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Fluoroscopy Safety


Fluoroscopy Safety Using Time to Reduce Exposure: Summary When image quality allows, choosing to use low dose fluoro modes and last image hold, while limiting the use ... – PowerPoint PPT presentation

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Title: Fluoroscopy Safety

Fluoroscopy Safety
New Wisconsin Regulations
  • In 2010, WI enacted new training regulations for
    clinicians who use fluoroscopy. Unless certified
    by the American Board of Radiology (or board
    eligible), clinicians are required to be trained
  • Principles of operation of the fluoroscopic x-ray
  • Biological effects of x-rays
  • Principles of radiation protection
  • Fluoroscopic outputs
  • High Level control options
  • Dose reduction techniques
  • Applicable state and federal regulations

What is Fluoroscopy?
  • Fluoroscopy is an imaging procedure that uses a
    continuous x-ray beam to create real-time images
    viewed on a monitor.
  • It enables physicians to view internal organs
    and vessels in motion.
  • Fluoroscopy is used in both diagnostic and
    therapeutic procedures.

Medical uses of fluoroscopy began shortly after
Roentgens discovery of x-rays in 1895.
Fluoroscopy Today
Fluoroscopy for tuberculosis (1940)
1990s Injuries Reported to FDA
  • From 1992 through 1995, the FDA received more
    than 100 reports of patients with radiation
    injuries from fluoroscopy.
  • Since 1992, reports of injuries to patients and
    physicians have appeared in radiology,
    cardiology, and medical physics journals.

What Kind of Injuries?

Skin Injury and Time to Onset Listed in order of
time of initial onset
Effect Approximate Threshold Dose (Gy) Time of Initial Occurance Note
Early transient erythema 2 Hours Inflammation of the skin caused by activation of a proteolytic enzyme that increases the permeability of the capillaries
Acute ulceration 20 lt 2 weeks Early loss of the epidermis that results from the death of fibroblasts and endothelial cells in interphase
Epilation 3 2 to 3 weeks Hair loss caused by the depletion of matrix cells in the hair follicles permanent at doses exceeding 6 Gy
Dry desquamation 8 3 to 6 weeks Atypical keratinization of the skin caused by the reduction of the number of clonogenic cells within the basal layer of the epidermis
Skin Injury and Time to Onset
Effect Approximate Threshold Dose (Gy) Time of Initial Occurance Note
Main erythema 3 Days to Weeks Inflammation of the skin caused by hyperemia of the basal cells and subsequent epidermal hypoplasia
Moist desquamation 15 4 to 6 weeks Loss of the epidermis caused by sterilization of a high proportion of clonogenic cells within the basal layer of the epidermis
Secondary ulceration 15 gt 6 weeks Secondary damage to the dermis as a consequence of dehydration and infection when moist desquamation is severe and protracted
Late erythema 20 8 to 20 weeks Inflammation of the skin caused by injury of the blood vessels edema and impaired lymphatic clearance precede a reduction in blood flow
Skin Injury and Time to Onset
Effect Approximate Threshold Dose (Gy) Time of Initial Occurance Note
Dermal necrosis 20 gt10 Weeks Necrosis of the dermal tissues as a consequence of vascular insufficiency
Invasive fibrosis 20 Month to years Method of healing associated with acute ulceration, secondary ulceration, and dermal necrosis, leading to scar tissue formation
Dermal atrophy 10 gt 26 Weeks Thinning of the dermal tissues associated with the contraction of the previously irradiated area
Source Centers for Disease Control and
Prevention. Cutaneous radiation injury fact
sheet for physicians.
Example 1
  • A 40-year-old male underwent coronary
    angiography, coronary angioplasty and a second
    angiography procedure due to complications,
    followed by a coronary artery by-pass graft, all
    on March 29, 1990.
  • Example and images provided by Thomas Shope,
    U.S. FDA Center for Devices and Radiological

6-8 weeks post procedure
Note the erythema in the shape of the radiation
16-21 weeks post procedure
Erythema reduced, Secondary Damage (not as well
18-21 months post procedure
Close-up view of lesion
Post Skin Graft
Example 2
Note Epilation

