IAEA Training Material on Radiation Protection in Nuclear Medicine
Part 6
Medical Exposure
Protection of the Patient
Objective
To become familiar with the BSS detailed
requirement for medical exposure in nuclear
medicine: responsibilities, justification,
optimization, guidance level, dose constraints
accidental exposure and medical records
Nuclear Medicine
Part 6. Medical Exposure
2
Contents









Introduction
Responsibilities
Justification
Optimization of examination
Guidance levels of activity
Dose constraints
Examination of children, pregnant women and
lactating women
Records
Local rules
Nuclear Medicine
Part 6. Medical Exposure
3
IAEA Training Material on Radiation Protection in Nuclear Medicine
Part 6. Medical Exposure
Protection of the Patient
Module 6.1. Introduction
Medical Exposure
(Definition)
“Exposure incurred by patients as part of their own medical or
dental diagnosis or treatment; by persons, other than those
occupationally exposed, knowingly while voluntarily helping in
the support and comfort of patients; and by volunteers in a
programme of biomedical research involving their exposure.”
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Part 6. Medical Exposure
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Nuclear Medicine
Part 6. Medical Exposure
6
Nuclear Medicine
Part 6. Medical Exposure
7
Protection from What?



Unnecessary examination or treatment
(justification)
Unnecessary exposure (optimization)
Inadequate examinations, which can lead to
incorrect or incomplete diagnosis
(optimization)
Nuclear Medicine
Part 6. Medical Exposure
8

Nuclear Medicine
Mr. Sharp, I am given
to understand that 2
bone scans and a
cardiac study done
on me have given me
22 mSv whereas 20
mSv is the safe dose.
I want to file legal
suit against the
doctor. What do you
feel??
Part 6. Medical Exposure
9
Medical Exposure
versus
Occupational
Nuclear Medicine
Part 6. Medical Exposure
10
My resident doctor
has got 12 mSv in
her last badge
report as she was
wearing the badge
while getting her
barium study. She
wants off from
radiation work.
?????
Nuclear Medicine
Part 6. Medical Exposure
11
Medical Exposure
versus
Occupational Exposure
Nuclear Medicine
Part 6. Medical Exposure
12
While caring for his
spouse Mr. Joseph
got 2 mSv.
As a member of the
public with 1 mSv
dose limit, he can not
get any radiation
dose this year.
???????
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Part 6. Medical Exposure
13
Medical Exposure
(BSS: Interim Edition)
• Responsibilities
• Justification of medical exposure
• Optimization of protection for medical exposure
• Guidance levels
• Dose constraints
• Maximum activity for patients in therapy on
discharge from hospital
• Investigation of accidental medical exposures
• Records
Nuclear Medicine
Part 6. Medical Exposure
14
IAEA Training Material on Radiation Protection in Nuclear Medicine
Part 6. Medical Exposure
Protection of the Patient
Module 6.2. Responsibilities
Responsibilities: BSS (2011)
“3.149. The regulatory body shall ensure that the authorization for
medical exposures to be performed at a particular medical radiation
facility allows personnel (radiological medical practitioners, medical
physicists, medical radiation technologists and any other health
professionals with specific duties in relation to the radiation
protection of patients) to take on the responsibilities specified in
these Standards only if they:
(a) are specialized in the appropriate area;
(b) meet the respective requirements for education, training
and competence in radiation protection,
(c) are named in a list maintained up to date by the registrant
or licensee.”
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Part 6. Medical Exposure
16
Responsibilities: BSS (2011) contd.
“3.150. Registrants and licensees shall ensure that no
patient, whether symptomatic or asymptomatic, undergoes
a medical exposure unless:
(a) The radiological procedure has been requested by a referring medical
practitioner and information on the clinical context has been provided,
or it is part of an approved health screening programme;
(b) The medical exposure has been justified through consultation
between the radiological medical practitioner and the referring medical
practitioner, as appropriate, or it is part of an approved health screening
programme;
(c) A radiological medical practitioner has assumed responsibility for
protection and safety in the planning and delivery of the medical exposure;
(d) The patient or the patient’s legal authorized representative has been
informed, as appropriate, of the expected diagnostic or therapeutic
benefits of the radiological procedure as well as the radiation risks.”
