Transcript Radiation Protection in Paediatric Radiology Standards and Guidelines in Radiological Procedures in Children L08 IAEA International Atomic Energy Agency.

Radiation Protection in Paediatric Radiology
Standards and Guidelines in
Radiological Procedures in Children
L08
IAEA
International Atomic Energy Agency
Educational Objectives
At the end of the programme, the participants
should become familiar with:
• International standards & guidelines
• Responsibilities of medical practitioners
• How these standards are applied in paediatric
radiology
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Answer True or False
1. ICRP provides recommendations for use in
diagnostic radiology for the protection of the
patients and staff.
2. Dose limits apply to medical exposures of
patients.
3. Radiologists need special training for paediatric
radiology.
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Contents
• Why we do need standards and guidelines?
• International framework of radiation
protection for medical exposures
• Application of basic principles of radiation
protection in paediatric radiology
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Why do we need Standards and guidelines ?
• International Standards are a
set of mandatory
requirements agreed on by
worldwide consensus
• Application of standards and
guidelines ensures
implementation of principles:
• To minimize the occurrence of
stochastic effects
• To avoid tissue reactions
• Children are recognized as a
special case
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International framework for radiation
protection
• Requirement that there be a clear delineation of
responsibility extending from the level of the
highest official body of the hospital or clinic
involved, to the operational level
• Relies on three principles adopted in most
regulatory systems throughout the world:
• Justification of the activity or practice involved
• Optimization of the activity in terms of risks, costs,
benefits etc.
• Limitation of the doses received by various groups
including workers and the general public
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UNSCEAR
• UNSCEAR: United Nations
Scientific Committee on the
Effects of Atomic Radiation:
• Assess and report levels
and effects of exposure to
ionizing radiation
http://www.unscear.org/
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ICRP
• ICRP: International
Commission on Radiological
Protection
• Provides recommendations
and guidance on all
aspects of protection
against ionizing radiation
http://www.icrp.org/
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IAEA
• IAEA: International Atomic Energy
Agency
• Establish standards of safety for
the protection of health and
minimization of danger to life, in
collaboration with the appropriate
organs of the UN and the
specialized agencies concerned,
and provide for the application of
these standards
http://www.iaea.org/
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International framework for radiation
protection
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Safety
Fundamentals
and Standards
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Safety
Practices
TECDOCs
Safety
Guides
Radiation Protection in Paediatric Radiology
Technical
Reports
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International Basic Safety Standard (BSS)
“…marks the culmination of efforts
that have continued over the past
several decades
towards the
harmonization of
radiation protection
and safety standards
internationally”
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Medical Exposure
Radiation doses incurred:
By patients as part of their own medical or
dental diagnosis or treatment
By individuals (other than those occupationally
exposed) knowingly exposed while voluntarily
helping patients
By volunteers exposed for biomedical research
purposes (must be under approved protocol;
usually children may not participate, only
exceptionally and for their own diagnosis or
treatment)
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Responsibilities
• Principal responsibility for radiation
protection
• Legal person subject of authorization (licensee)
and employer
• Subsidiary responsibilities
Supervisor
Medical Practitioner
Worker
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Radiation Protection in Paediatric Radiology
Radiologists
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BSS
Responsibilities
Advice of a qualified
expert, medical
physicist
Radiologist
Patient
Protection
Training
criteria
Justification
Equipment
design and
suppliers
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Optimization
Quality
assurance
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Responsibilities for Medical Exposure
• Medical exposure has to be prescribed by a medical
practitioner (justification)
• Medical practitioners are assigned the primary task
and obligation of ensuring overall patient protection
and safety in the prescription of, and during the
delivery of, medical exposure
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Responsibility for Medical Exposure
• … training criteria are to be specified or be
subject to approval, as appropriate, by the
Regulatory Authority in consultation with
relevant professional bodies (i.e., cardiology,
radiology, interventional cardiology)
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Justification
• Education and training of both referring physicians and
