Docstoc

Radiation Protection in Nuclear Medicine

Document Sample
Radiation Protection in Nuclear Medicine Powered By Docstoc
					 IAEA Training Material on Radiation Protection in Nuclear Medicine




                      Part 6



   Medical Exposure
Protection of the Patient
                   Objective

  To become familiar with the BSS detailed
  requirement for medical exposure in nuclear
  medicine: responsibilities, justification,
  optimization, guidance level, dose constraints
  accidental exposure and medical records




Nuclear Medicine     Part 6. Medical Exposure   2
Contents
     Introduction
     Responsibilities
     Justification
     Optimization of examination
     Guidance levels of activity
     Dose constraints
     Examination of children, pregnant women and
      lactating women
     Records
     Local rules


    Nuclear Medicine     Part 6. Medical Exposure   3
  IAEA Training Material on Radiation Protection in Nuclear Medicine



Part 6. Medical Exposure
Protection of the Patient




  Module 6.1. Introduction
                   Medical Exposure
                     (Definition)

  “Exposure incurred by patients as part of their own medical or
  dental diagnosis or treatment; by persons, other than those
  occupationally exposed, knowingly while voluntarily helping in
  the support and comfort of patients; and by volunteers in a
  programme of biomedical research involving their exposure.”




Nuclear Medicine            Part 6. Medical Exposure           5
Nuclear Medicine   Part 6. Medical Exposure   6
Nuclear Medicine   Part 6. Medical Exposure   7
              Protection from What?

   Unnecessary examination or treatment
    (justification)
   Unnecessary exposure (optimization)
   Inadequate examinations, which can lead to
    incorrect or incomplete diagnosis
    (optimization)




Nuclear Medicine      Part 6. Medical Exposure   8
                                Mr. Sharp, I am given
                                 to understand that 2
                                 bone scans and a
                                 cardiac study done
                                 on me have given me
                                 22 mSv whereas 20
                                 mSv is the safe dose.
                                 I want to file legal
                                 suit against the
                                 doctor. What do you
                                 feel??

Nuclear Medicine   Part 6. Medical Exposure        9
                   Medical Exposure
                        versus
                    Occupational


Nuclear Medicine         Part 6. Medical Exposure   10
                             My resident doctor
                             has got 12 mSv in
                             her last badge
                             report as she was
                             wearing the badge
                             while getting her
                             barium study. She
                             wants off from
                             radiation work.
                             ?????

Nuclear Medicine   Part 6. Medical Exposure   11
          Medical Exposure
               versus
        Occupational Exposure



Nuclear Medicine   Part 6. Medical Exposure   12
                             While caring for his
                             spouse Mr. Joseph
                             got 2 mSv.
                             As a member of the
                             public with 1 mSv
                             dose limit, he can not
                             get any radiation
                             dose this year.
                             ???????




Nuclear Medicine   Part 6. Medical Exposure      13
                      Medical Exposure
                    (BSS: Interim Edition)
• Responsibilities
• Justification of medical exposure
• Optimization of protection for medical exposure
• Guidance levels
• Dose constraints
• Maximum activity for patients in therapy on
discharge from hospital
• Investigation of accidental medical exposures
• Records



 Nuclear Medicine           Part 6. Medical Exposure   14
  IAEA Training Material on Radiation Protection in Nuclear Medicine



Part 6. Medical Exposure
Protection of the Patient




Module 6.2. Responsibilities
  Responsibilities: BSS (2011)
“3.149. The regulatory body shall ensure that the authorization for
medical exposures to be performed at a particular medical radiation
facility allows personnel (radiological medical practitioners, medical
physicists, medical radiation technologists and any other health
professionals with specific duties in relation to the radiation
protection of patients) to take on the responsibilities specified in
these Standards only if they:
     (a) are specialized in the appropriate area;
     (b) meet the respective requirements for education, training
     and competence in radiation protection,
     (c) are named in a list maintained up to date by the registrant
     or licensee.”




 Nuclear Medicine            Part 6. Medical Exposure             16
  Responsibilities: BSS (2011) contd.
“3.150. Registrants and licensees shall ensure that no
patient, whether symptomatic or asymptomatic, undergoes
a medical exposure unless:
    (a) The radiological procedure has been requested by a referring medical
        practitioner and information on the clinical context has been provided,
        or it is part of an approved health screening programme;
    (b) The medical exposure has been justified through consultation
    between the radiological medical practitioner and the referring medical
    practitioner, as appropriate, or it is part of an approved health screening
    programme;
    (c) A radiological medical practitioner has assumed responsibility for
    protection and safety in the planning and delivery of the medical exposure;
    (d) The patient or the patient’s legal authorized representative has been
    informed, as appropriate, of the expected diagnostic or therapeutic
    benefits of the radiological procedure as well as the radiation risks.”

  Nuclear Medicine                Part 6. Medical Exposure                17
 Responsibilities: BSS (2011) contd.
“3.153. Registrants and licensees shall ensure that:

     (a) The radiological medical practitioner performing or overseeing the
     radiological procedure has assumed responsibility for ensuring overall
     protection and safety for patients during the planning and delivery of the
     medical exposure, including the justification of the procedure as required
     in paras 3.154–3.160 and the optimization of protection and safety, in
     cooperation with the medical physicist and the medical radiation
     technologist as required in paras 3.161–3.176;
     (b) Radiological medical practitioners, medical physicists, medical
     radiation technologists and other health professionals with specific duties
     in relation to protection and safety for patients in a given radiological
     procedure have the appropriate specialization;
     (c) Sufficient medical personnel and paramedical personnel are
     available as specified by the health authority;”
     . *Interim version of revised BSS

  Nuclear Medicine                Part 6. Medical Exposure                 18
Responsibilities: BSS (2011) contd.
         “(d) For therapeutic uses of radiation, the requirements of these
          Standards for calibration, dosimetry and quality assurance,
          including the acceptance and commissioning of medical
          radiological equipment, as specified in paras 3.166, 3.167(c), 3.169
          and 3.170, are fulfilled by or under the supervision of a medical
          physicist;
         (e) For diagnostic radiological procedures and image guided
          interventional procedures, the requirements of these Standards for
          medical imaging, calibration, dosimetry and quality assurance,
          including the acceptance and commissioning of medical
          radiological equipment, as specified in paras 3.166, 3.167(a),
          3.167(b), 3.168, 3.169 and 3.170, are fulfilled by or under the
          supervision of or with the documented advice of a medical
          physicist, whose degree of involvement is determined by the
          complexity of the radiological procedures and the associated
          radiation risks;
         (f) Any delegation of responsibilities by a principal party is
          documented.”
Nuclear Medicine                  Part 6. Medical Exposure               19
Nuclear Medicine   Part 6. Medical Exposure   20
              FACTORS AFFECTING
              MEDICAL EXPOSURE
                                        Request
                                 Examination or treatment
                                   Biomedical research

Patient identification     Administration of
                                                                Examination       Treatment
  and information        radiopharmaceutical

Child ?                  Safe preparation of           Method                 Dose constraints
Lactating woman ?        prescribed radio-             Quality of equip-      to comforters and
Pregnant woman ?         pharmaceutical and            ment                   visitors
                         activity                      Correct use of
                         Dose constraints              equipment


                              Accidental medical exposure


                             Who is responsible?