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Part 6. Medical Exposure
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Responsibilities: BSS (2011) contd.
“3.153. Registrants and licensees shall ensure that:
(a) The radiological medical practitioner performing or overseeing the
radiological procedure has assumed responsibility for ensuring overall
protection and safety for patients during the planning and delivery of the
medical exposure, including the justification of the procedure as required
in paras 3.154–3.160 and the optimization of protection and safety, in
cooperation with the medical physicist and the medical radiation
technologist as required in paras 3.161–3.176;
(b) Radiological medical practitioners, medical physicists, medical
radiation technologists and other health professionals with specific duties
in relation to protection and safety for patients in a given radiological
procedure have the appropriate specialization;
(c) Sufficient medical personnel and paramedical personnel are
available as specified by the health authority;”
. *Interim version of revised BSS
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Part 6. Medical Exposure
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Responsibilities: BSS (2011) contd.



“(d) For therapeutic uses of radiation, the requirements of these
Standards for calibration, dosimetry and quality assurance,
including the acceptance and commissioning of medical
radiological equipment, as specified in paras 3.166, 3.167(c), 3.169
and 3.170, are fulfilled by or under the supervision of a medical
physicist;
(e) For diagnostic radiological procedures and image guided
interventional procedures, the requirements of these Standards for
medical imaging, calibration, dosimetry and quality assurance,
including the acceptance and commissioning of medical
radiological equipment, as specified in paras 3.166, 3.167(a),
3.167(b), 3.168, 3.169 and 3.170, are fulfilled by or under the
supervision of or with the documented advice of a medical
physicist, whose degree of involvement is determined by the
complexity of the radiological procedures and the associated
radiation risks;
(f) Any delegation of responsibilities by a principal party is
documented.”
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Part 6. Medical Exposure
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Nuclear Medicine
Part 6. Medical Exposure
20
FACTORS AFFECTING
MEDICAL EXPOSURE
Request
Examination or treatment
Biomedical research
Patient identification
and information
Administration of
radiopharmaceutical
Child ?
Lactating woman ?
Pregnant woman ?
Safe preparation of
prescribed radiopharmaceutical and
activity
Dose constraints
Examination
Method
Quality of equipment
Correct use of
equipment
Treatment
Dose constraints
to comforters and
visitors
Accidental medical exposure
Who is responsible?
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Part 6. Medical Exposure
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RESPONSIBILITY STRUCTURE
Licensee/Hospital management
Optimization of medical exposure
through
organization and resources
Nuclear Medicine Department
Referring physician
Justification
of medical exposure
Optimization of medical exposure
through well educated personnel
with clearly defined responsibilities
NM specialist
Qualified expert
NM technologist
Nurse
Engineer
Radiopharmacist
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Part 6. Medical Exposure
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Referring Physician
Prescribe and justify diagnostic procedures
and therapy in writing in co-operation with
the nuclear medicine specialist
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Part 6. Medical Exposure
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Administrative Manager
• Appoint the necessary personnel and ensure the individuals
have the necessary education to perform their duties.
• Establish a radiation protection programme and provide the
necessary resources.
• Assign clear responsibilities for personnel.
• Appoint a Radiation Protection Officer.
• Establish a comprehensive QA programme.
• Support education and training of personnel.
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Part 6. Medical Exposure
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Nuclear Medicine Staff
Individuals with key positions, i.e., responsibilities for protection
and safety and those who could substantially affect protection and
safety by virtue of tasks involving operation or manipulation of
sources, or equipment which could lead to an accidental exposure
should have documented evidence of education and training. The
objective is to ensure that only qualified personnel fill such
positions. In nuclear medicine, these individuals are:
Nuclear medicine physicians
Qualified experts in nuclear medicine physics (medical physicists)
Other health professionals in nuclear medicine (radiopharmacists,
nuclear medicine technologists, nurses,…)
Radiation Protection Officer
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Part 6. Medical Exposure
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Personal Authorization
To obtain the personal authorization, the nuclear medicine staff
should comply with the following requirements:
 university degree or equivalent relevant to the profession by
the competent education authorities as required in the
country;
 accreditation to exercise the profession granted by the
competent authorities or institutions as required in the
country;
 course on radiation protection for which the contents, the
methodology and the teaching institution are approved by
the Regulatory Authority. This course may be integrated in
the curricula of the professional education; and
 on the job training supervised by professionals with
authorization by the Regulatory Authority.
