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 Table of Contents  
REVIEW ARTICLE
Year : 2017  |  Volume : 13  |  Issue : 6  |  Page : 901-907

Occupational doses of cardiologists in cath labs and simulation method


Department of Radiology, Faculty of Paramedical Sciences, Shiraz University of Medical Sciences, Shiraz, Iran

Date of Web Publication13-Dec-2017

Correspondence Address:
Mr. Hadi Rezaei
Department of Radiology, Faculty of Paramedical Sciences, Shiraz University of Medical Sciences, Shiraz
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.192767

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 > Abstract 

In recent years, using the ionizing radiation in the interventional cardiology has been increased; this is because of the rapid growth of the number of interventional procedures and the high levels of radiation dose in these examinations. Therefore, it is necessary to develop procedures for managing the use of fluoroscopy radiation to ensure that patients and personnel are not exposed to excessive levels of radiation. It seems that by the new generation devices of fluoroscopy that are equipped with a real dosimeters or dose area product (DAP)-meter which are able to record the produced dose rate in the area of patient's body in each procedure, it is possible to calculate the cardiologist dose with simulation. In addition, a relationship can be made between the patient DAP and cardiologist dose that is defined as an appropriate conversion factor. Hence, in each procedure, besides the record of patient's DAP, the cardiologist dose is recorded as well.

Keywords: Cath lab monitoring, occupational exposure, simulation method (Monte Carlo N-Particle), staff dosimeter


How to cite this article:
Fardid R, Mirzadeh F, Rezaei H. Occupational doses of cardiologists in cath labs and simulation method. J Can Res Ther 2017;13:901-7

How to cite this URL:
Fardid R, Mirzadeh F, Rezaei H. Occupational doses of cardiologists in cath labs and simulation method. J Can Res Ther [serial online] 2017 [cited 2018 Oct 24];13:901-7. Available from: http://www.cancerjournal.net/text.asp?2017/13/6/901/192767


 > Introduction Top


Following the discovery of X-ray in 1895, this radiation has been used widely in medicine which is arising from a growing number of radiological examinations per year that lead to an increase in the medical radiation exposure.[1] Besides, the coronary artery disease is the main reason of mortality in civilized societies, which is the reason of about 33.7% of global death.[2],[3]

Choosing the diagnostic and therapeutic methods for these diseases and the health care of population is very important. The techniques of imaging, that play an important role in the accurate diagnosis of heart diseases, have been greatly expanded.[4]

Over the past 20 years, among the imaging methods, fluoroscopically guided procedures including interventional cardiology have been expanded greatly.[5] Interventional cardiology includes three main examination groups as follows: Coronary angiography (CA), percutaneous transluminal coronary angioplasty (PTCA), and electrophysiology procedures.[1]

CA is a technique for visualization of the coronary vessels; after injection of the contrast agents with a catheter through the femoral or radial arteries with the fluoroscopy technique, it is possible to observe the heart's coronary arteries.[4],[6] In these tests, while the patient is in the lying position and supine on the table, X-ray tube moves rotationally in two perpendicular planes (horizontal and vertical).[2]

In the angiography and fluoroscopy departments, due to the high level of radiation dose and the presence of cardiologist near the patient during the procedure and the longtime which is needed for fluoroscopy, the cardiologists receive high levels of radiation dose, so a strong supervision on the dose of these operators is essential.[7] In this study, we have performed a mini review of the occupational radiation dose of cardiologists based on the previously conducted studies.