   Nuclear Medicine                  Part 6. Medical Exposure                             21
  RESPONSIBILITY STRUCTURE
                        Licensee/Hospital management
                        Optimization of medical exposure
                                    through
                          organization and resources
                          Nuclear Medicine Department
Referring physician    Optimization of medical exposure
    Justification      through well educated personnel
of medical exposure   with clearly defined responsibilities

                                      NM specialist
                                     Qualified expert
                                     NM technologist
                                          Nurse
                                        Engineer
                                     Radiopharmacist

   Nuclear Medicine       Part 6. Medical Exposure            22
                    Referring Physician

                   Prescribe and justify diagnostic procedures
                   and therapy in writing in co-operation with
                   the nuclear medicine specialist




Nuclear Medicine                Part 6. Medical Exposure   23
                   Administrative Manager

• Appoint the necessary personnel and ensure the individuals
  have the necessary education to perform their duties.
• Establish a radiation protection programme and provide the
  necessary resources.
• Assign clear responsibilities for personnel.
• Appoint a Radiation Protection Officer.
• Establish a comprehensive QA programme.
• Support education and training of personnel.




Nuclear Medicine           Part 6. Medical Exposure    24
                      Nuclear Medicine Staff
Individuals with key positions, i.e., responsibilities for protection
and safety and those who could substantially affect protection and
safety by virtue of tasks involving operation or manipulation of
sources, or equipment which could lead to an accidental exposure
should have documented evidence of education and training. The
objective is to ensure that only qualified personnel fill such
positions. In nuclear medicine, these individuals are:

Nuclear medicine physicians
Qualified experts in nuclear medicine physics (medical physicists)
Other health professionals in nuclear medicine (radiopharmacists,
 nuclear medicine technologists, nurses,…)
Radiation Protection Officer


   Nuclear Medicine            Part 6. Medical Exposure            25
                    Personal Authorization
To obtain the personal authorization, the nuclear medicine staff
should comply with the following requirements:

        university degree or equivalent relevant to the profession by
         the competent education authorities as required in the
         country;
        accreditation to exercise the profession granted by the
         competent authorities or institutions as required in the
         country;
        course on radiation protection for which the contents, the
         methodology and the teaching institution are approved by
         the Regulatory Authority. This course may be integrated in
         the curricula of the professional education; and
        on the job training supervised by professionals with
         authorization by the Regulatory Authority.
 Nuclear Medicine              Part 6. Medical Exposure            26
          Nuclear Medicine Specialist
Ensure overall patient protection and safety;
provide consultation and clinical evaluation of patients
ensure that the exposure of patients be the
 minimum required to achieve the intended objective;
take into account relevant information from previous
 examinations in order to avoid unnecessary additional
examinations;
take into account the relevant guidance levels for medical
exposure;
determine dose prescription for therapy in consultation with
the medical physicist; and
provide evaluation of any radiation incident and accident
from medical point of view.
 Nuclear Medicine          Part 6. Medical Exposure           27
                    Medical Physicist
 Participate in continuing review of the nuclear medicine practice’s
resources (including budget, equipment, and staffing), operations, and
policies and procedures;
 Develop requirements and specifications for the purchase of
appropriate equipment assuring radiation safety;
 Plan in conjunction with the nuclear medicine physician the facilities for
nuclear medicine practice;
 Carry out acceptance testing;
 Establish dose calculation procedures in nuclear medicine therapy;
 Establish and implement QA procedures in nuclear medicine;
 Supervise equipment maintenance;
 Investigate and evaluate incidents and accidents.




 Nuclear Medicine                 Part 6. Medical Exposure               28
    Nuclear Medicine Technologist
• Patient identification;
• Patient information;
• Information to accompanying persons and staff nursing a patient after a
nuclear medicine examination or therapy;
• Verifying that the female patient is non-pregnant;
• Assure that a mother in lactation is given information about discontinuation of
nursing;
• Make the calculation of administered activity to a child according to the local
rules;
• Verify the administered radiopharmaceutical and its activity;
• Perform regular quality control of activity meter and other relevant equipment;
• Perform regular workplace monitoring;
• Correct handling of the equipment and safety accessories;
• Inform the RPO in the case of accident or incident;
• Inform the Nuclear Medicine Physician in the case of misadministrations;
• Participate in education and training of new personnel.

  Nuclear Medicine                Part 6. Medical Exposure                 29
  IAEA Training Material on Radiation Protection in Nuclear Medicine



Part 6. Medical Exposure
Protection of the Patient




  Module 6.3. Justification
                        Justification
       Although Nuclear Medicine is a justified diagnostic tool
       a case-by-case justification shall be applied.

       This is the responsibility of the referring physician in
       co-operation with the nuclear medicine specialist and
       other specialists in diagnostic imaging, taking relevant
       guidelines into account.




Nuclear Medicine               Part 6. Medical Exposure           31
              Justification :BSS (2011)
Relevant parties shall ensure that medical
exposures are justified:

“3.154. Medical exposures shall be justified by weighing the
expected diagnostic or therapeutic benefits that they yield
against the radiation detriment that they might cause, with
account taken of the benefits and the risks of available
alternative techniques that do not involve medical exposure.

3.155. Generic justification of a radiological procedure shall
be carried out by the health authority in conjunction with
appropriate professional bodies, and shall be reviewed from
time to time, with account taken of advances in knowledge
and technological developments.”


Nuclear Medicine          Part 6. Medical Exposure         32
Justification: BSS (2011) Contd…
“3.156. The justification of medical exposure for an individual
patient shall be carried out through consultation between the
radiological medical practitioner and the referring medical
practitioner, as appropriate, with account taken, in particular for
patients who are pregnant or breast-feeding or paediatric, of:
    (a) The appropriateness of the request;
    (b) The urgency of the procedure;
    (c) The characteristics of the medical exposure;
    (d) The characteristics of the individual patient;
    (e) Relevant information from the patient’s previous
         radiological procedures.

3.157. Relevant national or international referral guidelines shall be
taken into account for the justification of the medical exposure of an
individual patient in a radiological procedure.”

 Nuclear Medicine            Part 6. Medical Exposure                 33
Justification: BSS (2011) contd..
“3.158. Justification for radiological procedures to be
performed as part of a health screening programme for
asymptomatic populations shall be carried out by the health
authority in conjunction with appropriate professional
bodies.

3.159. Any radiological procedure on an asymptomatic
individual that is intended to be performed for the early
detection of disease, but not as part of an approved health
screening programme, shall require specific justification for
that individual by the radiological medical practitioner and
the referring medical practitioner, in accordance with the
guidelines of relevant professional bodies or the health
authority. As part of this process, the individual shall be
informed in advance of the expected benefits, risks and
limitations of the procedure.”
Nuclear Medicine         Part 6. Medical Exposure         34
Justification: BSS (2011) contd…
“ 3.160. The medical exposure of volunteers as part of a
    programme of biomedical research is deemed to be not justified
    unless:
      (a) It is in accordance with the provisions of the Helsinki
       Declaration [20] and takes into account the guidelines
       published by the Council for International Organizations of
       Medical Sciences [21], together with the recommendations
       of the ICRP [22];
      (b) It is subject to approval by an ethics committee (or other
       institutional body that has been assigned similar functions by
       the relevant authority), subject to any dose constraints that
       may be specified (as required in paras 3.148(a)(ii) and
       3.173), and subject to applicable national regulations and
       local regulations.”
 Nuclear Medicine            Part 6. Medical Exposure            35
  IAEA Training Material on Radiation Protection in Nuclear Medicine



Part 6. Medical Exposure
Protection of the Patient




 Module 6.4. Optimization of
       Examination
                       Otimization of
                    Patient Examination




                   Diagnostic Objective                      Medical Exposure


Nuclear Medicine                  Part 6. Medical Exposure                      37
          Optimization of Medical
       Exposure in Nuclear Medicine
“3.162. For diagnostic radiological procedures and image guided
   interventional procedures, the radiological medical practitioner, in
   cooperation with the medical radiation technologist and the
   medical physicist, and if appropriate with the radiopharmacist or
   radiochemist , shall ensure that the following are used:
         (a) Appropriate medical radiological equipment and software and
          also, for nuclear medicine, appropriate radiopharmaceuticals;
         (b) Appropriate techniques and parameters to deliver a medical
          exposure of the patient that is the minimum necessary to fulfil the
          clinical purpose of the procedure, with account taken of relevant
          norms of acceptable image quality established by relevant
          professional bodies and relevant diagnostic reference levels
          established in accordance with paras 3.147 and 3.168.”