Injury following three procedures involving
transjugular intrahepatic portosystemic shunt
placement (TIPS), demonstrating disfigurement
after surgical correction. Koenig TR, Wolff D,
Mettler FA et al. Skin injuries from
fluoroscopically guided procedures part 1,
characteristics of radiation injury. AJR Am J
Roentgenol 2001 177(1)3-11.
Example 3
  • Injury to arm of patient.
  • Patient was draped for
  • procedure and physicians
  • did not realize that she
  • had moved her arm so that
  • it was resting on the port of
  • the X-ray tube during the
  • procedure.
  • Wagner LK, Archer BR. Minimizing Risks from
    Fluoroscopic X Rays. 4th edition.
  • The Woodlands, Texas Partners in Radiation
    Management, 2004.  

Why Are Injuries Occurring?
  • One contributing factor is the growth in number
    and types of interventional procedures using
    fluoroscopy. But any procedure using fluoroscopy
    has the potential for patient injury.
  • Another factor may be more overweight and obese
    patients. Higher energy x-rays and higher
    radiation dose rates are required to penetrate
    through these patients.

FDA Actions
  • In 1994, the FDA issued a Public Health Advisory
    on avoidance of serious skin injuries to patients
    during fluoroscopy-guided procedures.
  • In 1995, the FDA issued a follow-up advisory on
    recording information in the patients record
    that identifies the potential for serious skin
    injury from fluoroscopy.

Joint Commission Action
  • In 2006, the Joint Commission added a Sentinel
    Event category for radiation overdose involving
    prolonged fluoroscopy with a cumulative dose of
    more than 15 Gray to a single field.
  • Fluoroscopy machines manufactured after June
    2006 measure and display a reference patient
    radiation dose. The reference dose can be
    monitored during the procedure, and the
    cumulative dose can be recorded in the patients
    medical record.

  • All of the following injuries can be
  • caused by radiation
  • Skin erythema and desquamation
  • Epilation
  • Skin ulceration

What About Personnel Safety?
  • Physicians and staff using fluoroscopy are
    exposed to
  • - Scattered radiation from the patient
  • Leakage radiation from
  • the x-ray tube
  • Primary radiation from the
  • x-ray beam if their hands
  • are in the radiation field

Detector/image intensifier
x-ray tube
Personnel Safety
  • Although clinician radiation dose is much lower
    than the patient dose, it is proportional to
    patient dose.
  • Higher patient doses will usually lead to higher
    operator and staff doses.

Radiation Risks
  • High doses of radiation (gt1 Gray in a single
    exposure), such as those received by patients
    injured by fluoroscopy, are linked to skin injury
    and increased risk of cancer.
  • Low doses of radiation over long periods of
    time, such as those received by medical
    personnel, may result in an increased risk of
    cancer, although this has not been conclusively

ALARA (As Low As Reasonably Achievable)
  • Because we know that large doses of radiation
    can cause long term health effects, such as
    increasing the risk of developing cancer, we
    assume that all radiation exposure entails some
  • Therefore, we should try to limit the radiation
    exposure to patients and staff, consistent with
    obtaining the necessary clinical information.

  • In fluoroscopy, there are three practical
    techniques to reduce radiation exposure to
    patients and personnel.
  • Reduce Fluoro Time
  • Increase Distance
  • Provide Shielding
  • The following slides demonstrate how to use these
    techniques to reduce radiation exposure.

Time Identify if the patient has had other
recent long fluoro procedures
  • Check the patients medical record to see if they
    have had a recent long fluoroscopy procedure in
    the same location.
  • If yes, try to change the C-Arm angle so that you
    are not irradiating the same area of skin again.

Time Recognize the Fluoroscopy Beam-On Controls
  • Typical x-ray beam-on foot pedal.
  • Most units also have a beam-on button or switch
    the user can operate by hand.

Time Minimize Beam-On time
  • Use short taps of the fluoroscopy beam-on
    control. Dont use a lead foot on the
  • fluoroscopy pedal.
  • Reducing beam-on
  • time is the most
  • effective way to
  • reduce dose.