 > Medical Exposure Top


Medical exposures are the major ionizing radiation sources for human; as up to now, about 3.6 billion diagnostic radiology X-ray examinations have been done worldwide.[8] The progress of cardiovascular imaging and increasing the number of interventional procedures have led to an increase in the use of the ionizing radiation rapidly in recent years.[9],[10]


 > Dose Levels in Angiography Top


The radiation dose of patients in the interventional cardiology is much higher than conventional radiology. This event is due to complication of these procedures; furthermore, fluoroscopy is a time-consuming process.[1],[6],[11] These high levels of patient dose lead to receive high levels of radiation by the operator.[6]

The average radiation dose of the patient in interventional cardiology is 10–50 mSv per procedure, and the average dose for operator is estimated to be 0.04–38 μSv per procedure. In a comprehensive study by Morrish and Goldstone.[6] performed early from 1970s till the present, the effective doses are ranged from 0.02 to 38.0 μSv for diagnostic catheterizations. Fardid et al.[12] in 2013 performed a study with the purpose of estimating the dose of cardiologists in several hospitals of Mashhad. The results of their study indicated that the average of cardiologists effective dose per procedure was equal to 2.7 μSv (range: 0.3–14.3 μSv) for CA and 6.4 μSv (range: 1.3–27.5 μSv) for PTCA procedures. Moreover, the average monthly effective dose of cardiologist has been reported to be 158.3 μSv (range: 8.3–1050 μSv).[9],[13]


 > Biological Effects of Ionizing Radiation Top


The ionizing radiations have two main biological effects on the human's body, including the deterministic effects and stochastic effects. The deterministic effects occur when the dose level exceeds a specific threshold called dose threshold level and by increasing the dose, the severity of these effects increases as well. Skin damage, hair loss, cataracts, and cardiovascular diseases are among these biologic effects. The threshold stochastic effects have no specific dose, but by increasing the radiation dose, the probability of their effects increases too.[1],[14],[15],[16],[17]

Despite the clearness of occupational dose limit and observation of nonexceeding radiation limits, there are several reports indicating cataract and receiving dose more than the threshold dose by the cardiologists. The occurrence of these deterministic effects and even some cases of brain cancer have highlighted the importance of dosimetry and radiation protection among the radiologists.[18],[19],[20],[21]


 > Strategies to Reduce Occupational Exposure Top


Training: Informing personnel about the dose reference levels and adverse effects of radiation

At first, we warned the physicians who worked with the X-ray machines about the positive and negative effects of radiation as identified in early 20th century. The radiation of X-ray is nonsense, and hence, it leads to a lack of concern of physicians about the potential risks of radiation.

The physicians should be aware of the adverse effects of ionizing radiation and apply the protective techniques accurately.[9],[22]

Observation of as low as reasonably achievable principle using the protective strategies

The main goal of radiation protection is observation of as low as reasonably achievable principle and keeping the exposure in the acceptable level.[9] These protective strategies should be observed in three fields of time, distance, and shield.

Time: (1) Reduction of fluoroscopy time (2) using pulsed fluoroscopy.

Distance: (1) Increasing the distance of operator to patient (2) increasing the distance between tube and patient (3) reducing the distance between the detector and patient (4) the correct way to keep the tube (keeping the tube under the C-arm table leads to reduction of thyroid, hands' and eyes' radiation doses).

Shield: there are three types of shields in the angiography departments as the following:

  • The building shields such as the rooms' walls
  • The installed equipment in the room includes the lead curtains hanging from the table to protect the feet, the ceiling-suspended radiation shield usually used to protect the eyes and hands
  • The personal protective devices such as lead apron, thyroid shield, lead glasses, and gloves.[23],[24]


A study accomplished by Vano et al.[25] showed that using ceiling-suspended screen shield accompanied by lead apron reduces the radiologist effective dose by a factor of 3.

