Radiation risk to healthcare workers from diagnostic and interventional imaging procedures
- Reza Fazel, MD, MSc
Reza Fazel, MD, MSc
- Associate Physician
- Brigham and Women's Hospital
- Harvard Medical School
- Andrew J Einstein, MD, PhD, FACC, FAHA
Andrew J Einstein, MD, PhD, FACC, FAHA
- Herbert Irving Associate Professor of Medicine
- Columbia University Medical Center
- Section Editors
- Donald Cutlip, MD
Donald Cutlip, MD
- Section Editor — Interventional Cardiology
- Professor of Medicine
- Harvard Medical School
- Beth Israel Deaconess Medical Center
- Stephan Windecker, MD
Stephan Windecker, MD
- Section Editor — Coronary Heart Disease
- Professor of Medicine
- Department of Cardiology
- Bern University Hospital
- N A Mark Estes, III, MD
N A Mark Estes, III, MD
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Cardiac Arrhythmias
- Professor of Medicine
- Tufts University School of Medicine
In addition to the patient, health care workers are exposed to significant amounts of radiation during cardiovascular imaging procedures. With advancing technology, the realm of procedures being performed percutaneously is steadily expanding. The increased anatomic and technical complexity of these procedures often requires longer fluoroscopy and image capture time and leads to greater radiation exposure to the patient and interventional laboratory staff . In addition, these procedures are exposing new groups of health care workers, including echocardiographers and anesthesiology and operating room staff, to radiation exposure from fluoroscopic imaging while assisting with these procedures. It is imperative that health care workers involved in these procedures be aware of the radiation exposure and are provided with the tools necessary to protect and monitor themselves .
This topic will present radiation risks related to occupational exposure in diagnostic and interventional imaging suites, the role of dosimetry, and tools for minimizing radiation exposure to health care workers. Other related topics, including discussions of radiation injury and radiation exposure in cardiovascular imaging, are presented separately. (See "Biology and clinical features of radiation injury in adults" and "Radiation-related risks of imaging studies" and "Radiation dose and risk of malignancy from cardiovascular imaging".)
Exposure to ionizing radiation can lead to tissue reactions (formerly known as deterministic effects) or stochastic effects (a stochastic effect represents an outcome for which the probability of occurrence, rather than severity, is determined by the dose). An example is radiation-induced carcinogenesis. (See "Radiation dose and risk of malignancy from cardiovascular imaging".)
When standard radiation protection tools are used in the cardiovascular interventional lab, doses to the operator and staff do not typically approach thresholds of tissue reactions and the principle risks to consider are the stochastic risks of induced cataract formation and cancer .
Cataracts — The lens of the eye is one of the most radiosensitive tissues in the body [4,5]. In spite of the well documented history of radiation-induced cataract, there is still considerable uncertainty surrounding the relationship between dose and radiation cataract development . Studies of exposed human subjects suggest that there is no clear threshold dose for cataract formation. It also appears that the latency period is inversely related to the exposure dose.
- Bernardi G, Padovani R, Morocutti G, et al. Clinical and technical determinants of the complexity of percutaneous transluminal coronary angioplasty procedures: analysis in relation to radiation exposure parameters. Catheter Cardiovasc Interv 2000; 51:1.
- Klein LW, Miller DL, Balter S, et al. Occupational health hazards in the interventional laboratory: time for a safer environment. J Vasc Interv Radiol 2009; 20:S278.
- http://www.icrp.org/publication.asp?id=ICRP Publication 113.
- Brown NP. The lens is more sensitive to radiation than we had believed. Br J Ophthalmol 1997; 81:257.
- Ainsbury EA, Bouffler SD, Dörr W, et al. Radiation cataractogenesis: a review of recent studies. Radiat Res 2009; 172:1.
- Authors on behalf of ICRP, Stewart FA, Akleyev AV, et al. ICRP publication 118: ICRP statement on tissue reactions and early and late effects of radiation in normal tissues and organs--threshold doses for tissue reactions in a radiation protection context. Ann ICRP 2012; 41:1.
- Vano E, Kleiman NJ, Duran A, et al. Radiation-associated lens opacities in catheterization personnel: results of a survey and direct assessments. J Vasc Interv Radiol 2013; 24:197.
