Update Course Rewind: Intraoperative Radiation Safety 2022

Radiation exposure in medicine is prevalent. And while minor exposure may not have an effect, the accumulation of radiation exposure from medicalized children and healthcare professionals can lead to a large lifetime dose of excess radiation. That's why we've brought an update course rewind from 2022, where Dr. Mary Edwards discusses the importance of radiation safety in the operating room. Now you're in the operating room. You're putting in a meta port in a one-year-old for chemotherapy. You get the port in, everything goes well. You take out the introducer sheath though, and the tip of the catheter is in the cardiac silhouette and you just are having a really hard time seeing exactly where it is. To aid visualization while minimizing radiation to the patient and the staff in the room, what should you do? And we pulled the audience and the majority said D, to collimate the beam. So minimizing exposure of children to ionizing radiation should be standard, but you have to get an adequate image. You want to minimize exposure not only to the patients, but also to yourself and the rest of the OR team. Best practice guidelines for fluoroscopy, which at least in the United States is not routinely taught to surgeons, includes positioning the patient as close as possible to the image intensifier or the flat plate detector, which usually means in a standard configuration of the C-arm, raising the bed as far as possible close to that II. Of course, we want to shield appropriately, but you also want to use pulse mode. This is a feasible option in most pediatric surgery applications. Colimation is key and you want to avoid use of mag if at all possible. When Every time you hit the mag setting on the fluoro machine, it significantly increases the radiation dose, not only to the patient, but also to the room. Colimation focuses the x-ray beam to a specific area, which increases the image detail and its clarity. But because it limits the field, it decreases the total dose of the patient because the surface area getting irradiated is smaller and it also decreases the dose to the room. These are two esophagrams that I did and hopefully you can appreciate that the one where colimation was used, it's just much more clear. You can see the mucosal detail of the esophagus better. In small patients, you want to be careful when you collimate, so you don't overexpose the images. But when used appropriately, the outcome is a more detailed image with less radiation. For me, there were two modes of fluoroscopy on or off. I didn't know there all these other things. So Mary, do we just tell the technician, can you help me collimate? I just tell the tech, collimate down on the mediastinum. Um, and they can collimate down in a uniform circle, they can collimate down in a stripe and it's the same with pulse mode. I just tell them four frames a second, two frames a second, and they know how to do it. Maybe that's what we work on is having better communication and proactive suggestions by the technicians. All right, next patient. So, the next question is kind of similar. A nine-year-old girl is undergoing an elective choledocal cyst resection and you plan to start with an intraoperative colangigram. In order to obtain the best image with the least radiation exposure to the patient and the room, you plan to do all of the following except. Again, we pulled the audience and for this question, 35% of the audience said D, collimate the beam. You need to appreciate that by convention, the x-ray source in the C-arm is placed below the table. It doesn't have to be that way, but the tech is always going to put it that way because the patient in the table protects you and everyone else in the room from the radiation. But if you put a drape on top of a patient, you're doing absolutely nothing to protect them from radiation because it's coming from below the table. Now, the other thing you need to understand is the way these machines work is they utilize this thing called automatic brightness control. So basically, if there's something in the field blocking the beam from reaching the image intensifier, the computer automatically tells the x-ray source to increase the energy. So if that shield is in the field, you're actually increasing exposure to the patient. So if you're going to shield, you need to put those drapes below the patient. The texts know this, but the texts don't come in the room until all the drapes are on and they don't know where the shields are. So it is a commonly made mistake and it's a bad mistake. If you put the shielding below the patient, does that mean you keep the shielding there throughout the case and the patient's lying on the shielding and does that cause problems with sores and pressure issues and whatnot? So you can put the shielding underneath the gel pad or whatever it is that you have. The other thing that you need to remember is a good colimation is your friend here too. What I'm hearing you say is that it's not that we should be shielding underneath the patient, but that we should be doing all those other things that you were talking about because I think shielding underneath the patient is probably problematic for a lot of reasons, including the increased potential for increased exposure if you're not getting the right image. The only time I really make it a point to shield is if the patient's pregnant. Again, that's just my practice. This is one of those things that I do nothing about, so this was huge for me. Awesome. Thanks for joining Dr. Edwards along with the rest of the Abs of Professional Development Committee for this update course rewind. Remember to check out the stay current app for more content related to pediatric surgery and more.