   Nuclear Medicine                 Part 6. Medical Exposure                38
                    Optimization contd...
“3.163. For therapeutic radiological procedures, the radiological
   medical practitioner, in cooperation with the medical physicist
   and the medical radiation technologist, shall ensure that for each
   patient the exposure of volumes other than the planning target
   volume is kept as low as reasonably achievable consistent with
   delivery of the prescribed dose to the planning target volume
   within the required tolerances.
 3.164. For therapeutic radiological procedures in which
   radiopharmaceuticals are administered, the radiological medical
   practitioner, in cooperation with the medical physicist and the
   medical radiation technologist, and if appropriate with the
   radiopharmacist or radiochemist, shall ensure that for each
   patient the appropriate radiopharmaceutical with the appropriate
   activity is selected and administered so that the radioactivity is
   primarily localized in the organ(s) of interest, while the
   radioactivity in the rest of the body is kept as low as reasonably
   achievable.”
 Nuclear Medicine           Part 6. Medical Exposure            39
                    Optimization contd...
“3.165. Registrants and licensees shall ensure that the particular
   aspects of medical exposures are considered in the optimization
   process for:
          (a) Paediatric patients subject to medical exposure;
          (b) Individuals subject to medical exposure as part of a health
           screening programme;
          (c) Volunteers subject to medical exposure as part of a programme
           of biomedical research;
          (d) Relatively high doses to the patient;
          (e) Exposure of the embryo or fetus, in particular for radiological
           procedures in which the abdomen or pelvis of the pregnant woman
           is exposed to the useful radiation beam or could otherwise receive
           a significant dose;
          (f) Exposure of a breast-fed infant as a result of a female patient
           undergoing a radiological procedure with radiopharmaceuticals.


 Nuclear Medicine                  Part 6. Medical Exposure              40
   Optimization of Medical Exposure

                                    Radionuclide
                                     Biokinetics
                                       Patient



                                    Administered
                                      activity



                     Effective                                   Quality of
                       dose                                    equipment etc



                   Radiation risk                              Image quality




Nuclear Medicine                    Part 6. Medical Exposure                   41
                   Radiopharmaceuticals
Considering that, according to the BSS, the activities listed
below also require authorization, regulatory authorities may
require the licensee of a nuclear medicine practice to
contract any of the following services only to enterprises
authorized by the Regulatory Authority:

                production, import, distribution, sale or transfer of
                 radioactive sources
                personal monitoring
                installation, maintenance of nuclear medicine
                equipment
                disposal of radioactive sources
Use only radiopharmaceuticals from an authorized
manufacturer!
Nuclear Medicine                 Part 6. Medical Exposure           42
                   Radiopharmaceuticals
If more than one radiopharmaceutical can be used for a
procedure consideration should be given to physical,
chemical and biological properties.


Example:            Leucocytes labelled with
In-111                                                    Tc-99m
0.36 mSv/MBq                                              0.011 mSv/MBq
20 MBq  7.2 mSv                                          200 MBq  2.2 mSv
T1/2 = 2.8 days                                           T1/2 = 6 hours



Nuclear Medicine               Part 6. Medical Exposure                       43
                   Radiopharmaceuticals




                    Tl-201                              Tc-99m
                    25 mSv                               8 mSv
Nuclear Medicine             Part 6. Medical Exposure            44
      Optimization of Image Quality
Image quality depends on:

   Administered activity
   Technical factors - equipment used
                        - acquisition protocol
                        - image processing & evaluation
                        - noise
                        - spatial resolution
                        - scatter
   Patient factors     - size
                        - age
                        - disease
                        - movement
    Nuclear Medicine     Part 6. Medical Exposure     45
      Optimization of Administered
                 Activity

  In general, doses should be maintained as low as reasonable
  achievable but high enough to obtain the desired diagnostic
  information. This means that exposures above clinically
  acceptable maximum doses must be avoided as well as doses
  below clinically acceptable minimum doses




Nuclear Medicine          Part 6. Medical Exposure         46
      Optimization of Administered
                 Activity
  Value of diagnostic information                         There is a threshold below
                                                          which no useful information
                                                          can be expected

                                                          Above this threshold the
                                                          diagnostic quality increases
                                                          steeply with the administered
                                                          activity

                                                          Once an acceptable level has
                                                          been reached further increase
                                                          of activity will not improve
                                                          the result
                   Administered activity
                                                          (ICRP 52)


Nuclear Medicine               Part 6. Medical Exposure                          47
                                        Administered Activity to Children
             Optimization is Necessary!

                                        120
          Administered activity (MBq)




                                        100

                                        80

                                        60

                                        40

                                        20

                                          0
                                              0   4   8              12              16   20   24
                                                              Age (years)


    Administered activity to children referred to DMSA scan in Swedish hospitals

Nuclear Medicine                                          Part 6. Medical Exposure                  48
       …..noting the special requirements for patients with impairment of

                                       Organ Function
                                            KIDNEY FUNCTION
                                          (100 MBq Tc99m-DTPA)
                                50
            Kidney dose (mGy)




                                40
                                30
                                20
                                10
                                0
                                          1
                                      normal       2            3
                                                partially obstructed              4
                                                                             totally obstructed
                                     function          outflow                     outflow


Nuclear Medicine                                  Part 6. Medical Exposure                        49
                     Optimization
        (ii) use of methods for blocking the uptake in
        organs not under study and for accelerated
        excretion when applicable;


                        • Blocking agents for thyroid
                        • Hydration and frequent
                          voiding of the urinary bladder
                        • Laxatives
                        • Catheterisation to empty the
                          bladder???
                        • Cholecystokinin (fatty meal)
                          for gallbladder emptying

Nuclear Medicine               Part 6. Medical Exposure    50
    Tc-99m-MAG3, Two different first voiding times, girl 7 years
                                              Time between injection
                                              and first void

                   Organ                      30 min              2 hours    2h/30min

                   Bladder wall (mGy/MBq)            0,07            0,15       2,1

                   Gall bladder wall               0,099             0,01       1,0

                   Kidneys                        0,0078            0,0081      1,0

                   Liver                          0,0018            0,002       1,1

                   Red marrow                     0,0018            0,0022      1,2

                   Ovaries                         0,005            0,0086      1,7

                   Testes                         0,0045            0,0082      1,8

                   Effective dose (mSv/MBq)       0,0062            0,011       1,8
                   (Eleonor Westergren)
Nuclear Medicine                       Part 6. Medical Exposure                         51
                   Optimization
    (iii) appropriate image acquisition and processing;

Equipment used:
•Single head/dual head
 camera
•Collimator used




Nuclear Medicine         Part 6. Medical Exposure     52
                   Aquisition Protocol




                     Static?                              Tomographic?




