The Korean Journal of Pain

  • 제35권2호
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  • Pages.129-139
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  • 2022
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  • 2005-9159(pISSN)
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  • 2093-0569(eISSN)
대한통증학회 (The Korean Pain Society)
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Radiation safety for pain physicians: principles and recommendations

  • Park, Sewon (Department of Anesthesiology and Pain Medicine, Konkuk University School of Medicine) ;
  • Kim, Minjung (Department of Anesthesiology and Pain Medicine, Konkuk University School of Medicine) ;
  • Kim, Jae Hun (Department of Anesthesiology and Pain Medicine, Konkuk University School of Medicine)
  • 투고 : 2021.11.23
  • 심사 : 2022.02.13
  • 발행 : 2022.04.01
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초록

C-arm fluoroscopy is a useful tool for interventional pain management. However, with the increasing use of C-arm fluoroscopy, the risk of accumulated radiation exposure is a significant concern for pain physicians. Therefore, efforts are needed to reduce radiation exposure. There are three types of radiation exposure sources: (1) the primary X-ray beam, (2) scattered radiation, and (3) leakage from the X-ray tube. The major radiation exposure risk for most medical staff members is scattered radiation, the amount of which is affected by many factors. Pain physicians can reduce their radiation exposure by use of several effective methods, which utilize the following main principles: reducing the exposure time, increasing the distance from the radiation source, and radiation shielding. Some methods reduce not only the pain physician's but also the patient's radiation exposure. Taking images with collimation and minimal use of magnification are ways to reduce the intensity of the primary X-ray beam and the amount of scattered radiation. It is also important to carefully select the C-arm fluoroscopy mode, such as pulsed mode or low-dose mode, for ensuring the physician's and patient's radiation safety. Pain physicians should practice these principles and also be aware of the annual permissible radiation dose as well as checking their radiation exposure. This article aimed to review the literature on radiation safety in relation to C-arm fluoroscopy and provide recommendations to pain physicians during C-arm fluoroscopy-guided interventional pain management.

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참고문헌

  1. Tapio S, Little MP, Kaiser JC, Impens N, Hamada N, Georgakilas AG, et al. Ionizing radiation-induced circulatory and metabolic diseases. Environ Int 2021; 146: 106235. https://doi.org/10.1016/j.envint.2020.106235
  2. Paulo G, Bartal G, Vano E. Radiation dose of patients in fluoroscopically guided interventions: an update. Cardiovasc Intervent Radiol 2021; 44: 842-8. https://doi.org/10.1007/s00270-020-02667-3
  3. Vera GV, Aleksandra F, Dragan K, Andrija H. Assessment of genome damage in occupational exposure to ionising radiation and ultrasound. Mutat Res 1997; 395: 101-5. https://doi.org/10.1016/S1383-5718(97)00149-6
  4. Maffei F, Angelini S, Forti GC, Violante FS, Lodi V, Mattioli S, et al. Spectrum of chromosomal aberrations in peripheral lymphocytes of hospital workers occupationally exposed to low doses of ionizing radiation. Mutat Res 2004; 547: 91-9. https://doi.org/10.1016/j.mrfmmm.2003.12.003
  5. Milacic S. Risk of occupational radiation-induced cataract in medical workers. Med Lav 2009; 100: 178-86.
  6. Mastrangelo G, Fedeli U, Fadda E, Giovanazzi A, Scoizzato L, Saia B. Increased cancer risk among surgeons in an orthopaedic hospital. Occup Med (Lond) 2005; 55: 498-500. https://doi.org/10.1093/occmed/kqi048
  7. Roguin A, Goldstein J, Bar O, Goldstein JA. Brain and neck tumors among physicians performing interventional procedures. Am J Cardiol 2013; 111: 1368-72. https://doi.org/10.1016/j.amjcard.2012.12.060
  8. Chartier H, Fassier P, Leuraud K, Jacob S, Baudin C, Laurier D, et al. Occupational low-dose irradiation and cancer risk among medical radiation workers. Occup Med (Lond) 2020; 70: 476-84. https://doi.org/10.1093/occmed/kqaa130
  9. Schueler BA. Operator shielding: how and why. Tech Vasc Interv Radiol 2010; 13: 167-71. https://doi.org/10.1053/j.tvir.2010.03.005
  10. Dagal A. Radiation safety for anesthesiologists. Curr Opin Anaesthesiol 2011; 24: 445-50. https://doi.org/10.1097/ACO.0b013e328347f984
  11. Cheon BK, Kim CL, Kim KR, Kang MH, Lim JA, Woo NS, et al. Radiation safety: a focus on lead aprons and thyroid shields in interventional pain management. Korean J Pain 2018; 31: 244-52. https://doi.org/10.3344/kjp.2018.31.4.244