The ceiling-suspended shield (lead screen) leads to reduction of 97% eye lens dose and 70% hands dose.[26] In a comprehensive study in 2013, it was found that the average of radiologist's annual radiation dose without shield was 42.2 mSv; this amount by wearing the lead apron reduces to 3.5 mSv, and in the case of using a lead apron and thyroid shield, it reduces to 1.7 mSv annually.[16]

Several studies have shown that the annual effective operators' radiation dose using the protective techniques and equipment in the interventional radiology (IR) reaches 2–4 mSv; this is much less than the recommended radiation dose by the International Commission on Radiological Protection (ICRP) (annually 20 mSv).[17]

Occupational monitoring and staff dose monitoring

Besides using the strategies and protection equipment, regular monitoring of occupational radiation dose is recommended to adapt the radiation dose with the dose limits.[25]

[Table 1] lists the radiation limits for staff that recommended by NCRP and ICRP.[13]
Table 1: Limits of Regulatory Considerations for Radiation [13]

Click here to view


There is no great interest to continue applying the current dosimetry methods which use the film badge, due to low accuracy in measurement and also being time-consuming to access the results.[16],[27] Hence, it can be replaced with the new dosimetry methods which can be recommended more accurate personal dosimeter using the computer simulation method.[6]

The standard method of dose monitoring staff is wearing a dosimeter under the lead apron that is able to measure Hp (10) which is the individual equivalent dose for penetrating radiation assessed at a depth of 10 mm; the mentioned quantity, in fact, measures the exposure reaching the organs of the body that is equal to the same effective radiation dose (E). However, the dose of some organs such as hands and eyes that are not protected cannot be estimated.[28] On the other hand, Hp (10) depends on the position of the dosimeter on the body. It means that for the staff who put the dosimeter on their lead apron, the amount of the effective dose is reported more than the real amount; and for the staff who put the dosimeter under their apron, the amount of effective dose is reported less than the real amount. Therefore, ICRP has recommended that in the departments such as IR where the dose levels are high, wearing two dosimeters is necessary; one dosimeter over the apron to provide an assessment of the dose of the tissues that are not protected and the other dosimeter under the apron to provide assessment of the dose of the tissues that are protected.[16],[28],[29],[30],[31] In general, using the personal dosimeter for the estimation of radiation workers has some limitations as noted in the following section.

The problems of using the personal dosimeters in the interventional radiology departments

The first problem is inaccessibility to the correct effective radiation dose (E) while estimating the effective dose of an essential element is in the occupational monitoring program.[12] For the staff working while exposed to X-ray photons with more than 1 MeV energies, the effective dose is equal to the dosimeter reading, i.e. Hp (10). However, in the IR, this condition is not seen. It means, first, the scattered radiation is not distributed uniformly, and second, the photon energies are around 80 KeV.

As in the IR, the effective dose is not equal to the dosimeter reading. The solution to this problem is to use an appropriate algorithm to convert the dosimeter readings to an effective dose.

The second problem is selecting the position of dosimeter on the body. IR staff uses the lead apron. On the other hand, Hp (10) is so dependent on the position of the dosimeter on the body. If the dosimeter is placed on the apron, the amount of effective dose would be expressed more than the real radiation dose, and if it is placed under the apron, it would be expressed lower than the real amount.

The solution for this problem is based on the ICRP, NCRP, and most of the authors' recommendations, such as the use of two dosimeters for estimating the effective dose, so that one of them lies over the shield and the other lies under the shield and then using the appropriate algorithm to reach the effective radiation dose from the dosimeter reading.

The third problem is that there is no any agreement to select an appropriate algorithm for calculating the effective dose.

The fourth problem is inaccessibility to the radiation dose of the eyes and limbs because of complications of monitoring the lower limbs and eyes in the IR and measuring the radiation dose of the hands due to the prevention of the nonsterile hand problems.[5]


 > Different Algorithms to Estimate the Annual Radiation Worker Dose Top


There are different algorithms to calculate the effective dose using the dosimeter reading. These algorithms have many variations, and several researchers try to present more appropriate algorithms.[1]

In the study conducted by Clerinx, the relationship of changing the double-dosimeter readings effective dose (E) is compared with each other using the double dosimetry method and one of the best algorithms that is observed in the following part is confirmed. This relation estimates the amount of effective dose with 10% lower and 60% more than the real amount.[30]