- Jacob S, Boveda S, Bar O, et al. Interventional cardiologists and risk of radiation-induced cataract: results of a French multicenter observational study. Int J Cardiol 2013; 167:1843.
- Finkelstein MM. Is brain cancer an occupational disease of cardiologists? Can J Cardiol 1998; 14:1385.
- Klein LW, Miller DL, Balter S, et al. Occupational health hazards in the interventional laboratory: time for a safer environment. Catheter Cardiovasc Interv 2009; 73:432.
- Picano E, Vano E, Domenici L, et al. Cancer and non-cancer brain and eye effects of chronic low-dose ionizing radiation exposure. BMC Cancer 2012; 12:157.
- Roguin A, Goldstein J, Bar O, Goldstein JA. Brain and neck tumors among physicians performing interventional procedures. Am J Cardiol 2013; 111:1368.
- http://www.icrp.org/publication.asp?id=ICRP Publication 116.
- NCRP Report 122: Use of Personal Monitors to Estimate Effective Dose Equivalent and Effective Dose to Workers for External Exposure to Low‐let Radiation. http://scitation.aip.org/content/aapm/journal/medphys/23/8/10.1118/1.597881 (Accessed on March 01, 2016).
- Whitby M, Martin CJ. A study of the distribution of dose across the hands of interventional radiologists and cardiologists. Br J Radiol 2005; 78:219.
- Balter S, Miller DL, Vano E, et al. A pilot study exploring the possibility of establishing guidance levels in x-ray directed interventional procedures. Med Phys 2008; 35:673.
- Delichas M, Psarrakos K, Molyvda-Athanassopoulou E, et al. Radiation exposure to cardiologists performing interventional cardiology procedures. Eur J Radiol 2003; 48:268.
- Chambers CE, Fetterly KA, Holzer R, et al. Radiation safety program for the cardiac catheterization laboratory. Catheter Cardiovasc Interv 2011; 77:546.
- Miller DL, Vañó E, Bartal G, et al. Occupational radiation protection in interventional radiology: a joint guideline of the Cardiovascular and Interventional Radiology Society of Europe and the Society of Interventional Radiology. Cardiovasc Intervent Radiol 2010; 33:230.
- NCRP Report No. 116 - Limitation of Exposure to Ionizing Radiation (Supersedes NCRP Report No. 91). http://www.ncrppublications.org/Reports/116 (Accessed on March 14, 2016).
- Dromi S, Wood BJ, Oberoi J, Neeman Z. Heavy metal pad shielding during fluoroscopic interventions. J Vasc Interv Radiol 2006; 17:1201.
- Germano JJ, Day G, Gregorious D, et al. A novel radiation protection drape reduces radiation exposure during fluoroscopy guided electrophysiology procedures. J Invasive Cardiol 2005; 17:469.
- Sawdy JM, Gocha MD, Olshove V, et al. Radiation protection during hybrid procedures: innovation creates new challenges. J Invasive Cardiol 2009; 21:437.
- King JN, Champlin AM, Kelsey CA, Tripp DA. Using a sterile disposable protective surgical drape for reduction of radiation exposure to interventionalists. AJR Am J Roentgenol 2002; 178:153.
- McIlwain EF, Coon PD, Einstein AJ, et al. Radiation safety for the cardiac sonographer: recommendations of the Radiation Safety Writing Group for the Council on Cardiovascular Sonography of the American Society of Echocardiography. J Am Soc Echocardiogr 2014; 27:811.
- Christodoulou EG, Goodsitt MM, Larson SC, et al. Evaluation of the transmitted exposure through lead equivalent aprons used in a radiology department, including the contribution from backscatter. Med Phys 2003; 30:1033.
- European Commission, Directorate-General for Energy. Guidelines on Radiation Protection Education and Training of Medical Professionals in the European Union. Luxembourg: Publications Office 2014.
- Dauer LT, Thornton RH, Solomon SB, St Germain J. Unprotected operator eye lens doses in oncologic interventional radiology are clinically significant: estimation from patient kerma-area-product data. J Vasc Interv Radiol 2010; 21:1859.