                                  Dynamic?
Nuclear Medicine               Part 6. Medical Exposure                  53
                   Acquisition Protocol
      Static imaging                          - matrix size
                                              - number of counts
                                              - projections, zoom
      Dynamic imaging                         - matrix size
                                              - time/frame
                                              - number of groups
      Tomographic imaging                     - 180o or 360o
                                              - matrix size
                                              - number of angles
                                              - time/angle


Nuclear Medicine          Part 6. Medical Exposure                  54
 Image Processing & Evaluation

          Static             - smoothing
                             - image filtering
                             - quantification
                             - applications programme
          Dynamic            - regions of interest (ROI)
                             - time-activity curves
                             - application programme
          Tomographic        - attenuation correction
                             - reconstruction method
                             - image filtering
                             - slices displayed
                             - application programme
Nuclear Medicine        Part 6. Medical Exposure           55
                                 Noise
      Random variations in the number of counts (N) in a pixel,
       ROI or in a point in a time-activity curve
         true uptakes may not be seen
         false uptakes may occur
         uncertainty in quantitative values
      Lower noise requires more administered activity or longer
       acquisition times


                         100
      Noise                  SD %
                          N


    Nuclear Medicine             Part 6. Medical Exposure      56
                              Noise




                   1000000 counts                        100000 counts

Nuclear Medicine              Part 6. Medical Exposure                   57
   Phantom: Different number of counts




       50 k        250 k                      1000 k


Nuclear Medicine   Part 6. Medical Exposure            58
                    Thyroid Scintigraphy,
                    different acquisition times



1 min                                                   2 min




4 min                                                   8 min


 Nuclear Medicine            Part 6. Medical Exposure           59
The noise level versus activity levels for an adult, CBF


                 9
                 8
                 7
                 6
        CV (%)




                 5
                 4
                 3
                 2
                 1
                 0
                     0   500   1000   1500        2000         2500     3000   3500   4000
                                         Activity (MBq)

   Eleonor Westergren

Nuclear Medicine                             Part 6. Medical Exposure                        60
                       Spatial Resolution

   Describes how a point source is reproduced
      small details are not seen
      uptakes seem to be lower
   Improved spatial resolution can be achieved by
    changing to a collimator with higher resolution
    but:
      lower sensitivity requires more administered
       activity or longer acquisition times



    Nuclear Medicine         Part 6. Medical Exposure   61
Appropriate Image Acquisition




         Close      15 cm                     Wrong setting
                                              of energy window



Nuclear Medicine   Part 6. Medical Exposure              62
                   Patient Factors

     Size               increased scatter
                        spatial resolution

     Age & Disease      radiopharmaceutical distribution
                        movement artifacts




Nuclear Medicine        Part 6. Medical Exposure    63
                     Image Quality
                   Patient Movement




                   Movement                              Corrected


Nuclear Medicine              Part 6. Medical Exposure               64
                       Staff and Procedures


                   •Well trained staff with access to manuals
                     and other documentation.
                   • Quality control program.
                   • Regular maintenance of equipment




Nuclear Medicine                  Part 6. Medical Exposure      65
   IAEA Training Material on Radiation Protection in Nuclear Medicine



Part 6. Medical Exposure
Protection of the Patient




Module 6.5. Reference Levels of
            Activity
 Diagnostic Reference Levels
            (BSS)
“3.168. Registrants and licensees shall ensure that:
     (a) Local assessments, on the basis of the measurements required
     in para. 3.167, are made at approved intervals for those
     radiological procedures for which diagnostic reference levels have
     been established (para. 3.147);
     (b) A review is conducted to determine whether the optimization
     of protection and safety for patients is adequate, or whether
     corrective action is required if, for a given radiological procedure:
         (i) typical doses or activities exceed the relevant diagnostic
     reference level; or
         (ii) typical doses or activities fall substantially below the
     relevant diagnostic reference level and the exposures do not
     provide useful diagnostic information or do not yield the expected
     medical benefit to the patient.”

 Nuclear Medicine              Part 6. Medical Exposure              67
   Reference Levels of Activity
Examination        Radionuclide   Chemical form               Guidance level   Effective dose
                                                                 (MBq)             (mSv)
Bone scan            Tc-99m        phosphonate                     600              4.8
Brain scan           Tc-99m        pertechnetate                   500              2.7
CBF                  Tc-99m          HMPAO                         500              5.5
Thyroid imaging      Tc-99m        pertechnetate                   200              2.6
Thyroid imaging       I-123           iodide                       20               3.4
Parathyroid          Tl-201          chloride                      80                18
Lung perfusion       Tc-99m            MAA                         100              1.2
Lung ventilation     Tc-99m           aerosol                      80               0.6
Lung ventilation     Kr-81m             gas                       6000              0.2
Lung ventilation     Xe-133             gas                        400              0.4
Liver & spleen       Tc-99m           colloid                      80               0.6
Myocardium           Tl-201          chloride                      100               23
Myocardium           Tc-99m         isonitriles                    600              4.2
Kidneys              Tc-99m           DMSA                         160              2.5
Kidneys              Tc-99m           DTPA                         350              2.2
Kidneys               I-123          hippuran                      20               0.3
Tumours               Ga-67           citrate                      300               36
Tumour                I-123           MIBG                         400              7.2
Tumour                I-131           MIBG                         20                 4



Nuclear Medicine                   Part 6. Medical Exposure                                     68
                   Reference Levels

How to establish:

1. Elimination of outliers
2. State-of-the practice (good practice)
3. State-of-the art (optimal practice)




Nuclear Medicine        Part 6. Medical Exposure   69
Distribution of Administered Activities
                          Log-normal distributions

Number of patients




                   Optimized?                                 Activity
                                Guidance level
Nuclear Medicine                   Part 6. Medical Exposure          70
Activity, MBq
   900
                                                            Max
   800
   700
   600               IAEA guidance level
   500                                                            Mean and
                                                                  range of mean
   400                                                            (Sweden,
   300                  Optimized?                                1995)

   200
   100
        0     0                                                                   1


                               Bone scintigraphy
  Nuclear Medicine                    Part 6. Medical Exposure                        71
  IAEA Training Material on Radiation Protection in Nuclear Medicine



Part 6. Medical Exposure
Protection of the Patient




Module 6.6. Dose Constraints:
 Volunteers and Comforters
                   Dose Constraints
“3.151. Registrants and licensees shall ensure that
no individual incurs a medical exposure as part of a
programme of biomedical research unless the
exposure has been approved by an ethics
committee (or other institutional body that has been
assigned similar functions by the relevant authority)
as required in para. 3.160 and a radiological medical
practitioner has assumed responsibility as specified
in para. 3.153(a). Registrants and licensees shall
ensure that the requirements specified in para. 3.173
are met for the optimization of protection and safety
for persons subject to exposure as part of a
programme of biomedical research.”