  12. Valentin J. Avoidance of radiation injuries from medical interventional procedures. Ann ICRP 2000; 30: 7-67.
  13. Vano E, Gonzalez L, Fernandez JM, Prieto C, Guibelalde E. Influence of patient thickness and operation modes on occupational and patient radiation doses in interventional cardiology. Radiat Prot Dosimetry 2006; 118: 325-30. https://doi.org/10.1093/rpd/nci369
  14. Manchikanti L, Cash KA, Moss TL, Pampati V. Radiation exposure to the physician in interventional pain management. Pain Physician 2002; 5: 385-93. Erratum in: Pain Physician 2003; 6: 141.
  15. Madder RD, VanOosterhout S, Mulder A, Ten Brock T, Clarey AT, Parker JL, et al. Patient body mass index and physician radiation dose during coronary angiography. Circ Cardiovasc Interv 2019; 12: e006823. https://doi.org/10.1161/CIRCINTERVENTIONS.118.006823
  16. Chang YJ, Kim AN, Oh IS, Woo NS, Kim HK, Kim JH. The radiation exposure of radiographer related to the location in Carm fluoroscopy-guided pain interventions. Korean J Pain 2014; 27: 162-7. https://doi.org/10.3344/kjp.2014.27.2.162
  17. Fink GE. Radiation safety in fluoroscopy for neuraxial injections. AANA J 2009; 77: 265-9.
  18. Peled A, Moshe S, Chodick G. [Ionizing radiation and the risk for cataract and lens opacities]. Harefuah 2018; 157: 650-4. Hebrew.
  19. Albi E, Cataldi S, Lazzarini A, Codini M, Beccari T, AmbesiImpiombato FS, et al. Radiation and thyroid cancer. Int J Mol Sci 2017; 18: 911. https://doi.org/10.3390/ijms18050911
  20. National Council on Radiation Protection and Measurements. Limitation of exposure to ionizing radiation: recommendations of the National Council on Radiation Protection and Measurements. Bethesda, National Council on Radiation Protection and Measurements. 1993, pp 1-86.
  21. Hamada N, Fujimichi Y. Role of carcinogenesis related mechanisms in cataractogenesis and its implications for ionizing radiation cataractogenesis. Cancer Lett 2015; 368: 262-74. https://doi.org/10.1016/j.canlet.2015.02.017
  22. Authors on behalf of ICRP, Stewart FA, Akleyev AV, Hauer-Jensen M, Hendry JH, Kleiman NJ, et al. ICRP publication 118: ICRP statement on tissue reactions and early and late effects of radiation in normal tissues and organs--threshold doses for tissue reactions in a radiation protection context. Ann ICRP 2012; 41: 1-322.
  23. Dauer LT, Ainsbury EA, Dynlacht J, Hoel D, Klein BEK, Mayer D, et al. Guidance on radiation dose limits for the lens of the eye: overview of the recommendations in NCRP Commentary No. 26. Int J Radiat Biol 2017; 93: 1015-23. https://doi.org/10.1080/09553002.2017.1304669
  24. Kim MJ, Kim JH. Radiation exposure and protection for eyes in pain management. Anesth Pain Med 2017; 12: 297-305. https://doi.org/10.17085/apm.2017.12.4.297
  25. Choi EJ, Go G, Han WK, Lee PB. Radiation exposure to the eyes and thyroid during C-arm fluoroscopy-guided cervical epidural injections is far below the safety limit. Korean J Pain 2020; 33: 73-80. https://doi.org/10.3344/kjp.2020.33.1.73
  26. National Council on Radiation Protection and Measurements. Management of exposure to ionizing radiation: radiation protection guidance for the United States. Bethesda (MD): National Council on Radiation Protection and Measurements; 2018. Report No.: 180.
