Safety is of key importance with radiation emitting devices
TIPS AND SUGGESTIONS
Image Intensifier - UP or DOWN?
There are two principle means for fluoroscopy:
- Standard technique is x-ray tube down and image intensifier at top
- Inverted technique is image intensifier under table, or used as a table, and the x-ray tube is up
DOES INVERTED TECHNIQUE REDUCE RADIATION?
Some studies have shown that the Inverted technique significantly reduced radiation to both the surgeon and patient. The dose rate to patient was reduced by 59% in the study while the exposure to surgeon’s head was 67% of the measured dose with the standard technique. Similarly exposure to the surgeon’s body was 45% and groin was 15% of the measures dose with the standard technique. When magnification mode of the image intensifier was used, the doses were reduced to 46%, 32% and 11% of the standard configuration values.
SAFETY IS IMPORTANT ALWAYS
It is essential to remember the importance of radiation safety. From how you use the C-Arm to how you protect yourself, your staff and your patients, there have been a number of studies done with regard to safety. Many theories abound and there is little consensus nor a definitive study on the issue. As a user of a radiation-emitting device, the onus falls on you to protect yourself, your staff and your patients.
So, Is Fluoroscopy Really Safe?
YES - BUT ONLY IF the surgeon and staff follow certain steps, e.g.,
RADIATION SAFETY SUGGESTIONS
For the User/Practitioner/Surgeon
For the Patient
- Use the fastest combination possible to obtain pictures
- Collimate the primary beam to include only the area of interest
- Use a reasonable film-focal distance
- Avoid repeat exposures
For the Public
- While the beam scatter is minimal on a C-Arm, check local regulations to determine shielding requirements for the treatment room
- Warning lights should be placed outside the procedure room to signal preparation and exposure
- Radiation warning signs should be present on doors leading to the procedure room
- People under 16 and pregnant women should not be allowed to assist in procedures.
A WORD ABOUT ROOM SHIELDING
Safety from radiation is of utmost concern for every facility, state, physician and patient. When it comes to shielding for a room where the C-Arm will be utilized, the typical answer is that shielding is not required and the beam limiting design of the system reduces scatter. However, some states and federal authorities may require it. It is always best to contact your state department of radiation safety to be certain that you are in compliance. NOTE WELL: this is true of every state, you must have a physicist inspect and check the calibration of the unit prior to using it on patients.
CDC Recommendations
Recent investigations undertaken by state and local health departments and the Centers for Disease Control and Prevention (CDC) have identified improper use of syringes, needles, and medication vials during routine healthcare procedures, such as administering injections. These practices have resulted in one or more of the following:
- Transmission of bloodborne viruses, including hepatitis C virus to patients
- Notification of thousands of patients of possible exposure to bloodborne pathogens and recommendation that they be tested for HCV, HBV, and HIV
- Referral of providers to licensing boards for disciplinary action
- Malpractice suits filed by patients
These unfortunate events serve as a reminder of the serious consequences of failure to maintain strict adherence to safe injection practices during patient care. Injection safety and other basic infection control practices are central to patient safety. All healthcare providers are urged to carefully review their infection control practices and the practices of all staff under their supervision. In particular, providers should ensure that staff:
- Never administer medications from the same syringe to more than one patient, even if the needle is changed
- Do not enter a vial with a used syringe or needle
Hepatitis C virus, hepatitis B virus, and HIV can be spread from patient to patient when these simple precautions are not followed. Additional protection is offered when medication vials can be dedicated to a single patient. It is important that:
- Medications packaged as single-use vials never be used for more than one patient
- Medications packaged as multi-use vials be assigned to a single patient whenever possible
- Bags or bottles of intravenous solution not be used as a common source of supply for more than one patient
- Absolute adherence to proper infection control practices be maintained during the preparation and administration of injected medications
In 2004, CDC investigated eight cases of post-myelography meningitis that either were reported to CDC or identified through a survey of the Emerging Infections Network of the Infectious Disease Society of America. Blood and/or cerebrospinal fluid of all eight cases yielded streptococcal species consistent with oropharyngeal flora and there were changes in the CSF indices and clinical status indicative of bacterial meningitis. Equipment and products used during these procedures (e.g., contrast media) were excluded as probable sources of contamination. Procedural details available for seven cases determined that antiseptic skin preparations and sterile gloves had been used. However, none of the clinicians wore a face mask, giving rise to the speculation that droplet transmission of oralpharyngeal flora was the most likely explanation for these infections. Bacterial meningitis following myelogram and other spinal procedures (e.g., lumbar puncture, spinal and epidural anesthesia, intrathecal chemotherapy) has been reported previously 906-915. As a result, the question of whether face masks should be worn to prevent droplet spread of oral flora during spinal procedures (e.g., myelogram, lumbar puncture, spinal anesthesia) has been debated 916, 917. Face masks are effective in limiting the dispersal of oropharyngeal droplets 918 and are recommended for the placement of central venous catheters 919. In October 2005, the Healthcare Infection Control Practices Advisory Committee (HICPAC) reviewed the evidence and concluded that there is sufficient experience to warrant the additional protection of a face mask for the individual placing a catheter or injecting material into the spinal or epidural space.
Recommendations
IV.H. Safe injection practices The following recommendations apply to the use of needles, cannulas that replace needles, and, where applicable intravenous delivery systems
IV.H.1. Use aseptic technique to avoid contamination of sterile injection equipment 1002, 1003. Category IA
IV.H.2. Do not administer medications from a syringe to multiple patients, even if the needle or cannula on the syringe is changed. Needles, cannulae and syringes are sterile, single-use items; they should not be reused for another patient nor to access a medication or solution that might be used for a subsequent patient 453, 919, 1004, 1005. Category IA
IV.H.3. Use fluid infusion and administration sets (i.e., intravenous bags, tubing and connectors) for one patient only and dispose appropriately after use. Consider a syringe or needle/cannula contaminated once it has been used to enter or connect to a patient's intravenous infusion bag or administration set 453. Category IB
IV.H.4. Use single-dose vials for parenteral medications whenever possible 453. Category IA
IV.H.5. Do not administer medications from single-dose vials or ampules to multiple patients or combine leftover contents for later use 369 453, 1005. Category IA
IV.H.6. If multidose vials must be used, both the needle or cannula and syringe used to access the multidose vial must be sterile 453, 1002. Category IA
IV.H.7. Do not keep multidose vials in the immediate patient treatment area and store in accordance with the manufacturer's recommendations; discard if sterility is compromised or questionable 453, 1003. Category IA
IV.H.8. Do not use bags or bottles of intravenous solution as a common source of supply for multiple patients 453, 1006. Category IB
IV.I. Infection control practices for special lumbar puncture procedures Wear a surgical mask when placing a catheter or injecting material into the spinal canal or subdural space (i.e., during myelograms, lumbar puncture and spinal or epidural anesthesia 906 907-909 910, 911 912-914, 918 1007. Category IB
