissue reactions.
• Radiation doses in CT examinations are unlikely to cause any Tissue reactions. Radiation doses in
normal flouroscopic (non interventional/cardiological) procedures are unlikely to cause any
deterministic effects.
However, any X-ray procedures contribute to increase in probability of stochastic effects.
• Radiation Doses to patient in some interventional radiology procedures can be high
enough (>2 Gy) to cause Tissue reactions - Close monitoring of the doses and follow up of
patients for skin reactions is essential in such cases.
• Any fluoroscopic intervention has the potential to cause injury to patient if the radiation dose
exceeds the deterministic threshold.
 Reported Injuries due to IR procedures
Grade 2 skin reaction on a patient’s back (photograph
courtesy of S. Balter), IAEA RPoP Web site

Grade 4 skin reaction on a

patient’s back (photo IAEA
RPoP

First
Case
reported
1993 “Technology has advanced since 1993.. Now
my machine takes care of patient safety.” Is it
True???
 India, 2016: Reported Injuries to patient
1. Initial stages of injury from Interventional
Radiology Procedure for Pelvic AVM : Injury
consistent with the entry port of the radiation beam :
Note the discoloration of skin in the posterior and Rt.
Lateral pelvis
2.Rt Arm is exposed during
the procedure

4. Injury in Rt.
Gluteal region
progresses to a
non healing ulcer
requiring skin 3.Arm injury progresses
graft
Radiation Safety – Whose Responsibility?
 Radiation
Radiatio
n Safety
Safety

Built in
Radiatio Operational
(Design)
n Safety Safety
Safety

Radiation
Safety of Safe work
Adequately safety
Equipment
Training, practice and
shielded (Type
Approval by
QA, dose
Room Layout qualified
AERB) optimization
staff
 Safety in work practice
Design Safety of Installation:
• Install the equipment in an adequately shielded room.
• Ensure all the equipment specific safety (such as ceiling suspended lead glass, couch hanging lead rubber flaps
etc) accessories are provided.
• Refer Model Layout of X-ray installations provided on AERB web site.
Design Safety of the Equipment:
• Install only those equipment that are Type Approved by AERB.
• Take requisite AERB permissions prior to installation.
• Ensure the performance evaluation of the equipment is acceptable after installation.
• Use the equipment after obtaining license for operation.
 Safety in work practice
Remember the TDS Principle

Ensure Safety using the Time,

Distance and Shielding parameters

1. LESS (Exposure) TIME

2. MORE DISTANCE (from the patient),
3. ADEQUATE SHIELDING (protective
accessories)

If you double your distance from source

of radiation, your dose is reduced by a
factor of 4, i.e., it is 25% of what it
would have been!
HOW TO MONITOR PATIENT DOSE

Real-time KAP values

displayed on monitor

UNDERSTAND THE DOSEMETRICS OF

YOUR IR SYSTEM.
IDENTIFY THE DOSE AND TIME
DISPLAYS ON THE MONITOR. Maintain a
Record of the Patient Doses in IR Procedures
 GOOD WORK PRACTICE IN IR
Factors Affecting Dose
HEIGHT OF STAFF
X-ray tube

RELATIVE POSITION WITH

RESPECT TO THE PATIENT

IRRADIATED PATIENT
patient VOLUME
X-AY TUBE POSITION

kV, mA and time (NUMBER AND

CHARACTERISTICS OF PULSES)
EFFECTIVE USE OF ARTICULATED
SHIELDING AND/OR PROTECTION
GOGGLES
 FACTOR AFFECTING YOUR RADIATION DOSE

Scattered dose
Angle, Field size and Distance rate is lower
opposite to the
mGy/h at 0.5m mGy/h at 1m
100 kV entrance side of
the beam, higher
with large field
11x11 cm
size and lower
when distance
from the patient
increases

Source Of Radiation To Patient Is The Primary X-ray Beam – Keep Xray Tube At
Optimum Distance From Patient
Source Of Radiation To Operator Is The Patient – Keep Max Possible Distance From
Patient 41
 X-RAY TUBE POSITIONING

THE BEST INTENSIFIER UP

CONFIGURATION

X-RAY TUBE DOWN

SAVES A FACTOR OF
3 OR MORE IN DOSE
Tube under couch
X-RAY TUBE UP position reduces, in
IN COMPARISON general, high dose
TO: INTENSIFIER DOWN rates to the
specialist’s eye lens
TRY TO KEEP X-RAY TUBE UNDERCOUCH ; IN OBLIQUE POSITIONS MIND
YOUR POSITION ….continued
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POSITION OF THE INTERVENTIONIST
In Oblique
Projections,
stand near
the Imager
Side.

