The ORAMED project: Optimization of Radiation Protection for Medical Staff in Interventional Radiology, Cardiology and Nuclear Medicine

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1 The ORAMED project: Optimization of Radiation Protection for Medical Staff in Interventional Radiology, Cardiology and Nuclear Medicine N. Ruiz Lopez 1, M. Sans Merce 1, I. Barth 2, E. Carinou 3, A. Carnicer 4, I. Clairand 5, J. Domienik 6, L. Donadille 5, P. Ferrari 7, M. Fulop 8, M. Ginjaume 4, G. Gualdrini 7, C. Koukorava 3, S. Krim 9, F. Mariotti 7, D. Nikodemova 8, A. Rimpler 2,K. Smans 9, L. Struelens 9, F. Vanhavere International Symposium on Standards, Applications and Quality Assurance in Medical Radiation Dosimetry Vienna, 9-12 November 2010

2 The ORAMED project ORAMED: is a collaborative project funded in 2008 within the 7 th EU Framework Programme, Euratom Programme for Nuclear Research and training. Participants: 12 partners from 9 European countries Improve standards of protection for medical staff for procedures resulting in potentially high exposures Started: Feb./2008 End: Jan./2011

3 Organisation of ORAMED WP0: Management SCK-CEN (Belgium): Filip Vanhavere WP1 : Extremity dosimetry and eye lens dosimetry in interventional radiology/cardiology GAEC (Greece) : Eleftheria Carinou WP2 : Development of practical eye lens dosimetry ENEA (Italy) : Gianfranco Gualdrini WP3 : Optimization of the use of active personal dosemeters in interventional radiology/cardiology IRSN (France) : Isabelle Clairand WP4 : Extremity dosimetry in nuclear medicine CHUV (Switzerland) : Marta Sans Merce WP5 : Training and dissemination of results UPC (Spain) : Merce Ginjaume

4 Extremity dosimetry and eye lens dosimetry in IR/IC WP1: Motivation indicated that the extremity doses in interventional radiology and cardiology can be high and even exceed occupational limits. In most of the cases, only finger or hand doses are reported, while doses to the eye lens and feet are missing and these can be even higher than finger doses. ICRP recommendation : Routine monitoring of extremities is difficult, since the most exposed area cannot easily be found Participants:

5 Extremity dosimetry and eye lens dosimetry in IR/IC WP1:Objectives To study the parameters that influence the extremity doses for the medical staff in IR and IC. To perform a systematic study of measurements and simulations in selected IR and IC procedures in order to study extremity and eye lens doses of medical staff. To propose a methodology for reducing the doses of medical staff.

6 Extremity dosimetry and eye lens dosimetry in IR/IC WP1: Measurements campaign 6 different countries, 3 hospitals per country 10 measurements/type of procedure/hospital 3 procedures of IC and 5 procedures of IR A common measurement protocol was established R wrist R finger R leg Middle eye L wrist Lfinger L leg L eye Interventional cardiology: CA/PTCA RF Ablation Pacemakers Interventional radiology: Angiography and angioplasty (DSA & PTA) : olower limb ocarotid orenal Embolization Endoscopic Retrograde Cholangiopancreatography(ERCP) 8 TLDs positions per procedure

7 Extremity dosimetry and eye lens dosimetry in IR/IC WP1: Some results Distribution of KAP values for differents procedures ZOOM Higher value for embolizations Lower value for PM Range: 13 μgy m 2 (PM) μgy m 2 (Embo) KAP presents large variability, even within the same type of procedure - complexity of particular procedure - experience of the physician

8 Extremity dosimetry and eye lens dosimetry in IR/IC WP1: Some results Median of doses for various procedures in the different anatomic regions >:PM, DSA PTA R & embolizations Left side is more exposed. <:DSA/PTA Ca Ce & ERCP

9 Extremity dosimetry and eye lens dosimetry in IR/IC WP1: Some results Median of normalized doses for various procedures in the different anatomic regions >:PM; operator is more close to the patient and stays all procedure in the room

10 Extremity dosimetry and eye lens dosimetry in IR/IC WP1: Parameters which might influence the doses Use of additional protective equipment: Lead table curtain Transparent lead glass attached to ceiling Wholebody shielding(rp cabin) Individual practice: Operator out during cine mode or not Hands in the beam Tube configuration and position of operator: Tube above the patient table Tube below the patient table Position of operator vs. X-Ray tube

11 Extremity dosimetry and eye lens dosimetry in IR/IC WP1: Example Use of additional protective equipment : There are not measurements available using table protection with tube above