  27. Rivett C, Dixon M, Matthews L, Rowles N. An assessment of the dose reduction of commercially available lead protective glasses for interventional radiology staff. Radiat Prot Dosimetry 2016; 172: 443-52. https://doi.org/10.1093/rpd/ncv540
  28. Magee JS, Martin CJ, Sandblom V, Carter MJ, Almen A, Cederblad A, et al. Derivation and application of dose reduction factors for protective eyewear worn in interventional radiology and cardiology. J Radiol Prot 2014; 34: 811-23. https://doi.org/10.1088/0952-4746/34/4/811
  29. Miller DL, Vano E, Bartal G, Balter S, Dixon R, Padovani R, et al. Occupational radiation protection in interventional radiology: a joint guideline of the Cardiovascular and Interventional Radiology Society of Europe and the Society of Interventional Radiology. Cardiovasc Intervent Radiol 2010; 33: 230-9. https://doi.org/10.1007/s00270-009-9756-7
  30. Kuipers G, Velders XL, de Winter RJ, Reekers JA, Piek JJ. Evaluation of the occupational doses of interventional radiologists. Cardiovasc Intervent Radiol 2008; 31: 483-9. https://doi.org/10.1007/s00270-008-9307-7
  31. Wang RR, Kumar AH, Tanaka P, Macario A. Occupational Radiation exposure of anesthesia providers: a summary of key learning points and resident-led radiation safety projects. Semin Cardiothorac Vasc Anesth 2017; 21: 165-71. https://doi.org/10.1177/1089253217692110
  32. Bryant PA, Croft J, Cole P. Integration of risks from multiple hazards into a holistic ALARA/ALARP demonstration. J Radiol Prot 2018; 38: 81-91. https://doi.org/10.1088/1361-6498/aa8e53
  33. Kim JH. Three principles for radiation safety: time, distance, and shielding. Korean J Pain 2018; 31: 145-6. https://doi.org/10.3344/kjp.2018.31.3.145
  34. Shuler FD, Daigre JL, Pham D, Kish VL. Laser targeting with C-arm fluoroscopy: effect on image acquisition and radiation exposure. J Orthop Trauma 2013; 27: e97-102. https://doi.org/10.1097/BOT.0b013e31826625df
  35. Kim AN, Chang YJ, Cheon BK, Kim JH. How effective are radiation reducing gloves in C-arm fluoroscopy-guided pain interventions? Korean J Pain 2014; 27: 145-51. https://doi.org/10.3344/kjp.2014.27.2.145
  36. Jung CH, Ryu JS, Baek SW, Oh JH, Woo NS, Kim HK, et al. Radiation exposure of the hand and chest during C-arm fluoroscopy-guided procedures. Korean J Pain 2013; 26: 51-6. https://doi.org/10.3344/kjp.2013.26.1.51
  37. Livingstone RS, Varghese A. A simple quality control tool for assessing integrity of lead equivalent aprons. Indian J Radiol Imaging 2018; 28: 258-62. https://doi.org/10.4103/ijri.ijri_374_17
  38. Fakhoury E, Provencher JA, Subramaniam R, Finlay DJ. Not all lightweight lead aprons and thyroid shields are alike. J Vasc Surg 2019; 70: 246-50. https://doi.org/10.1016/j.jvs.2018.07.055
  39. Singer G. Occupational radiation exposure to the surgeon. J Am Acad Orthop Surg 2005; 13: 69-76. https://doi.org/10.5435/00124635-200501000-00009
  40. Hong SW, Kim TW, Kim JH. Radiation exposure to the back with different types of aprons. Radiat Prot Dosimetry 2021; 193: 185-9. https://doi.org/10.1093/rpd/ncab044
  41. Livingstone RS, Varghese A, Keshava SN. A study on the use of radiation-protective apron among interventionists in radiology. J Clin Imaging Sci 2018; 8: 34. https://doi.org/10.4103/jcis.jcis_34_18
  42. Chou LB, Cox CA, Tung JJ, Harris AH, Brooks-Terrell D, Sieh W. Prevalence of cancer in female orthopaedic surgeons in the United States. J Bone Joint Surg Am 2010; 92: 240-4.