Kicken et al.[32] in 1999 stated: “It seems that in the conditions that the radiation shield is used, using a dosimeter on the neck shield can be an acceptable estimation of effective radiation dose.” However, the report of NCRP 122 showed that when a dosimeter on the neck shield is used, the estimation more than the real amount with factor 3 is obtained, and an estimation of more than the real amount with factor 2 would be obtained when two dosimeters based on the Rosenstein-Webster algorithm are used.[33]

Järvinen et al.[31] in 2008 conducted a study with the purpose of comparison of double dosimetry algorithms for estimating the effective dose of IR staff. In this study, a few of the recently developed algorithms had been tested in IR conditions. The effective dose and dosimeter reading were obtained by two methods: Measurement using thermoluminescent dosimeters and Monte Carlo simulation. From the double dosimetry algorithms tested, the algorithms given in the Swiss Ordinance and by McEwan seem to best meet the specified criteria.

In addition, Järvinen et al.[34] in 2008 reviewed the double dosimetry practices and algorithms for calculation of the effective dose in IR procedures by circulating a questionnaire. The results indicated that regulations for double dosimetry almost did not exist and there was no firm consensus on the most suitable calculation algorithms.

Padovani et al.[35] in 2001 conducted a study with the purpose of comparing two algorithms of Niklason and Webster. In this study, both algorithms showed the limitation in comparison with the experimental data but Nicholson's algorithm in comparison with Webster has two performance excels:

First, in the Nicholson's algorithm, the thyroid shield is considered, and second, the estimates of Nicholson's algorithm in comparison with Webster show a better compatibility with the experimental measurements.


 > Simulation Method, A Useful Method to Improve the Accuracy of Estimating the Occupational Effective Dose Top


The simulation method is a useful and popular way of dosimetry. In fact, due to the nature of being time-consuming and complexity of physical exposure dose measurement methods, simulation is a realistic mean for investigating the radiation dose of patients and operators in IC.[36],[37]

The Monte Carlo N-Particle (MCNP) code as a multiuser code uses these simulations that are applied in designs of medical radiation, detection, dosimetry, and shielding the nuclear reactors.[38]

The base of this method is probably and randomly distribution of particles which is one of the strongest calculation codes in the nuclear and radiation issues. MCNP code has been used in medical physics for more than 50 years.[39] Some examples of the current research in the field of using the Monte-Carlo method in the IR are as follows:

Application of Monte Carlo in calculation of patient's radiation dose

A pilot study was done by Rannikko et al.[40] in 1997 aiming at estimating the radiation dose of patients with simulation. In this study, the man phantom with the average height of 170 cm and weight of 85 kg and woman phantom with the average height of 143 cm and weight of 43 kg were used. The ratio of entrance dose to effective dose for the patient's body was in the range of 1.5–2.

In 2000, van de Putte et al.[41] performed a study aiming at finding a correlation between patients' skin dose and dose area product (DAP) values in the interventional procedures. In this study, the standard projections of heart catheterization with different X-ray tube angulations and fluoroscopy times, kV and mA were simulated in each projection. In this simulation, a layer of skin with the thickness of 0.2 cm was considered; conversion factors were calculated relating DAP to skin dose for 3456 skin regions. The results of their study are shown in [Figure 1]. Moreover, it was identified that the rate of skin dose in the back and right side of the body was higher than the left and front sides; this is caused by positions of the X-ray tubes.
Figure 1: Contour plot of dose distribution (mGy) for cardiac catheterization

Click here to view


Application of Monte Carlo in occupational dose calculation

In 2007–2008, the group of STUK Finland performed a study related to the occupational radiation dose using the MCNP code. The results of this study showed that the operator radiation dose changed greatly by changing the distance of operator to patient. For example, 20-cm movement of the radiologist may change the ratio of the measured dose that was placed on the apron of the operator in the chest region by 50%.[25],[42]

In 2007, Bozkurt and Bor.[36] used MCNP code to simulate the VIP-man (image-based voxel phantom) phantom as a patient who was laid on the table and also as an operator standing at 15-cm distance from the table.