Time LIH and LFH
  • Use Last Image Hold (LIH) or
  • Last Fluoroscopy Hold (LFH)
  • when possible instead of re-
  • exposing the patient.
  • Last Image Hold saves the last fluoroscopy image
    and displays it on the monitor.
  • Last Fluoroscopy Hold saves the last video
    sequence of fluoroscopy images for instant replay.

Time Fluoroscopy Dose Modes
  • Different dose mode selections may be available
  • Low Dose (?patient dose, ? image noise)
  • High Dose (?patient dose, ? image noise)
  • Low Frame Rate (?patient dose, ? frame rate)
  • When Image Quality allows, use low dose mode
    and/or a lower frame rate.

Time Minimize Use of High Dose Mode
  • High dose rate mode may be needed for large
    patients or for seeing greater detail.
  • High dose mode selection is usually denoted
    by a sign.

Do not routinely use high dose mode.
Time Digital Acquisition Mode
  • X-Ray machines used for
  • interventional procedures have a
  • digital acquisition or cine mode.
  • A high radiation dose rate is used to obtain a
    series of high resolution images with reduced
    image noise.
  • The radiation dose per frame for digital
    acquisitions can be 15 times greater than for

Time Use Digital Acquisition/Cine Mode
  • The number and length of digital
  • acquisition or cine runs may be
  • the greatest source of patient
  • radiation dose in interventional
  • radiology procedures.
  • Be aware of the increased dose rate and do not
    use digital acquisition/cine mode as a substitute
    for fluoroscopy.

Using Time to Reduce Exposure Summary
  • When image quality allows, choosing to use low
    dose fluoro modes and last image hold, while
    limiting the use of boost fluoro and high dose
    digital acquisitions, will reduce patient and
    staff radiation exposure.

Distance Scattered Radiation
  • During fluoroscopy, radiation is scattered from
    the surface of the patient where the x-ray beam
  • Scattered radiation is the main source of
    radiation dose to staff. It also decreases
    image contrast and degrades image quality.

Detector/Image Intensifier
x-ray tube
Distance C-Arm Position
  • Position the X-ray tube underneath the patient,
    not above the patient.
  • The greatest amount of scatter radiation is
    produced where the x-ray beam enters the patient.
  • By positioning the x-ray tube below the patient,
    you receive less scatter radiation.

Image Intensifier
X-ray Tube
Distance C-Arm Position
  • For lateral and oblique projections, position the
    C-arm so that the x-ray tube is on the opposite
    side of the patient from where you are working.
  • This will reduce the scatter radiation reaching

Always stand closer to the detector/image
Always stand farther from the X-Ray Tube.
Distance C-Arm Position
  • Position the x-ray tube and image intensifier so
    you are working on the image intensifier side of
    the patient.
  • Position the x-ray tube as far from the patient
    as possible.
  • Position the Image intensifier as close to the
    patient as possible.

X-ray tube
Image intensifier
Distance Proximity to the X-Ray Tube
  • The patients skin should never touch or be near
    the x-ray tube port (where the x-rays come out).
  • Staff should also never touch or be near the
    x-ray tube port.
  • Burns can occur in seconds if skin is touching or
    near the x-ray tube port.

X-ray tube port
Distance Minimize the Air Gap
  • Move the detector or image intensifier as close
    to the patient as possible.
  • A smaller air gap reduces radiation dose to the
    patient and staff and improves image quality.

Distance When possible increase your distance
from the patient when the x-ray beam is on
  • When possible, simply taking a step back from the
    radiation source whenever possible will greatly
    reduce your radiation dose.
  • Moving from 30cm to 60 cm from the patient will
    reduce your exposure by a factor of 4.

Distance Stay Out of the Fluoroscopy Beam
  • Dont put your hands in the fluoroscopy beam
    unless absolutely necessary for the procedure.

This is the hand of a physician who was exposed
to repeated small doses of x-ray radiation for 15
years. The skin cancer appeared several years
after his work with x-rays had ceased.
Meissner, William A. and Warren, Shields
Neoplasms, In Anderson W.A.D. editor Pathology,
edition 6, St. Louis, 1971, The C.V. Mosby Co
Using Distance to Reduce Exposure Summary
  • When possible, always position the image
    intensifier over the patient.
  • Maximize the distance from the x-ray tube to the
  • Move the image intensifier as close to the
    patient as you can.
  • Maximize the distance between you and the patient
    during the x-ray exposure.
  • Do not put your hands in the primary beam.