Nuclear Medicine        Part 6. Medical Exposure   73
                   Biomedical Research
                               ICRP and WHO categorization of risk

  Level of Risk:                        Trivial                    Minor to           Moderate
                                                                 Intermediate

  Risk Category:                            I                    I.A.      I.             III


  Total detriment                      ~ 10-6 or               ~ 10-5    ~ 10-4        ~ 10-3 or
                                         less                                           more

  Range of effective                     < 0.1                0.1 - 1    1 - 10         > 10a
  doses (adults), mSv

  Anticipated level of                   Minor                 Intermediate to        Substantial
  benefit to Society                                              moderate

  a   To be kept below deterministic thresholds except for therapeutic experiments.

Nuclear Medicine                            Part 6. Medical Exposure                               74
              Research on Pregnant
                    Patients
 Radiation
  research
  involving
  pregnant
  patients should
  be discouraged


Nuclear Medicine     Part 6. Medical Exposure   75
                   Dose Constraints
“3.152. Registrants and licensees shall ensure that
no individual incurs a medical exposure as a carer
or comforter unless he or she has received, and
has indicated an understanding of, relevant
information on radiation protection and
information on the radiation risks prior to
providing care and comfort to an individual
undergoing a radiological procedure. Registrants
and licensees shall ensure that the requirements
specified in para. 3.172 are met for the optimization
of protection and safety for any procedure in which
an individual acts as a carer or comforter.”

Nuclear Medicine        Part 6. Medical Exposure   76
                    Dose Constraints
..The dose shall be constrained so that it is unlikely that his or
her dose will exceed 5 mSv during the period of a patient’s
diagnostic examination or treatment. The dose to children
visiting patients who have ingested radioactive materials should
be similarly constrained to less than 1 mSv




 Nuclear Medicine            Part 6. Medical Exposure            77
NM patient with pregnant family
      member at home

For most diagnostic nuclear medicine
procedures, the total decay dose at 0.5
meter from the patient ranges from .02-0.25
mGy and at 1 meter from the patient the
dose is 0.05-0.10 mGy. This poses no
significant risk to pregnant family members.



Nuclear Medicine   Part 6. Medical Exposure   78
   IAEA Training Material on Radiation Protection in Nuclear Medicine



 Part 6. Medical Exposure
 Protection of the Patient



  Module 6.7. Examination of
Children, Pregnant and Lactating
             Women
                         Optimization
“3.165. Registrants and licensees shall ensure that the particular aspects of
    medical exposures are considered in the optimization process for:
      (a) Paediatric patients subject to medical exposure;
      ……..
      (e) Exposure of the embryo or fetus, in particular for radiological
        procedures in which the abdomen or pelvis of the pregnant woman is
        exposed to the useful radiation beam or could otherwise receive a
        significant dose;
      (f) Exposure of a breast-fed infant as a result of a female patient
        undergoing a radiological procedure with radiopharmaceuticals.”




   Nuclear Medicine              Part 6. Medical Exposure               80
Nuclear Medicine   Part 6. Medical Exposure   81
                   Radiation Risks
                                           16

                   LIFE-TIME RISK (%/Sv)   14

                                           12

                                           10

                                           8

                                           6

                                           4

                                           2

                                           0
                                                0   5   15 25 35 45 55 65 75 85 95
                                                              AGE AT EXPOSURE



Nuclear Medicine                                         Part 6. Medical Exposure    82
                   Activity to Children
 The amount of activity administered to an
 adult can for children be reduced by one of
 the following methods:

                  body weight/70 kg
                  body surface area/1.73 m2
                  height/174 cm




Nuclear Medicine                Part 6. Medical Exposure   83
                                     Fraction of the Adult Activity

                               1,2

                               1,0
  Fraction of adult activity




                               0,8

                               0,6                                                     BW
                                                                                       H
                               0,4                                                     BSA

                               0,2

                               0,0
                                     0    4   8         12                   16   20     24
                                                     Age (years)



Nuclear Medicine                                  Part 6. Medical Exposure                    84
      European Association of
      Nuclear Medicine (EANM)
                                       1
                                      0,9
                                      0,8
         Fraction of adult activity




                                      0,7
                                      0,6
                                      0,5
                                      0,4
                                      0,3
                                      0,2
                                      0,1
                                       0
                                            0   10   20              30              40   50   60
                                                          Body Weight (kg)



Nuclear Medicine                                          Part 6. Medical Exposure                  85
                     …...noting the special requirements for


                                 Children
Local rules for administered activities to children should be
available. Recommendations from international professional
organizations should be followed.




  Nuclear Medicine                   Part 6. Medical Exposure   86
                   Pregnancy




Nuclear Medicine     Part 6. Medical Exposure   87
Example of justified use of CT in a pregnant
female who was in a motor vehicle accident

                                               ribs
         Fetal
                                                      Blood
         skull
                                                      outside
                                                      uterus




                            Fetal dose 20 mGy
Nuclear Medicine    Part 6. Medical Exposure               88
3 minute CT exam and taken to the operating
room. She and the child survived

Free blood




 Kidney ripped off aorta
 (no contrast in it)
                                                 Splenic laceration
 Nuclear Medicine     Part 6. Medical Exposure                   89
                    Introduction

 Thousands of pregnant women are
  exposed to ionizing radiation each year
 Lack of knowledge is responsible for
  great anxiety and probably unnecessary
  termination of pregnancies
 For most patients, radiation exposure is
  medically appropriate and the radiation
  risk is minimal

 Nuclear Medicine      Part 6. Medical Exposure   90
   In some circumstances, the exposure is
    inappropriate and the unborn child may be at
    increased risk.
   Prenatal doses from most properly done
    diagnostic procedures present no measurably
    increased risk of prenatal death,
    malformation, mental impairment.
   Higher doses such as those from therapeutic
    procedures can result in significant fetal
    harm.


Nuclear Medicine     Part 6. Medical Exposure   91
       An example of media nonsense




Nuclear Medicine   Part 6. Medical Exposure   92
                    Pregnant Women
“3.175. Registrants and licensees shall ensure that there
   are procedures in place for ascertaining the pregnancy
   status of a female patient of reproductive capacity before
   the performance of any radiological procedure that could
   result in a significant dose to the embryo or fetus, so that
   this information can be considered in the justification for
   the radiological procedure (para. 3.154) and in the
   optimization of protection and safety (para. 3.165).”




 Nuclear Medicine          Part 6. Medical Exposure         93
                   Situation Analysis
   Number of females getting exposed every
    week without knowing that they are pregnant:
    Inadvertent radiation exposure of early
    conceptus
   Planned Exposures:
      patients needing nuclear medicine
       examinations or even therapy while
       pregnant
   Accidental exposure in pregnancy
   Occupational exposures in pregnancy
   Exposure of female of reproductive capacity

Nuclear Medicine         Part 6. Medical Exposure   94
               How Sensitive is Early
                   Conceptus?
Threshold dose
deterministic effects                              100 - 200 mSv

Mental retardation                                     40 % /Sv

Cancer and leukemia
  before 10 years of age                               2 % /Sv
  lifetime                                             15 % /Sv

Hereditary effects                                      1 % /Sv
Nuclear Medicine        Part 6. Medical Exposure                   95
        Irradiation of Fetus Results
                    from:
   Placental transfer
          distribution of activity in fetal organs
             not much data available
             I-131 as iodide Tc-99m pertechnetate

   External radiation from activity present
    in the mothers organs and tissues
          radiopharmaceuticals eliminated via the
           kidneys