  43. Muller LP, Suffner J, Wenda K, Mohr W, Rommens PM. Radiation exposure to the hands and the thyroid of the surgeon during intramedullary nailing. Injury 1998; 29: 461-8. https://doi.org/10.1016/S0020-1383(98)00088-6
  44. Lee SY, Min E, Bae J, Chung CY, Lee KM, Kwon SS, et al. Types and arrangement of thyroid shields to reduce exposure of surgeons to ionizing radiation during intraoperative use of C-arm fluoroscopy. Spine (Phila Pa 1976) 2013; 38: 2108-12. https://doi.org/10.1097/BRS.0b013e3182a8270d
  45. Wagner LK, Mulhern OR. Radiation-attenuating surgical gloves: effects of scatter and secondary electron production. Radiology 1996; 200: 45-8. https://doi.org/10.1148/radiology.200.1.8657942
  46. Cousin AJ, Lawdahl RB, Chakraborty DP, Koehler RE. The case for radioprotective eyewear/facewear. Practical implications and suggestions. Invest Radiol 1987; 22: 688-92. https://doi.org/10.1097/00004424-198708000-00012
  47. Kirkwood ML, Klein A, Guild J, Arbique G, Xi Y, Tsai S, et al. Novel modification to leaded eyewear results in significant operator eye radiation dose reduction. J Vasc Surg 2020; 72: 2139-44. https://doi.org/10.1016/j.jvs.2020.02.049
  48. Koukorava C, Farah J, Struelens L, Clairand I, Donadille L, Vanhavere F, et al. Efficiency of radiation protection equipment in interventional radiology: a systematic Monte Carlo study of eye lens and whole body doses. J Radiol Prot 2014; 34: 509-28. https://doi.org/10.1088/0952-4746/34/3/509
  49. Lian Y, Xiao J, Ji X, Guan S, Ge H, Li F, et al. Protracted lowdose radiation exposure and cataract in a cohort of Chinese industry radiographers. Occup Environ Med 2015; 72: 640-7. https://doi.org/10.1136/oemed-2014-102772
  50. Maina PM, Motto JA, Hazell LJ. Investigation of radiation protection and safety measures in Rwandan public hospitals: readiness for the implementation of the new regulations. J Med Imaging Radiat Sci 2020; 51: 629-38. https://doi.org/10.1016/j.jmir.2020.07.056
  51. Ryu JS, Baek SW, Jung CH, Cho SJ, Jung EG, Kim HK, et al. The survey about the degree of damage of radiation-protective shields in operation room. Korean J Pain 2013; 26: 142-7. https://doi.org/10.3344/kjp.2013.26.2.142
  52. Christodoulou EG, Goodsitt MM, Larson SC, Darner KL, Satti J, Chan HP. Evaluation of the transmitted exposure through lead equivalent aprons used in a radiology department, including the contribution from backscatter. Med Phys 2003; 30: 1033-8. https://doi.org/10.1118/1.1573207
  53. Brown PH, Thomas RD, Silberberg PJ, Johnson LM. Optimization of a fluoroscope to reduce radiation exposure in pediatric imaging. Pediatr Radiol 2000; 30: 229-35. https://doi.org/10.1007/s002470050728
  54. Cho JH, Kim JY, Kang JE, Park PE, Kim JH, Lim JA, et al. A study to compare the radiation absorbed dose of the C-arm fluoroscopic modes. Korean J Pain 2011; 24: 199-204. https://doi.org/10.3344/kjp.2011.24.4.199
  55. Aufrichtig R, Xue P, Thomas CW, Gilmore GC, Wilson DL. Perceptual comparison of pulsed and continuous fluoroscopy. Med Phys 1994; 21: 245-56. https://doi.org/10.1118/1.597285
  56. Baek SW, Ryu JS, Jung CH, Lee JH, Kwon WK, Woo NS, et al. A randomized controlled trial about the levels of radiation exposure depends on the use of collimation C-arm fluoroscopic-guided medial branch block. Korean J Pain 2013; 26: 148-53. https://doi.org/10.3344/kjp.2013.26.2.148
  57. Mahesh M. Fluoroscopy: patient radiation exposure issues. Radiographics 2001; 21: 1033-45. https://doi.org/10.1148/radiographics.21.4.g01jl271033
  58. Kim TH, Hong SW, Woo NS, Kim HK, Kim JH. The radiation safety education and the pain physicians' efforts to reduce radiation exposure. Korean J Pain 2017; 30: 104-15. https://doi.org/10.3344/kjp.2017.30.2.104