radiologists plays a crucial role in ensuring that justification
works well in practice
• The knowledge required for Justification includes:
• Clinical history, including examinations already performed,
• Potential benefits of the action,
• Awareness of short term and long term consequences, including the
risks,
• Up-to-date knowledge of any available alternative actions,
• Knowledge of the consequences of not taking any action, and
• Knowledge of referral guidelines and/or appropriateness criteria
where they are available
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Justification of medical exposures
and dose limits
• ICRP has recommended that dose limits not be
applied to medical exposures
• Even with the higher radiation sensitivity of
children, this recommendation is also applied to
paediatrics
• It is based on the fact that the exposed individual
will derive benefit from the procedure, provided it
has been properly justified
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Responsibility for Medical Exposure
• … the imaging and quality assurance
requirements of the Standards should be fulfilled
with the advice of a qualified expert in … medical
physics
• Optimization requirement on equipment design:
ensure that whether imported into or manufactured
in the country where it is used, the equipment
conforms to applicable standards of the:
• International Electrotechnical Commission (IEC)
• International Organisation for Standardization (ISO) or to
equivalent national standards;
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Optimization
• Once justified, examinations must be optimised:
• Generic: for examination type and equipment
and procedures involved
• Specific: for the individual patients
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Optimization
• Ensure that the appropriate equipment be used
• The medical practitioner, the technologist or other
imaging staff select the relevant combination of
parameters, that results in:
• minimum patient exposure consistent with
acceptable image quality and the clinical
purpose of the examination,
• paying particular attention to this selection for
paediatric radiology and interventional radiology
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Diagnostic reference levels (DRL)
• Guidance for radiologists and other practitioners to help to
achieve good examinations at reasonable dose levels
• In paediatric radiology, adoption and use of paediatric
protocols
• If DRLs are exceeded regularly, the practice involved
should be investigated.
• DRL for an examination is derived from a regional, national,
or sometimes international, survey of the doses for that
examination ( usually taken as the third quartile value for
the dose distribution obtained in the survey)
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Dose constraints
• Dose constraints are used as an upper bound
on the doses that individuals might expect to
receive in comforting, caring for or assisting with
immobilization of a patient
• Should not be applied as a dose limit
• Exposure of comforters and carers is
considered as medical exposure (dose
constraint is applied)
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Unintended exposure
• Unintended exposures of patients arise from
failures in justification, failures in
optimisation or errors
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Accidental Medical Exposures
• … any diagnostic exposure substantially
greater than intended …
• Investigation required
• Calculate or estimate doses received
• Indicate corrective measures
• Submit a report
• Inform the patient and his/her doctor about the
incident
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Pregnancy issues
Special care should be observed with respect to:
• irradiation of pregnant or potentially pregnant
occupationally exposed workers
• comforters and carers
• members of the public
Pregnancy can occur in adolescent girls, thus
precautions for this group should be followed for
exposures which may involve a foetus
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BSS
Responsibilities
Personal
protective
devices
Pregnant
workers
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Occupational
Protection
Individual
exposure
monitoring
Workplace
monitoring
Health
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Dose limits for occupationally exposed
workers and members of the public
Type of limit
Occupational
Public
Effective dose
20 mSv/year
1 mSv/year
Annual equivalent dose
Lens of the eye
150 mSv
15 mSv
Skin
500 mSv
50 mSv
Hand and feet
500 mSv
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Education and training
• Special education and training related to radiation
protection in paediatric radiology, techniques and
equipment used:
• medical practitioners providing radiological
services
• other professions including medical physicists
and technologists
• Further, continuous professional development
allows professionals to continue to cope with new
developments
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http://europa.eu.int/com
m/environment/radprot
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http://rpop.iaea.org/RPOP/RPoP/Content/Additional
Resources/Training/1_TrainingMaterial/index.htm
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Applying standards in practice
European Guidelines on Quality
Criteria for Diagnostic
Radiographic Images in
Paediatrics, July 1996.
