iaea international atomic energy agency radiation protection in paediatric radiology standards and...

IAEAInternational Atomic Energy

Agency

Radiation Protection in Paediatric Radiation Protection in Paediatric RadiologyRadiology

Standards and Guidelines in Standards and Guidelines in Radiological Procedures in Radiological Procedures in

Children Children

L08L08

IAEA 2Radiation Protection in Paediatric Radiology L08. Standards and guidelines

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


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.


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


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


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


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/


ICRP

• ICRP: International Commission on Radiological Protection•Provides

recommendations and guidance on all aspects of protection against ionizing radiation

http://www.icrp.org/


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/


International framework for radiation protection


IAEA

SafetyGuides

SafetyPractices

TECDOCs

TechnicalReports

SafetyFundamentals and Standards


“…marks the culmination of efforts that have continued over the past

several decades towards the

harmonization of radiation protection and safety standards internationally”

International Basic Safety Standard (BSS)


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)


SupervisorMedical Practitioner

Worker

Responsibilities

• Principal responsibility for radiation protection•Legal person subject of authorization

(licensee) and employer

• Subsidiary responsibilities

Radiologists


Advice of a qualified expert, medical physicist

Radiologist

Patient Protectio

n

Responsibilities

Training criteria

OptimizationEquipment

design and suppliers

Quality assurance

BSS

Justification


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


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)


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


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


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;


Optimization

• Once justified, examinations must be optimised:

•Generic: for examination type and equipment and procedures involved

•Specific: for the individual patients


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


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)


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)


Unintended exposure

• Unintended exposures of patients arise from failures in justification, failures in optimisation or errors


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


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


Occupational

Protection

Responsibilities

Personal protective

devices

Individual exposure

monitoring

BSS

Pregnant workers

Workplace monitoring

Health surveillanc

e


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

ICRP 103


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


http://europa.eu.int/comm/environment/

radprot

http://rpop.iaea.org/RPOP/RPoP/Content/AdditionalResources/Training/1_TrainingMaterial/index.htm


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/fp5-euratom/src/lib_docs.htm

Applying standards in practice


EUR 16261 EN


Quality Criteria List


Example:MCU


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


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 non-cooperative 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)


http://rpop.iaea.org/RPOP/RPoP/Content/InformationFor/HealthProfessionals/1_Radiology/Standards.htm


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



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.



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.


References

• 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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