In Bozkurt's study, the dose of lead apron and thyroid collar for the operator was calculated. To determine the entrance dose of the patient's skin and calculation of DAP, a space with dimensions of 10 cm × 10 cm × 1 cm including the air between the table and patient was considered. Five most frequently used X-ray tube angulations with different voltages of 60–120 kV were simulated. The results were reported in the form of calculated coefficient factors consisting of effective doses per DAP for the patient and physician [Table 2] and [Table 3]. An important result of this study was that the physical dosimeter methods might overestimate the effective dose per DAP for physician.[36],[43]
Table 2: Effective dose per dose area product (mSv/[Gy·cm2]) for the patient[36]

Click here to view
Table 3: Effective dose per dose area product (μSv/[Gy·cm2]) for the physician[36]

Click here to view


The relationship between the patient dose area product and the cardiologist dose

In the interventional procedures, the patients are exposed to the primary beam while the physicians are exposed to scattered radiations from the table and the surrounding equipment.[44] The radiation received by the patient is defined with DAP while the radiation received by the cardiologist is obtained from the dosimeter reading or personal dose equivalent (Hp (10)).[44] Accordingly, the dose of operator arises from the radiation dose of the patient. For this reason, in recent years, the research teams are looking for the relationship between the recorded DAP of the patient and the dose of cardiologist during the cardiac fluoroscopy. ICRP recommended the calculation and simulation of the dose conversion coefficients (DCCs) in the IR.[45]

As the DCCs reported by the international laws are not appropriate for IR, there is a need to update the systematic DCCs table, so it would be able to estimate the equivalent dose and effective dose in IR. It should be noted that the main purpose of these studies is to use the patient DAP to estimate the occupational dose during the interventional procedures.[45]

The studies accomplished in the field of finding a relationship between dose area product and the cardiologist dose

Tsapaki et al.[46] in 2004 could find a linear relationship with the correlation coefficient of R2 = 0.88 between the dose over the apron of the cardiologist and DAP during the cardiac angiography.

In another study performed by Tsapaki et al.[47] in 2005 in 5 European countries, they found a weak relationship between the correlation coefficient of R2 = 0.29 between the radiation dose of the left shoulder of the physician and patient DAP.

Kuipers et al.[44] in 2010 performed a study with the purpose of investigating the relationship between absorbed dose measured over the lead apron in the cardiologist's chest region and the exposure level of the patient during the fluoroscopy cardiac procedures. After analyzing the data, they found a linear relationship with the correlation coefficient of R2 = 0.55 between these two variables.

Moreover, in 2014, a study was done to find a relationship between the occupational dose of the cardiologist and DAP or the exposure attributed to the patient. The results showed that a linear relationship existed between the level of patient DAP and cardiologist exposure as measured by the radical ionization chamber with coefficient correlation of R2 = 0.88, and also between patient DAP and estimated exposure in the experiment conditions; it means by phantom, there was a linear relationship with the correlation coefficient of R2 = 0.95.[11]

The studies conducted in this field emphasize the ICRP recommendation based on the proportionality of the physician exposure with the imposed DAP to the patient in the cardiac fluoroscopy procedures.[42]


 > Conclusion Top


By considering the space of cath lab and the sensitivity and high stress of the angiographer, usually the cardiologist is not interested in using the personal dosimeters; hence, some steps should be taken toward obtaining accurate, rapid, and easy dosimetry according to the work conditions in these environments.

It seems that by fluoroscopy, the new generation of machines which are equipped with areal dosimeters or DAP-meter and are able to record the produced radiation dose in the region of patient's body in each procedure, it is possible to calculate the cardiologist radiation dose with simulation. In addition, a relationship can be made between the patient DAP and cardiologist radiation dose; also this relationship can be in the form of an appropriate conversion factor which in each procedure, besides the recording of the patient DAP, the cardiologist is recorded as well.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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