Nuclear Medicine           Part 6. Medical Exposure   96
          Absorbed Dose to the Fetus
Examination                                            Activity            Dose to
   fetus
                                                        (MBq)              (mSv)
Bone (Tc99m)                                                600               4
Brain (CBF)                                                 500               4
Lung (Tc99m-MAA)                                            160             0.4
Kidneys (MAG3)                                              100               2
Tumour or abscess (Ga-67 citrate)                           300             28
Heart (Tc99m-MIBI)                                          300               5
Heart (Tl-201)                                              100             10
Thyroid (Tc99m)                                             100               1
Thyroid (I-131)                                             100               7
Kidney clearance (Cr-51-EDTA)                                    4         0.02

(Data from Russell, Stabin et al Radiation dose to the embryo/fetus from
radiopharmaceuticals Draft, 1997

   Nuclear Medicine                   Part 6. Medical Exposure                    97
            Absorbed Dose to the Fetus
                  0,3

                        I-131 iodide
                        Tc-99m-MAG3


                  0,2
        mGy/MBq




                  0,1




                  0,0
                        Early          3 months                6 months   9 months
                                          Pregnancy month
(Data from Russell, Stabin et al Radiation dose to the embryo/fetus from
radiopharmaceuticals Draft, 1997

   Nuclear Medicine                        Part 6. Medical Exposure                  98
      Risk of childhood cancer from mother’s
            diagnostic procedure in NM

      The risk to an embryo or fetus from absorbing 1 mSv of
       radiation dose - an increased risk of developing childhood
       cancer of 6 in 100,000 (3 of which would be fatal)
      Natural risk of complications of pregnancy or of birth anomalies
       is approximately 4,000 in 100,000
      Natural risk of the incidence of childhood cancer – 150 in
       100,000
      Fetal doses from diagnostic procedures in NM – max. tens of
       mSv ( 67Ga, 131I)




    Nuclear Medicine            Part 6. Medical Exposure           99
        Prevention of Inadvertent
         Exposure in Pregnancy
When a female of reproductive age presents for
an examination ask:
           Is she likely to be pregnant? Is period over-due?
           This should be recorded at appropriate place in the
            form
           Females under 16?
Depending upon answer
  No possibility of pregnancy
  Proceed with the examination
Nuclear Medicine             Part 6. Medical Exposure    100
IF YOU THINK THAT
YOU MIGHT BE
PREGNANT , NOTIFY
STAFF BEFORE
TREATMENT



Nuclear Medicine   Part 6. Medical Exposure   103
      Before Examination is Performed
•Many patients incorrectly assume that irradiation from a
 nuclear medicine examination begins when the gamma camera
 begins imaging,
•Therefore, before radiopharmaceutical administration, it is
 necessary to
 consider as pregnant any woman of reproductive age
 presenting for a nuclear medicine examination at a time when a
 menstrual period is overdue or missed, unless
•there is information that precludes pregnancy (e.g.,
 hysterectomy or tubal ligation).
•If the menstrual cycle is irregular, and a non-technetium or
 therapeutic radiopharmaceutical is being administered, a
 pregnancy test may be indicated before proceeding.


  Nuclear Medicine         Part 6. Medical Exposure       104
                       Informed Consent and
                           Understanding
    The pregnant patient has a right to know the
     magnitude and type of potential radiation
     effects that might result from in-utero
     exposure
    Communication should be related to the level
     of risk. Verbal communication may be
     adequate for low dose procedures.
    If fetal doses are above 1 mGy, usually a
     more detailed explanation is given

    Nuclear Medicine          Part 6. Medical Exposure   105
     If an examination of a pregnant
    woman is judged to be necessary
   Choice of radiopharmaceutical
   Is it possible to reduce the administered
    activity?
   Prolonged acquisition times?
   For radiopharmaceuticals eliminated via the
    kidneys:
      Partially filled urinary bladder at the time
        of administration
      Hydration and frequent voiding

Nuclear Medicine      Part 6. Medical Exposure   106
                    During the Examination

Using smaller administered activities
and longer imaging times can reduce
the absorbed dose to the fetus. This is
feasible if the patient is not too sick
and is able to remain still



 Nuclear Medicine           Part 6. Medical Exposure   107
             During the Examination
The sequence of the examinations can be adjusted
to reduce radiation dose.
•e.g. a ventilation-perfusion lung scan ordered on a
pregnant patient to exclude a pulmonary embolus.
• Many laboratories will perform the ventilation scan
first and then do the perfusion scan.
•In the specific case of a suspected pulmonary
embolus, the perfusion scan can be performed first,
and if it is normal, a ventilation scan is not needed at
all.

 Nuclear Medicine      Part 6. Medical Exposure    108
During the Examination (contd.)

• There will be much smaller fetal dose
  with Xenon-133
• If one does ventilation scans using
  99mTc-DTPA aerosol, this will be
  absorbed and excreted via the kidneys,
  and while in the bladder it will contribute
  to fetal dose


Nuclear Medicine   Part 6. Medical Exposure   109
Dose reduction after procedure has
        been performed

 Can the dose be reduced after the
 procedure has been performed?

• Yes, by accelerating voiding,
  bladder dose
• Not possible in radiology and RT



Nuclear Medicine   Part 6. Medical Exposure   110
         Termination of Pregnancy
    Termination of pregnancy at fetal doses of
     less than 100 mGy is NOT justified based
     upon radiation risk
    At fetal doses in excess of 100 mGy, there
     can be fetal damage, the magnitude and type
     of which is a function of dose and stage of
     pregnancy
    In these cases decisions should be based
     upon individual circumstances

    Nuclear Medicine   Part 6. Medical Exposure   111
 Becoming Pregnant after Irradiation
• ICRP has recommended that a woman not become
  pregnant until the potential fetal dose from
  remaining radionuclides is less than 1 mGy.
• This is not usually a consideration except for
  radiopharmaceuticals labelled with 59Fe (for
  metabolism studies) or 75Se (for adrenal imaging).
• As a result of the long physical half-lives of these
  radionuclides and their long residence times in the
  body, it is recommended that pregnancy be avoided
  for 6 and 12 months respectively.


 Nuclear Medicine      Part 6. Medical Exposure   112
Nuclear Medicine   Part 6. Medical Exposure   113
                   Mothers in Lactation




Nuclear Medicine          Part 6. Medical Exposure   114
      Optimization: Breast Feeding

“3.176. Registrants and licensees shall ensure that
   there are arrangements in place for establishing
   that a female patient is not breast-feeding before
   the performance of any radiological procedure
   involving the administration of a
   radiopharmaceutical that could result in a significant
   dose to an infant being breast-fed, so that this
   information can be considered in the justification for
   the radiological procedure (para. 3.154 and 3.156 )
   and in the optimization of protection and safety
   (para. 3.165).”

