Task 1. Avoidance of radiation injuries in interventional procedures using X rays and limiting probability of stochastic effects, especially in children

Ground reality (identification of lacuna): Increasing number of procedures are being performed using X rays to guide interventions in the body. Many of these procedures are performed to replace surgical interventions. For example, by-pass surgery had been the conventional method for treating condition of obstruction in the coronary artery of the heart. In many cases now it is possible to remove blockage by passing catheter in the artery and ballooning or by other procedures of similar kind. All such procedures require negotiating the catheter and associated devices under fluoroscopic guidance. X rays are used to continuously monitor the process resulting in prolonged exposure sometimes of the order of hour or more. Repeated procedures on the same patient have been responsible for radiation exposure reaching the level of deterministic effects. One of the important factors in such cases is that the doctors not having any training in radiation protection perform such procedures. Initially it was cardiologists but now increasing number of other medical specialists such as urologist, gastroenterologists, neurologists, anesthetists are performing interventional procedures. Their involvement in radiation work is very small part of their clinical work load but the amount of radiation involved even in smaller proportion of the work is much higher than that handled by most nuclear medicine physicians, radiotherapists and even radiologists not involved in interventional procedures. This occurs since interventionalist works close to the X ray source inside the room whereas others work on consoles out-side or work with much smaller doses and dose rates.

It is imperative that close watch is put on cases with potential to have deterministic effects such as those undergoing therapeutic interventions like angioplasty etc. Many such procedures being performed by clinicians, they do not have staff and facilities to handle and perform dose assessment by traditional means using TLD.

Action recommended:

A. Phase I. Pilot project

1. Identify representative Cardiac and interventional centers to participate in the project. Find out if they have personal dosimeters, lead aprons, lead glass shields and lead eye wears. Find out the work statistics for diagnostic and therapeutic procedures separately for children and adults. Also obtain information about dose area product (DAP) meter availability. [Action: country- information collection]
2. Support from IAEA: IAEA has developed training material (CD) for cardiologists which can be provided as also Gaf Chromic films for peak dose estimation. Some publications can also be provided. [Action: IAEA to provide on request]
3. Work: a) To find out how many procedures involve fluoroscopy time (FT) of more than 30 min b) Monitor patients for skin injuries c) Use Gafchromic films only for such procedures (FT >30 min) and estimate peak dose
4. Report the result to IAEA and express intention to go to Phase II

B. Phase II. Patient dose assessment (DAP)

1. One center in each country to be the nodal center and shall network with other centers in the country
2. Provision for dose area product (DAP) measurement
3. Centres to estimate patient doses as per protocol of IAEA
4. Report the results to IAEA

Note: Some countries with definite potential can take up Phases I and II together.

Additional requirement by Member State, if any.

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