Kiirgusohutus meditsiinis. Kalle Kepler, PhD
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1 Kiirgusohutus meditsiinis Kalle Kepler, PhD
2 Sissejuhatuseks
3 Teemad Ioniseerival kiirgusel põhinevad tänapäevased diagnostilised meetodid (modaliteedid) Meditsiinis kasutatava kiirguse panus kogu meie aastasesse kiirgusdoosi Meditsiinikiirituse mõõtmine ja optimeerimise vahendid diagnostilised referentsväärtused Efektiivdoos ja kiirgusriski hindamine
4 Ioniseeriv kiirgus tänapäeva meditsiinis Röntgenkiirgusega (kiirgusallikaks röntgentoru) tavaradiograafia mammograafia läbivalgustus, angiograafia kompuutertomograafia dentaalne radioloogia luudensitomeetria Gammakiirgusega (kiirgusallikaks patsiendisse viidud radioaktiivne aine) diagnostilise nukleaarmeditsiini meetodid (SPET, PET) Võrdluseks ioniseeriva kiirguseta diagnostilised meetodid: magnetresonantstomograafia ultraheliuuring
5 Kiirguskaitse eripärad meditsiinis Erinevus kutse- ja elanikukiiritusest - meditsiinikiiritusele puuduvad piirmäärad Vajadus minimeerida, kuid mitte nii väikeseks kui võimalik vaid, nii väikeseks, et pildi diagnostiline kvaliteet oleks siiski piisav vajalikud ka pildi kvaliteedi kriteeriumid Kas ja milliste näidustuste korral suunata mingile konkreetsele radioloogilisele uuringule referral guidelines Doosi optimeerimiseks referentsväärtused vaja mõõta praktikas kasutatavaid doose, et saata ettekujutus mingis protseduuris vajalikest doosidest leitakse dooside statistiline jaotus, sealt määratakse mingi suurus (enamasti mitte keskväärtus, vaid mediaan või kolmas kvartiil) Dosimeetria on osa radioloogia kvaliteeditagamise programmist ja jälgitav kliiniliste auditite kaudu Uuringu abilistele kehtestatakse doosipiirangud
6 Meditsiinikiirituse dooside muutused aastate lõikes 12 Keskmine efektiivdoos, msv UNSCEAR 2008
7 Meditsiinikiiritus USAs Bushberg et al. 2012
8 Röntgendiagnostiliste ja nukleaarmeditsiini protseduuride panus kollektiivdoosi Euroopas ddmed.eu
9 Elaniku aastane efektiivdoos (kogu maailmas keskmiselt) Kosmiline; 13% Tuumakatsetused; 0.17% Kutsekiiritus; 0.17% Tšernobõli avarii; 0.07% Sissesöömine; 10% Tuumaenergeetika; 0.01% Sissehingamine (sh Rn-222); 42% Maapinnast; 16% Meditsiinidiagnostika ; 20% Kokku 3,03 msv aastas UNSCEAR 2008
10 Efektiivdoosi jaotus USAs
11 Kiirgusdoosi mõõtmine meditsiinis Radiograafias Patsiendi naha pinnale kinnitatav dosimeeter TLD Patsiendi kehale langevasse kiirgusvoosse paigutatud läbipaistvate seintega dosimeeter DAP-meeter Mammograafias Patsiendile langeva kiirgusvoo mõõtmine Kompuutertomograafias Kindlate mõõtmetega pleksiklaasist fantoomi sees doosi mõõtmine Nukleaarmeditsiin Patsiendile manustatava radioaktiivse aine aktiivsuse mõõtmine
12 FIN, 2004 EC, 2008 EC, 1999 UK, 2004 IAEA, 2007 USA, 2012
13 Doosijuhend Juhend meditsiiniradioloogia protseduuridel patsiendidoosi hindamiseks. Sotsiaalministeerium, Tallinn, 2013, 57 lk /Tervishoid/DOOSIJUHEND.pdf
14 : tavaradiograafia
15
16 Diagnostiline referentsväärtus diagnostiline referentsväärtus (DRV) (ingl. diagnostic reference level, DRL) diagnostilise standardprotseduuriga kaasneva kiirgusdoosi või diagnostilise radiofarmatseutikumi aktiivsuse võrdlustase standardsuurusega patsiendi jaoks, mida kasutatakse patsiendidoosi optimeerimise eesmärgil referentsväärtus leitakse praktikas rakendatavate dooside sagedusjaotuse põhjal mingi statistilise parameetrina (nt kolmas kvartiil) või manustatud aktiivsuste sagedusjaotuse alusel ekspertgrupi hinnangu põhjal
17 Sagedus Dooside jaotus 75% 25% Doos, mgy
18 Doosijaotus Seadmete arv Doos, mgy
19 Doosijaotus Seadmete arv Doos, mgy
20 Doosijaotus Seadmete arv Doos, mgy
21 DRV-d Euroopa radioloogias Dose DataMed II, 2014, ddmed.eu
22 UK: nahadoosid radiograafias Hart, 2012
23 UK: doospindala (DA) radiograafias Hart, 2012
24 Eesti: doospindala kopsu otseülesvõtetel UK Kepler et al. 2014
25 Eesti: doospindala nimmelülide otseülesvõtetel UK Kepler et al. 2014