Nuclear Medicine        Part 6. Medical Exposure      115
    Irradiation of breastfed child
             results from:
                  Activity in milk
                  External radiation from the mother
                  Possible contamination




Nuclear Medicine                 Part 6. Medical Exposure   116
Recommendations for Cessation
     of Breast Feeding
      Radiopharmaceutical       Administered activity             Counseling?   Advice
                                       (MBq)
      Tc -99m DTPA                       740                          no
      Tc -99m MAA                        148                          yes       12 hr
      Tc -99m Pertechnetate              185                          yes        4 hr
      Tc -99m DISIDA                     300                          no
      Tc -99m glucoheptonate             740                          no
      Tc -99m HAM                        300                          no
      Tc -99m MIBI                      1110                          no
      Tc -99m MD P                       740                          no
      Tc -99m PYP                        740                          no
      Tc -99m RBC's in vivo              740                          yes       12 hr
      labelling
      Tc -99m RBC's in vitro             740                          no
      labelling
      Tc -99m Sulphur Colloid            444                          no
      Tc -99m DTPA Aerosol                37                          no
      Tc -99m WBC's                      185                          yes       48 hr
      Tc -99m MAG3                       370                          no




Nuclear Medicine                       Part 6. Medical Exposure                          117
Recommendations for Cessation
     of Breast Feeding
         Radiopharmaceutical   Adminis tered activity           Counseling?    Advice
                                      (MBq)
         Ga-67 Citrate                  185                         yes       Cessation
         I-131 NaI                     5550                         yes       Cessation
         Cr-51 EDTA                    1.85                         no
         In-111 WBC's                    20                         no
         I-123 NaI                       15                         yes       Cessation
         I-123 OIH                       74                         no
         I-123 mIBG                     370                         yes         48 hr
         I-125 OIH                     0.37                         no
         I-131 OIH                     11.1                         no
         Tl-201                         111                         yes         96 hr
         Xe-133 gas                                                 no




Nuclear Medicine                     Part 6. Medical Exposure                             118
IF YOU ARE BREAST-
FEEDING, PLEASE
NOTIFY THE STAFF




Nuclear Medicine   Part 6. Medical Exposure   119
  IAEA Training Material on Radiation Protection in Nuclear Medicine



Part 6. Medical Exposure
Protection of the Patient




      Module 6.8. Records
                            Records
“3.182. Registrants and licensees shall maintain for a period as specified by
the regulatory body and shall make available, as required, the following
personnel records:
     (a) Records of any delegation of responsibilities by principal parties
     (as required in para. 3.153(f));
     (b) Records of training of personnel in radiation protection (as required
         in para. 3.149(b)).

3.183. Registrants and licensees shall maintain for a period as specified by
the regulatory body and shall make available, as required, the following
records of calibration, dosimetry and quality assurance:
     (a) Records of the results of the calibrations and periodic checks of the
     relevant physical and clinical parameters selected during treatment of
     patients;
     (b) Records of dosimetry of patients, as required in para. 3.167;
     (c) Records of local assessments and reviews made with regard to
     diagnostic reference levels, as required in para. 3.168;
     (d) Records associated with the quality assurance programme, as
     required in para. 3.170(d).”
 Nuclear Medicine                Part 6. Medical Exposure                121
                      Records
“3.184. Registrants and licensees shall maintain for a period
as specified by the regulatory body and shall make available,
as required, the following records for medical exposure:
    …….
    (c) For nuclear medicine, the types of
    radiopharmaceutical administered and their activity;
    …….
    (e) Exposure records for volunteers subject to medical
    exposure as part of a programme of biomedical research;
    (f) Reports on investigations of unintended and
    accidental medical exposures (as required in para.
    3.180(d).”


  Nuclear Medicine        Part 6. Medical Exposure     122
             Records and Documents:
               Medical Exposures
•Administered radiopharmaceutical
 and activity (each patient)
•Route of administration (each patient)
•Incident and accident investigation reports
•Absorbed doses to patients
•Calibration certificate (activity meter)
•Quality control of equipment
 (gamma camera & activity meter)
•Maintenance and repair work
•Audits and reviews of radiation safety programme
•Training provided:
        initial
        refresher



Nuclear Medicine             Part 6. Medical Exposure   123
  IAEA Training Material on Radiation Protection in Nuclear Medicine



Part 6. Medical Exposure
Protection of the Patient




  Module 6.9. Local Rules
                     Local Rules:
                   Medical Exposures
             Activity to adults in nuclear medicine examinations
             Activity to children in nuclear medicine examinations
             Rules for pregnant women
             Rules for lactating women
             Preparation and dispensation of radiopharmaceuticals
             Procedure manual, activity meter
             Patient identification and information
             Administration of radiopharmaceuticals
             Procedure manual, gamma camera examinations
             Procedures in case of misadministrations
             Procedures in case of accidents
             Records



Nuclear Medicine                 Part 6. Medical Exposure            125
                                Local Rules
                            Department of Nuclear Medicine
                           Radiation Protection Manual
                            PROTECTION OF THE PATIENT


                     Activity to Adults                 Children & Young people

                     Pregnant women                            Lactating women

                   Radiopharmaceuticals                   Activity measurement

                     Misadministration                               Examination

                    Proceedure Manuals                      Patient Identification




Nuclear Medicine                          Part 6. Medical Exposure                   126
         Questions?


Nuclear Medicine   Part 6. Medical Exposure   127
                   Disccussion
• Increase the activity for elderly patients and patients with
  pain to reduce the examination time?

• Increase the activity for all patients in order to increase
  the throughput of patients?

• Increase the activity for paediatric patients in order to
  avoid sedation or general anaesthesia?

• Increase the activity to cancer patients who are
  nevertheless going to receive radiotherapy?




Nuclear Medicine           Part 6. Medical Exposure             128
                   Discussion

  A patient is referred to a bone scan. It is
  obvious from the information on the request
  that this is the wrong type of examination to
  get the right diagnosis. The examination is
  done anyway. Who is responsible for this non
  justified exposure?




Nuclear Medicine     Part 6. Medical Exposure     129
                     Discussion

         Discuss how to handle the problem when it is
         necessary to to examine or treat a woman who
         is pregnant.




Nuclear Medicine          Part 6. Medical Exposure      130
Where to Get More Information
    Other sessions
           Part 7 Optimization of protection in Nuclear Medicine Examinations
           Part 8 Optimization of protection in Nuclear Medicine therapy
           Part 11 Potential exposure and accidental medical exposure

    Further readings
           IAEA Basic Safety Standards: Interim Edition (2011)
           IAEA Safety Guide on Radiological Protection for Medical Exposure
           IAEA Model regulations on radiation safety in nuclear medicine
           WHO. Manual on Radiation Protection in Hospitals and General
            Practices. Volume 4: Nuclear Medicine
           ICRP publication 84

    Practical session
           Simulated inspection


    Nuclear Medicine                Part 6. Medical Exposure              131
                               Local Rules 1
                              Department of Nuclear Medicine
                              Radiation Protection Manual
                               PROTECTION OF THE PATIENT


                                           ADULTS

           Examination                    Radiopharmaceutical                 Activity (MBq)
           Bone scan                                 Tc99m DPD                         400
           Thyroid                           Tc99m-pertechnetate                       100
           Kidney                                  Tc99m-MAG3                           75


                   Note: For not listed examinations consult the nuclear medicine specialist




Nuclear Medicine                                Part 6. Medical Exposure                       132
                               Local Rules 2
                              Department of Nuclear Medicine
                              Radiation Protection Manual
                               PROTECTION OF THE PATIENT


                       CHILDREN & YOUNG PEOPLE

          Examination          Radiopharmaceutical                             Activity (MBq)
                                                                           Age 0-14     Age 15-18
          Bone scan                   Tc99m DPD                            BW x 3       BW x 6
          Thyroid               Tc99m-pertechnetate                        BW x 0.5     BW x 1
          Kidney                     Tc99m-MAG3                            BW x 0.5     BW x 1


                   Note: For not listed examinations consult the nuclear medicine specialist




Nuclear Medicine                                Part 6. Medical Exposure                            133
                    Local Rules 3
                    Department of Nuclear Medicine
                    Radiation Protection Manual
                    PROTECTION OF THE PATIENT

                    PREGNANT WOMEN
•If a female patient is pregnant or think that she might be, the responsible
physician shall always make a decision whether the examination shall be
done or shall be postponed either until after delivery or to the latter half of
the pregnancy, carefully considering the use of other diagnostic methods.