- Thornton RH, Dauer LT, Altamirano JP, et al. Comparing strategies for operator eye protection in the interventional radiology suite. J Vasc Interv Radiol 2010; 21:1703.
- NCRP Report No. 168 - Radiation Dose Management for Fluoroscopically-Guided Interventional Medical Procedures (2010). http://www.ncrppublications.org/Reports/168 (Accessed on March 01, 2016).
- Chen SJ, Hansgen AR, Carroll JD. The future cardiac catheterization laboratory. Cardiol Clin 2009; 27:541.
- Granada JF, Delgado JA, Uribe MP, et al. First-in-human evaluation of a novel robotic-assisted coronary angioplasty system. JACC Cardiovasc Interv 2011; 4:460.
- Smilowitz NR, Weisz G. Robotic-assisted angioplasty: current status and future possibilities. Curr Cardiol Rep 2012; 14:642.
- Vano E. Radiation exposure to cardiologists: how it could be reduced. Heart 2003; 89:1123.
- Kuon E, Glaser C, Dahm JB. Effective techniques for reduction of radiation dosage to patients undergoing invasive cardiac procedures. Br J Radiol 2003; 76:406.
- Balter S. Stray radiation in the cardiac catheterisation laboratory. Radiat Prot Dosimetry 2001; 94:183.
- Schueler BA, Vrieze TJ, Bjarnason H, Stanson AW. An investigation of operator exposure in interventional radiology. Radiographics 2006; 26:1533.
- Stratakis J, Damilakis J, Hatzidakis A, et al. Occupational radiation exposure from fluoroscopically guided percutaneous transhepatic biliary procedures. J Vasc Interv Radiol 2006; 17:863.
- Kuon E, Dahm JB, Empen K, et al. Identification of less-irradiating tube angulations in invasive cardiology. J Am Coll Cardiol 2004; 44:1420.
- Maeder M, Brunner-La Rocca HP, Wolber T, et al. Impact of a lead glass screen on scatter radiation to eyes and hands in interventional cardiologists. Catheter Cardiovasc Interv 2006; 67:18.
- Tsao CW, Frost LE, Fanning K, et al. Radiation dose in close proximity to patients after myocardial perfusion imaging: potential implications for hospital personnel and the public. J Am Coll Cardiol 2013; 62:351.
- Chiesa C, De Sanctis V, Crippa F, et al. Radiation dose to technicians per nuclear medicine procedure: comparison between technetium-99m, gallium-67, and iodine-131 radiotracers and fluorine-18 fluorodeoxyglucose. Eur J Nucl Med 1997; 24:1380.
- Benatar NA, Cronin BF, O'Doherty MJ. Radiation dose rates from patients undergoing PET: implications for technologists and waiting areas. Eur J Nucl Med 2000; 27:583.
- Guillet B, Quentin P, Waultier S, et al. Technologist radiation exposure in routine clinical practice with 18F-FDG PET. J Nucl Med Technol 2005; 33:175.
- Biran T, Weininger J, Malchi S, et al. Measurements of occupational exposure for a technologist performing 18F FDG PET scans. Health Phys 2004; 87:539.
- Roberts FO, Gunawardana DH, Pathmaraj K, et al. Radiation dose to PET technologists and strategies to lower occupational exposure. J Nucl Med Technol 2005; 33:44.
- Haines DE, Beheiry S, Akar JG, et al. Heart Rythm Society expert consensus statement on electrophysiology laboratory standards: process, protocols, equipment, personnel, and safety. Heart Rhythm 2014; 11:e9.
- RADIATION RISK
- MONITORING RADIATION EXPOSURE
- Quantities and units
- Occupational dose limits
- Dose limits during pregnancy
- RADIATION PROTECTION
- ROLE OF HOSPITAL/FACILITY
- TIPS FOR INTERVENTIONAL LAB STAFF
- TIPS FOR ECHOCARDIOGRAPHERS AND ANESTHESIA STAFF
- TIPS FOR NUCLEAR MEDICINE STAFF
- RECOMMENDATIONS OF OTHERS
- SUMMARY AND RECOMMENDATIONS