The ORAMED project:

Optimization of Radiation Protection for Medical Staff in Interventional Radiology,

Cardiology and Nuclear MedicineN. Ruiz Lopez1, M. Sans Merce1, I. Barth2, E. Carinou3

, A. Carnicer4, I. Clairand5, J. Domienik6, L. Donadille5, P. Ferrari7, M. Fulop8, M. Ginjaume4, G. Gualdrini7, C. Koukorava3, S. Krim9, F. Mariotti7, D.

Nikodemova8, A. Rimpler2,K. Smans9, L. Struelens9, F. Vanhavere9

1. 2. 3. 4. 5.

6. 7. 8. 9.

International Symposium on Standards, Applications and Quality Assurance in Medical Radiation DosimetryVienna, 9-12 November 2010

The ORAMED projectORAMED: is a collaborative project funded in 2008 within the 7th

EU Framework Programme, Euratom Programme for Nuclear Research and training.

Started: Feb./2008 End:

Jan./2011

Improve standards of protection for medical staff for procedures resulting in potentially high exposures

Participants: 12 partners from 9 European countries

WP0: ManagementSCK-CEN (Belgium): Filip Vanhavere

WP2

: Development of practical eye lens dosimetryENEA (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 medicineCHUV (Switzerland) : Marta Sans Merce

WP5

: Training and dissemination of resultsUPC (Spain) : Merce Ginjaume

Organisation of ORAMED

WP1

: Extremity dosimetry and eye lens dosimetry in interventional radiology/cardiology

GAEC (Greece) : Eleftheria Carinou

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

Extremity dosimetry and eye lens dosimetry in IR/IC

Participants:

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.

Extremity dosimetry and eye lens dosimetry in IR/IC

WP1: Measurements campaign

6 different countries, 3 hospitals per country10 measurements/type of procedure/hospital3 procedures of IC and 5 procedures of IR

A common measurement protocol was established

8 TLDs positions per procedure

Interventional cardiology:• CA/PTCA•RF Ablation •Pacemakers

Interventional radiology:•Angiography and angioplasty (DSA & PTA) :

olower limbocarotidorenal

•Embolization•Endoscopic Retrograde Cholangiopancreatography(ERCP)

Extremity dosimetry and eye lens dosimetry in IR/IC

LfingerR fingerL wristR wrist

L legR leg

Middle eye

L eye

WP1: Some resultsDistribution of KAP values for differents procedures

Range:13

μGy

m2

(PM)-358118

μGy

m2(Embo)

-

complexity of particular procedure -

experience of the physician

KAP presents large variability, even within the same type of procedure

ZOOM

Higher value for embolizationsLower value for PM

Extremity dosimetry and eye lens dosimetry in IR/IC

Median of doses for various procedures in the different anatomic regions

>:PM, DSA PTA R & embolizations <:DSA/PTA Ca Ce & ERCP• Left side is more exposed.

WP1: Some resultsExtremity dosimetry and eye lens dosimetry in IR/IC

>:PM; operator is more close to the patient and stays all procedure in the room

Median of normalized

doses for various procedures in the different anatomic regions

WP1: Some resultsExtremity 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

Extremity dosimetry and eye lens dosimetry in IR/IC

Use of additional protective equipment :

Extremity dosimetry and eye lens dosimetry in IR/IC

WP1: Example

There are not measurements available using table protection with tube above

WP4: Motivation

-

the extremity doses in NM can easily surpass operational limits.

Put in evidence:

Close to the limit, or bigger? Position of the monitoring dosemeter?

-Absence of a systematic study of exposure

- often not known which

part of the hand will receive the highest dose

Extremity dosimetry in NM

*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) 350-355

*

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.

Extremity dosimetry in NM

WP4: Campaign of measurements

99mTc 18F

90Y-Zevalin

•7 different countries, 2 hospitals by country2 workers per NM service (5 measurements/person)

Measures homogenized so the data is comparable

• An unified measurement protocol was fixed: -experience-dominant hand-radiation protection measures- etc.

Preparation

AdministrationDiagnostic

andTherapy

Extremity dosimetry in NM

MATERIALS AND METHODS:

•22 measuring points (11 different positions on each hand)

•High sensitivity TLD specific to beta and gamma radiation*:

• Intercomparison (done before measurements). •Purpose: to establish a common basis for the measurement campaign among all participants.• Standards TLDs (>200mg/cm2) irradiated with 137Cs• Thin TLDs (8-10 mg/cm2) irradiated with 85Kr• Results: All participants reported results within 10% of the reference value.

WP4: Campaign of measurements

Extremity dosimetry in NM

Type Measurements TLD Thickness (mg∙cm‐2)

TLD 707H (LiF:Mg:Cu:P) 7MCP‐Ns (LiF:Mg:Cu:P) 8.5TLD 720H (LiF:Mg:Cu:P) 100TLD 100 (LiF:Mg:Ti) 100GR200 (LiF:Mg:Cu:P) 200

TLD 100H (LiF:Mg:Cu:P) 220MCP‐N (LiF:Mg:Cu:P) 225TLD 100 (LiF:Mg:Ti) 240

18F, 90Y

99mTc

Very thin

Thin

Thick

*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. 43 565-57

WP4: Some results

Extremity dosimetry in NM

Diagnostic radionuclides Therapeutic radionuclides

A‐99mTc

P‐99mTc A‐18F P‐18F A‐90Y Zevalin P‐90Y Zevalin

Maximum (mSv/GBq) 0.94 0.99 4.11 4.43 6.43 40.96

Median (mSv/GBq) 0.03 0.08 0.16 0.33 0.73 1.11

Mean (mSv/GBq) 0.06 0.13 0.28 0.50 1.25 3.82

Position of max.index 

tip (nd)

index 

tip 

(nd)

INDEX TIP 

(D)

thumb 

(nd)

thumb (nd) ring tip (nd)

132 workers694 measurements

ZOOMDiagnostic radionuclides Therapeutic radionuclides

WP4: Frequency where maximum is found

Extremity dosimetry in NM

Non dominant hand,Index tip

Non dominant hand,Index tip

DOMINANT HAND,INDEX TIP

Examples of administration positions

Legend:Non dominant handDOMINANT HAND

WP4: Frequency where maximum is found

Extremity dosimetry in NM

DOMINANT HANDINDEX TIP

Non dominant hand,Index tip, thumb

Example of preparation positions

Example of administration positions

Legend:Non dominant handDOMINANT HAND

WP4: Frequency where maximum is found

Extremity dosimetry in NM

DOMINANT HAND,

Non dominant hand,thumb

Legend:Non dominant handDOMINANT HAND

Example of Zevalin preparation

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.

N.B: the positions usually used for routine monitoring are the base of ring finger and the wrist

Extremity dosimetry in NM

Now we have to conclude the better position for the monitoring dosemeter

Thank you for your attentionFor more information, please visit www.oramed-fp7.eu

All results and recommendations will be presented in a workshop in Barcelona from 20-22 January 2011