26 Kiirgusriski ealine sõltuvus 26 (ICRP, 1991)
27 Stohhastiline toime Kiirguse toime esinemissagedus (%) Doos ICRP, 2003
28 Kantserogeense ja päriliku toime nominaalsed riskitegurid (%/Sv) Kiiritatud populatsioon Vähk Pärilik toime Kokku Publ. 103 Publ. 60 Publ. 103 Publ. 60 Publ. 103 Publ. 60 Kõik Täiskasvanud ICRP 1990, ICRP 2007
29 Deterministlik toime Kiirguse toime esinemissagedus (%) Lävidoos Doos ICRP, 2003
30 Lävidoosid Toime Lävidoos (Gy) 20 mgy/min 200 mgy/min Ajutine erüteem Püsiv epilatsioon Naha nekroos Katarakt >5 >250 silmale >25 silmale Nahavähk Pole teada Pole teada Pole teada ICRP 85
31 Efektiivdoos kiirgusriski iseloomustav suurus Ei ole otseselt mõõdetav suurus, tuleb arvutada Arvutatakse kiirgustundlike elundite ja kudede koefaktoreid (suhtelist kiirgustundlikkust) arvestades Projektsioonradiograafias kasutades patsiendi matemaatilisi mudeleid arvutatakse efektiivdoos Monte Carlo meetodil Soome kiirguskeskuses (STUK) loodud programm PCXMC Keerukama kiiritusgeomeetria korral on kasutusele võetud lihtsustatud koefitsiendid, et arvutada mõõdetud doosist efektiivdoos kompuutertomograafias nukleaarmeditsiinis
32 Koefaktorid 1990 ja 2007 Koefaktor WT Kude või elund ICRP Publication 60 (1990) ICRP Publication 103 (2007) Sugunäärmed 0,20 0,08 Luuüdi 0,12 0,12 Käärsool 0,12 0,12 Kops 0,12 0,12 Magu 0,12 0,12 Põis 0,05 0,04 Rinnad 0,05 0,12 Maks 0,05 0,04 Söögitoru 0,05 0,04 Kilpnääre 0,05 0,04 Nahk 0,01 0,01 Luuümbris 0,01 0,01 Aju - 0,01 Süljenäärmed - 0,01 Muu x 0,05 0,12
33 Meditsiiniuuringute ja loodusliku taustkiirguse dooside võrdlus Lin, 2010 Modaliteet Uuring Efektiivdoos (msv) Pea 2,0 8 kuud Rindkere 7,0 2 aastat Kõht ja vaagen 10,0 3 aastat Radiograafia Rindkere 0,1 10 päeva Nimmelülid 0,7 3 kuud Kõht 1,2 5 kuud Muu Mammograafia 0,7 3 kuud Läbivalgustus Luutihedus 0,001 < 1 päev Luustik 4,2 1,3 aastat Müokardi perfusioon Kompuutertomograafia Nukleaarmeditsiin Koronaarangiograafia 12,5 4 aastat Loodusliku taustkiirguse võrreldav kestus kuud kuni 5 aastat
34 Efektiivdoosi riskiklassid Riskiklass Tüüpiline efektiivdoos (msv) Uuring 0 0 Ultraheli, MRT I < 1 Jäsemete, rindkere ülesvõte II 1-5 IVU, nimmelülide ülesvõte, NM (nt luustik), pea ja kaela KT III 5-10 Rindkere ja kõhu KT IV > 10 Mõned NM uuringud (nt PET) Radiation Protection 118
35 Patsiendidoosi hindamise VAJADUS Kiirgusdoosi ja pildikvaliteedi optimeerimine Kiirgusriskide hindamine Patsiendi, avalikkuse teavitamine Rahvusvahelise hea tava järgimine ja võrdlemine Diagnostiliste referentsväärtuste määramine Meditsiinikiirituse panuse hindamine elanikkonna kogu efektiivdoosis Õigusaktide nõuete täitmine
36 Ohutuskultuur meditsiinis Eeldab teadlikkust Kiirgusohu allikatest ja nende suhtelisest panusest kiirgusriski Ioniseeriva kiirguse toimest Kiirguse mõõtmisest (suurused, ühikud, mõõteriistad) Kiirgustingimuste (sh meditsiinikiirituse) optimeerimise võimalikkusest ja vajalikkusest
37 Lõpetuseks, Tšernobõl (1986), Fukushima (2011) ja meditsiinikiiritus Kuidas mõõta kiirgust, hinnata riske, optimeerida? UNSCEAR 2008
38 Kirjandus UNSCEAR. Sources and effects of ionizing radiation, UNSCEAR 2008, Volume I, Annex A: Medical radiation exposures, United Nations: New York, 2010 Bushberg J. T., et al. The essential physics of medical imaging, 3rd ed., Wolters Kluwer Health/Lippincott Williams & Wilkins, Philadelphia, DDM2 Project Report Part 1: European Population Dose (DRAFT ), ddmed.eu Hart D. et al. Doses to patients from radiographic and fluoroscopic X- ray imaging procedures in the UK 2010 Review. HPA-CRCE-034, 2012 Juhend meditsiiniradioloogia protseduuridel patsiendidoosi hindamiseks, Sotsiaalministeerium, Tallinn, Kepler K., Märs J., Preliminary results of the implementation of the patient radiation dosimetry guidelines in Estonia, Baltic Radiology congress, Pärnu, 2014 Lin E.C, Radiation risk from medical imaging, Mayo Clin. Proc. 2010; 85(12):
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