EUR 16261 EN
Free PDF version available at:
http://www.cordis.lu/fp5euratom/src/lib_docs.htm
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EUR 16261 EN
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Quality Criteria List
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Example:
MCU
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Criteria related to images
• The Image Criteria for paediatric patients
presented for a particular type of radiograph are
those deemed necessary to produce an image of
standard quality
• No attempt has been made to define acceptability
for particular clinical indications
• The image criteria allow an immediate evaluation
of the image quality, with respect to:
• the smaller body size, the age-dependent body
composition, lack of co-operation and other functional
differences
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Criteria related to images
• A lower level of image quality may be acceptable
for certain clinical indications
• An inferior image quality, however, cannot be
justified unless it is set for clinical indication to
reduce radiation dose
• The fact that the X-Ray was taken from a noncooperative paediatric patient (anxious, crying,
heavily resisting) is not an excuse for producing an
inferior quality image which is often associated
with an unnecessary dose (due to the need for a
repeat exam)
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http://rpop.iaea.org/RPOP/RPoP/Content/InformationFor/HealthProfessional
s/1_Radiology/Standards.htm
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Summary
• Radiation protection system has an international framework
• Radiology of children is different from adult radiology
• The special requirements that arise apply to all aspects of
the radiation protection system, including:
• justification
• optimization, including the use of DRL
• All persons directing and conducting medical radiation
exposure of children, including radiologists and
technologists, should have received recognised education
and training in their discipline
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Answer True or False
1. ICRP provides recommendations for use in
diagnostic radiology for the protection of the
patients and staff.
2. Dose limits apply to medical exposures of
patients.
3. Radiologists need special training for paediatric
radiology.
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Answer True or False
1. True – ICRP’s principles of justification,
optimization and dose limitation and specific
recommendations in different conditions are
available for the protection of the patients and
staff.
2. False – There are no regulatory dose limits that
apply to medical exposures of patients. However,
DRLs are available.
3. True – In view of peculiar situations in paediatric
radiology, specific training is required.
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References
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INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION, Radiological
Protection in Medicine, Publication 105, Elsevier, Oxford (2008).
INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION,
Recommendations of the ICRP, Publication 60, Pergamon Press, Oxford (1991).
INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION,
Recommendations of the ICRP, Publication 103, Elsevier, Oxford (2008).
FOOD AND AGRICULTURE ORGANIZATION OF THE UNITED NATIONS,
INTERNATIONAL ATOMIC ENERGY AGENCY, INTERNATIONAL LABOUR
ORGANIZATION, OECD NUCLEAR ENERGY AGENCY, PAN AMERICAN HEALTH
ORGANIZATION, WORLD HEALTH ORGANIZATION, International Basic Safety
Standards for Protection Against Ionizing Radiation and for the Safety of Radiation
Sources, Safety Series No. 115, IAEA, Vienna (1996).
EUROPEAN COMMISION, Council Directive 1997/43/Euratom on health protection of
individuals against ionizing radiation in relation to medical exposure, Off. J. Eur.
Commun. L. 180, 22–27 (1997).
EUROPEAN COMMISSION, Referral Guidelines for Imaging, Luxembourg, Radiation
Protection 118, Office for Official Publications of the European Communities,
Luxembourg (2001) and Update Mars 2008
EUROPEAN COMMISSION, Guidelines on Education and Training in Radiation
Protection for Medical Exposures. Radiation Protection 116, Office for Official
Publications of the European Communities, Luxembourg, (2000).
EUROPEAN COMMISSION, European Guidelines on Quality Criteria for Diagnostic
Radiographic Images in Paediatrics, Rep. EUR 16261, Office for Official Publications of
the European Communities, Luxembourg Communities, Luxembourg, (1996).
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