12 Extremity dosimetry in NM WP4: Motivation * Put in evidence: - the extremity doses in NM can easily surpass operational limits. - often not known which part of the hand will receive the highest dose -Absence of a systematic study of exposure Close to the limit, or bigger? Position of the monitoring dosemeter? *Vanhavere F, Carinou E, Donadille L, Ginjaume M, Jankowski J, Rimpler A and Sans Merce M 2008 An overview of extremity dosimetry in medical applications Radiat. Prot. Dosim. 129(1-3)

13 Extremity dosimetry in NM WP4: Objectives To evaluate extremity doses (and dose distributions across the hands) of medical staff working in nuclear medicine departments. To study the influence of protective devices such as syringe and vial shields and to improve such devices when possible. To propose levels of reference doses for each standard nuclear medicine procedure and to use these for risk assessment and optimisation of working methods. To propose a methodology to reduce dose to nuclear medicine workers.

14 Extremity dosimetry in NM WP4: Campaign of measurements 7 different countries, 2 hospitals by country 2 workers per NM service (5 measurements/person) An unified measurement protocol was fixed: -experience -dominant hand -radiation protection measures -etc. Measures homogenized so the data is comparable Preparation 99m Tc Diagnostic and Therapy 18 F Administration 90 Y-Zevalin

15 Extremity dosimetry in NM WP4: Campaign of measurements MATERIALS AND METHODS: 22 measuring points (11 different positions on each hand) High sensitivity TLD specific to beta and gamma radiation * : Type Measurements TLD Thickness (mg cm 2 ) TLD 707H (LiF:Mg:Cu:P) 7 Very thin 18 MCP Ns (LiF:Mg:Cu:P) 8.5 F, 90 Y TLD 720H (LiF:Mg:Cu:P) 100 Thin TLD 100 (LiF:Mg:Ti) 100 GR200 (LiF:Mg:Cu:P) 200 TLD 100H (LiF:Mg:Cu:P) 220 Thick 99m Tc MCP N (LiF:Mg:Cu:P) 225 TLD 100 (LiF:Mg:Ti) 240 Intercomparison (done before measurements). Purpose: to establish a common basis for the measurement campaign among all participants. Standards TLDs (>200mg/cm 2 ) irradiated with 137 Cs Thin TLDs (8-10 mg/cm 2 ) irradiated with 85 Kr Results: All participants reported results within 10% of the reference value. *Carinou E et al Intercomparison on measurements of the quantity personal dose equivalent, Hp(0.07), by extremity ring dosimeters in medical fields 2008 Radiat. Meas

16 Extremity dosimetry in NM WP4: Some results 132 workers 694 measurements A 99m Tc Diagnostic radionuclides Therapeutic radionuclides P 99m Tc A 18 F P 18 F A 90 Y Zevalin P 90 Y Zevalin Maximum (msv/gbq) Median (msv/gbq) Mean (msv/gbq) Position of max. index tip (nd) index tip (nd) INDEX TIP (D) thumb (nd) thumb (nd) ring tip (nd) Diagnostic radionuclides ZOOM Therapeutic radionuclides

17 Legend: Non dominant hand DOMINANT HAND Extremity dosimetry in NM WP4: Frequency where maximum is found Non dominant hand, Index tip Examples of administration positions DOMINANT HAND, INDEX TIP Non dominant hand, Index tip

18 Legend: Non dominant hand DOMINANT HAND Extremity dosimetry in NM WP4: Frequency where maximum is found Example of preparation positions DOMINANT HAND INDEX TIP Example of administration positions Non dominant hand, Index tip, thumb

19 Legend: Non dominant hand DOMINANT HAND Extremity dosimetry in NM WP4: Frequency where maximum is found Example of Zevalin preparation DOMINANT HAND, Non dominant hand, thumb

20 Extremity dosimetry in NM WP4: Some results Impact of placing the routine monitoring dosemeter at a different position than the one corresponding to the maximal hand dose Those ratios vary from 2 to 27 depending on the radionuclide and the procedure. From the available results it could be concluded that the wrist dosemeter underestimates the dose The ratios with respect to the base of the ring finger are usually higher than those with respect to the base of the index finger. Indeed, the index finger is usually one of the most exposed fingers. Now we have to conclude the better position for the monitoring dosemeter N.B: the positions usually used for routine monitoring are the base of ring finger and the wrist

21 Thank you for your attention For more information, please visit All results and recommendations will be presented in a workshop in Barcelona from January 2011