• If there is uncertainty concerning pregnancy, either because the period is
known to be overdue or for other reasons, the woman shall be treated as
pregnant until otherwise proved.

• The administered activity shall be in proportion to body weight using 70%
of the normal adult activity for the required examination



Nuclear Medicine                 Part 6. Medical Exposure                  134
                        Local Rules 4
                       Department of Nuclear Medicine
                       Radiation Protection Manual
                        PROTECTION OF THE PATIENT


                          LACTATING WOMEN
          No counseling of breastfeeding for the following radiopharmaceuticals:
          51Cr-EDTA, 99mTc-DMSA, 99mTc-DTPA, 99mTc-MDP, 99mTc-glycoheptonate
          99mTc-HMPAO, 99mTc-MIBI, 99mTc-colloids, 99mTc-MAG3(<100MBq),
          201Tl-chloride (<80MBq) and 111In-leucocytes (<20MBq).



          For other radiopharmaceuticals, see attached      table
          For not listed radiopharmaceuticals, consult the nuclear medicine specialist




Nuclear Medicine                   Part 6. Medical Exposure                135
                   Local Rules 4:1
                     Department of Nuclear Medicine
                    Radiation Protection Manual
                      PROTECTION OF THE PATIENT

                        LACTATING WOMEN
                            Counseling of breastfeeding

                   Radiopharmaceutical                          Advice
                   99mTc-pertechnetate                            4h
                   99mTc-MAA                                     12h
                   201Tl-chloride                                96h
                   67Ga-citrate                                Cessation
                   ………                                           …..




Nuclear Medicine                    Part 6. Medical Exposure               136
                         Local Rules 5
                       Department of Nuclear Medicine
                       Radiation Protection Manual
                       PROTECTION OF THE PATIENT


                    RADIOPHARMACEUTICALS
                   Preparation                               Dispensing


                                 Injection




Nuclear Medicine                  Part 6. Medical Exposure                137
                               Local Rules 5:1
                             Department of Nuclear Medicine
                            Radiation Protection Manual
                              PROTECTION OF THE PATIENT

      PREPARATION OF RADIOPHARMACEUTICALS
Name:        DPD (CIS bio)
Composition 13 mg 3,3-diphosphono-1,2-propanedicarboxylic acid, tetrasodium salt (DPD) 0.23 mg
             tin(II)oxide
Usage:       Bone scintigraphy
Preparation: Use a transparent vial shield. Put the kit vial in the shield. Dispense 5 ml pertechnetate
              (3000 MBq) in a shielded syringe. Add the solution to the vial containing the freeze dried
              kit.
             Remove an equal volume of gas to equalize the pressure. Shake the vial gently for 10 s.
             Store the preparation for 5 min. Temporarily remove the vial from the shield and measure
             the activity.
             Use a forceps when moving the vial. Put a label on the shield. The label shall contain: Name
             of radiopharmaceutical, activity and activity concentration as well as date and time. Check
             the label against the vial. Same radiopharmaceutical? Record the preparation and sign.
             The preparation can be used for 5 patient examinations within 6 h from time of
             preparation.
Storage:     Kit in fridge
             Radiopharmaceutical in the shielded container and protected from light




   Nuclear Medicine                         Part 6. Medical Exposure                             138
                       Local Rules 5:2
                        Department of Nuclear Medicine
                       Radiation Protection Manual
                        PROTECTION OF THE PATIENT



           DISPENSING RADIOPHARMACEUTICALS
  1.      Check the label on the vial shield. Is it the required
          radiopharmaceutical?
  2.      Calculate the volume to dispense from the decay corrected activity
          concentration and the requested activity for the intended
          examination.
  3.      Dispense the calculated volume using a shielded syringe.
  4.      Temporarily remove the syringe shield and measure the activity.
  5.      Write a label and put it on the syringe shield. The label shall contain
          patient name and id number, radiopharmaceutical, activity, date and
          time. The label shall be signed.




Nuclear Medicine                    Part 6. Medical Exposure                  139
                       Local Rules 5:3
                          Department of Nuclear Medicine
                          Radiation Protection Manual
                           PROTECTION OF THE PATIENT

                     IDENTIFICATION OF PATIENT
               INJECTION OF RADIOPHARMACEUTICALS

    1.       Ask the patient about name and birth date or identification number.
    2.       Ask a female patient about pregnancy.
    3.       Ask a female patient if she is breastfeeding a child.
    4.       If necessary, inform the patient about any restrictions according to
             the local rules.
    5.       Read the request
    6.       Check the label on the syringe shield.
    7.       Is it the correct radiopharmaceutical and activity for the requested
             examination?
    8.       Inject according to the local rules for intravenous injections
    9.       The radiopharmaceutical and the injected activity.shall be recorded




Nuclear Medicine                      Part 6. Medical Exposure                      140
                           Local Rules 6
                         Department of Nuclear Medicine
                         Radiation Protection Manual
                         PROTECTION OF THE PATIENT

                      ACTIVITY MEASUREMENT

       The activity of the radiopharmaceutical shall always be measured after
       preparation and before and after injection.

       1.      Select the isotope
       2.      Check the background reading and make a background adjustment
       3.      Put the syringe or the vial in the holder using a forceps
       4.      Put the holder into the chamber
       5.      Read the activity
       6.      Remove the holder and put the syringe or vial back into the shield




Nuclear Medicine                     Part 6. Medical Exposure               141
                            Local Rules 7
                            Department of Nuclear Medicine
                           Radiation Protection Manual
                            PROTECTION OF THE PATIENT

                            MISADMINISTRATION
The following are defined as misadministrations: Administration to the wrong patient, administration of the
wrong radiopharmaceutical, administration of wrong activity (>15% from prescribed activity in therapy and
>75% in diagnostic examinations) and wrong route of administration.

In case of misadministration:
1.      Inform the nuclear medicine specialist
2.      Inform the patient and the referring physician
3.      Inform the medical physicist (phone ……), who shall calculate and report the
        patient dose
4.      The responsible technician shall write a report about the event and try to
        explain the causes.
5.      The nuclear medicine specialist shall send the report to the Head of the
        Department who shall decide if the event shall be reported to the authorities.
6.      All members of the staff shall be informed



Nuclear Medicine                             Part 6. Medical Exposure                                  142
                           Local Rules 8
                           Department of Nuclear Medicine
                          Radiation Protection Manual
                           PROTECTION OF THE PATIENT

                   Study name:                         Bone scan
                   Preparation of patient:             Empty bladder
                   Radiopharmaceutical:                Tc99m-DPD
                   Route of administration:            iv injection
                   Activity:                           400 MBq
                   Start of measurement:                 3h post injection
                   Type of examination:                Whole body scan
                   Views:                              AP, PA
                   Scanning speed:                     10 cm/min
                   Collimator:                         LEHR
                   Window setting:                     140+/-20% keV
                   Positioning of patient:             Supine
                   Presentation of result:             Images in BW on film.



Nuclear Medicine                      Part 6. Medical Exposure                 143

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:20
posted:9/20/2012
language:English
pages:141