Exposure to
Scatter
radiation
from patient
is reduced in
this position
and patient
also acts as a
shield
Do you Know: 0.25mm Lead Apron reduces the dose to physician by 97% and also shields 80% of
Bone Marrow
 HOW DO I REDUCE PATIENT DOSE
• Keep the Imager as close as possible to the patient

• Radiation follows inverse square law. Dose at the patient entrance surface increases
when the imager is kept far - It is ok if the imager touches the patient. (If not
possible, may consider removing the grid)
• For the same reason, keep the X-ray tube away from patient (as feasible)
AVOID “MAG”NIFICATION MODE

6 9
” ”
0.15 mm / pixel vs. 0.23mm/pixel

Smaller Image Intensifier Mode

(“MAG”) has better resolution

… but gives higher

exposure to patient and
staff
MOVE THE BEAM-SPREAD THE DOSE
• Use higher kVp where ever possible.
• Use multiple projections – move the x-ray
tube to spread the dose.
• Do not Expose same area in different
projections.
• Make use of the Last Image Hold.
• Use pulsed flouroscopy with minimum
possible frame rate. Avoid hot spots due to
• Keep Flouroscopic Time to MINIMUM. overlapping projections

Influence of operation modes: from low fluoroscopy to cine mode, scatter

dose rate could increase by a factor of 10 (from 2 to 20 mSv/h for normal size
patient). Use the Cine/acquisition mode judiciously.
Pulsed fluoroscopy and heavy beam filtration provides imaging at a significantly
reduced radiation dose and its use is highly recommended.
The dose can be lowered by 50-70% with no perceivable loss in image quality.
The Radiation Safety Checklist
Appropriate protocols Optimum Field size and
Chosen Check unintended parts
(patient arms etc) are not in the field
Only authorized persons
Ceiling suspended shield In the room.
And barriers, lead curtains

Lead Apron & Goggles. Time, Distance, Shielding

Wearing TLD under lead Proper positioning of the

apron Tube and imager.

Use of low dose pulsed Watch foot on pedal

Flouroscopy with lowest Pedal only while looking
possible frame rate at the screen. Use LIH
Take care of the radiological protection of
your patient and this way you will also be
reducing your own dose
 Follow up of patients for skin injury
• Set “ Trigger Values” for Cumulative Skin Dose that roughly equates to peak skin
dose of 3 Gy
• 2-3 Gy for Neuroradiology
• 3-5 Gy for Cardiology
• Identify the cases where procedures are repeated on the same patient with skin dose
in this range
• Establish mechanism to follow up patients who could have received high skin doses
• Inform and Include the side effects due to radiation in the ‘consent form’ of the
patient
 SUMMARY
• Skin injuries are a possibility in prolonged IR procedures. Physicians must be able to identify
radiation-induced skin injuries in patients.
• Dose to patients and staff can be minimized by following Good Work Practices
• Understanding YOUR equipment helps in dose reduction
• Prior to performing a procedure, a detailed history of prior fluoroscopic interventions and
any observed skin effects is essential. If the patient has had such procedures, a brief
inspection of the skin is appropriate.
• Patients who receive a high skin dose (e.g., in excess of 3 Gy) should be counseled and
advised on examining their skin at the proper location. If any skin changes are observed, the
patient should be advised to contact the physician who performed the procedure.
• Monitoring of the doses during procedures helps in optimizing the radiation doses
to patient and operators

• Quality Assurance should be carried out periodically to assure high standards in

dose reduction and image quality.

• Use of a “Radiation Safety Checklist” prior and post procedures is recommended

 TRY THESE..
1. Which of these Modes of operation gives less patient doses
a. Pulsed flluoro at 4 Frames /second
b. Cine/Acquisition Mode
c. Pulsed fluoro at 30 Frames/second
d. None of these

2. How can Patient Doses be monitored during procedure

a. Fluoro time
b. DAP/KAP values
c. Cumulative Dose of procedure
d. All of the above
1. Skin Reactions are probable among which of these procedures
a. Routine Fluoroscopy
b. Abdominal CT with Contrast
c. Chest X-ray
d. TIPS procedure
2. What is the annual Dose Limit for occupational Exposures in India
a. 20mSv/year averaged over 5 years
b. 30 mSv/year
c. 1 mSv/year
d. Depends on the number of procedures
1. What is WRONG with this Image
a. Imager is above couch
b. Too many people in the room
c. Oblique position
d. Flouroscopy is ON but physician not looking at the screen

2. What suggests wrong practice in

this Image
a. Nothing
b. Field size is small
c. Beam not collimated
d. Hand visible in the image
 References
1. Radiation Dose Levels for Interventional CT Procedures Shuai Leng1, Jodie A. Christner1, Stephanie K.
Carlson1, Megan Jacobsen1, Thomas J. Vrieze1, Thomas D. Atwell1 and Cynthia H. McCollough1
American Journal of Roentgenology Volume 197, Issue 1, July 2011
2. Radiation Doses in Interventional Radiology Procedures: The RAD-IR Study; Donald L. Miller et al; Journal of
Vascular and Interventional Radiology; JVIR 2003
3. Current issues and actions in radiation protection of patients; Ola Holmberg,Jim Malone, Madan Rehani, Donald
McLean ,Renate Czarwinski; European Journal of Radiology October 2010 Volume 76, Issue 1, Pages 15–19
4. Justification of Medical Exposure in Diagnostic Imaging: Proceedings of IAEA International Workshop Brussels,
2–4 September 2009
5. http://ns-files.iaea.org/video/rpop-webinar-5april.mp4
6. IAEA Radiation Protection of Patients (RPoP) – Diagnostic Radiology
More information at…
 RADIATION WARNING SYMBOL
for X-RAY EQUIPMENT

All regulatory consents online can be obtained through e-LORA

For further information : please visit www.aerb.gov.in