Shielding Collimate Appropriately
  • Collimate tightly to the area of clinical
    interest to reduce patient and staff dose, reduce
    scatter, and improve image contrast.

Shielding Magnification Modes
  • Magnification enlarges the anatomy being viewed,
    but it also increases the radiation dose to the
  • Multiple electronic magnification modes may be

Use Shielding
  • Wisconsin DHS regulations require anyone
    within 6 feet of a fluoroscopy machine to wear a
    lead apron.
  • You may also wear a lead thyroid shield or
    leaded eyeglasses, depending on the type and
    amount of work you do.

Shielding Mini C-Arms
  • Although Mini C-Arms produce less scatter
    Radiation than full C-Arms, Aspirus Wausau
    Hospital radiation safety procedures require the
    use of lead aprons when performing any
    fluoroscopy procedure.

Shielding Hang Lead Aprons Properly
  • Hanging lead aprons on hangers/hooks prevents the
    lead from cracking and tearing.
  • This is for your safety, so please be sure to
    take care of your lead.

Using Shielding to Reduce Exposure Summary
  • Collimate the radiation to the area of interest.
  • Minimize the use of high magnification modes.
  • Always wear radiation protection devices.

Pediatric Patients
  • Children are estimated to be two to seven times
    more sensitive to radiation than adults.
  • They have more dividing and differentiating cells
    and have a longer time over which radiation
    effects such as cancer can appear.
  • Use techniques taught in this course to minimize
    the dose to pediatric patients as well.

To Reduce Pediatric Radiation Exposure
  • Use low dose or low pulse rate mode.
  • Collimate the beam to only show the area of
  • Maximize the distance from the x-ray tube to the
  • Minimize the distance from the image intensifier
    to the patient.
  • Use the minimum electronic magnification
  • Use the minimum amount of beam-on time

Radiation Dose Limits
  • Occupational radiation exposure to radiation
    workers is regulated by the federal government
    and the states.
  • Annual occupational radiation exposure limits are
    set to levels at which there is believed to be
    negligible risk of biological effects.
  • Whole Body 50 mSv/yr
  • Lens of the Eye 150
  • Extremities, Skin 500 mSv/yr

Dosimetry Badges
  • Workers likely to receive an occupational
    radiation dose greater than 5 mSv/year must be
  • Radiation exposure reviews determine which
    categories of workers are required to be
  • Workers with particular concern regarding
    radiation, such as pregnant workers, may also be
    monitored even if they are not likely to exceed 5

Dosimetry Badge
Dosimetry Badges
  • If you have been issued a single dosimetry badge,
    wear it outside your lead apron at collar level.
  • If you have been issued two badges, wear the
    collar badge outside your lead apron, and wear
    the body badge underneath your lead apron.

For More Information
  • These and other policies regarding radiation
    safety are available in the Aspirus Wausau
    Hospital Radiation Safety Plan which is available
    on the hospital network at
  • S\Radiation Safety Plan
  • or by contacting the Aspirus Wausau Hospital
    Radiation Safety Officer.

  • For questions about fluoroscopy safety, contact
    the Aspirus Wausau Hospital Radiation Safety
  • Raymond Wery, M.S., DABR
  • phone 715-847-2031
  • rayw_at_aspirus.org

Fluoroscopy Safety Certificate
  • A test will follow this presentation, to validate
    your understanding of these safety principles.
  • If you would like a certificate documenting that
    you have received training in Fluoroscopy Safety,
    call or e-mail the Aspirus Wausau Hospital
    Provider Support Services Department.
  • The certificate can satisfy other organizations
    requirements for fluoroscopy training, if needed.

  • Contributors
  • Mary Ellen Jafari, M.S., DABR
  • Alan M. Daus., M.S., DABR
  • Diagnostic Medical Physics Section
  • Imaging Department
  • Gundersen Lutheran Medical Center
  • La Crosse, Wisconsin
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