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Part 6. Medical Exposure
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Nuclear Medicine Specialist
Ensure overall patient protection and safety;
provide consultation and clinical evaluation of patients
ensure that the exposure of patients be the
minimum required to achieve the intended objective;
take into account relevant information from previous
examinations in order to avoid unnecessary additional
examinations;
take into account the relevant guidance levels for medical
exposure;
determine dose prescription for therapy in consultation with
the medical physicist; and
provide evaluation of any radiation incident and accident
from medical point of view.
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Part 6. Medical Exposure
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Medical Physicist
 Participate in continuing review of the nuclear medicine practice’s
resources (including budget, equipment, and staffing), operations, and
policies and procedures;
 Develop requirements and specifications for the purchase of
appropriate equipment assuring radiation safety;
 Plan in conjunction with the nuclear medicine physician the facilities for
nuclear medicine practice;
 Carry out acceptance testing;
 Establish dose calculation procedures in nuclear medicine therapy;
 Establish and implement QA procedures in nuclear medicine;
 Supervise equipment maintenance;
 Investigate and evaluate incidents and accidents.
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Part 6. Medical Exposure
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Nuclear Medicine Technologist
• Patient identification;
• Patient information;
• Information to accompanying persons and staff nursing a patient after a
nuclear medicine examination or therapy;
• Verifying that the female patient is non-pregnant;
• Assure that a mother in lactation is given information about discontinuation of
nursing;
• Make the calculation of administered activity to a child according to the local
rules;
• Verify the administered radiopharmaceutical and its activity;
• Perform regular quality control of activity meter and other relevant equipment;
• Perform regular workplace monitoring;
• Correct handling of the equipment and safety accessories;
• Inform the RPO in the case of accident or incident;
• Inform the Nuclear Medicine Physician in the case of misadministrations;
• Participate in education and training of new personnel.
Nuclear Medicine
Part 6. Medical Exposure
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IAEA Training Material on Radiation Protection in Nuclear Medicine
Part 6. Medical Exposure
Protection of the Patient
Module 6.3. Justification
Justification
Although Nuclear Medicine is a justified diagnostic tool
a case-by-case justification shall be applied.
This is the responsibility of the referring physician in
co-operation with the nuclear medicine specialist and
other specialists in diagnostic imaging, taking relevant
guidelines into account.
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Part 6. Medical Exposure
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Justification :BSS (2011)
Relevant parties shall ensure that medical
exposures are justified:
“3.154. Medical exposures shall be justified by weighing the
expected diagnostic or therapeutic benefits that they yield
against the radiation detriment that they might cause, with
account taken of the benefits and the risks of available
alternative techniques that do not involve medical exposure.
3.155. Generic justification of a radiological procedure shall
be carried out by the health authority in conjunction with
appropriate professional bodies, and shall be reviewed from
time to time, with account taken of advances in knowledge
and technological developments.”
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Part 6. Medical Exposure
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Justification: BSS (2011) Contd…
“3.156. The justification of medical exposure for an individual
patient shall be carried out through consultation between the
radiological medical practitioner and the referring medical
practitioner, as appropriate, with account taken, in particular for
patients who are pregnant or breast-feeding or paediatric, of:
(a) The appropriateness of the request;
(b) The urgency of the procedure;
(c) The characteristics of the medical exposure;
(d) The characteristics of the individual patient;
(e) Relevant information from the patient’s previous
radiological procedures.
3.157. Relevant national or international referral guidelines shall be
taken into account for the justification of the medical exposure of an
individual patient in a radiological procedure.”
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Part 6. Medical Exposure
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Justification: BSS (2011) contd..
“3.158. Justification for radiological procedures to be
performed as part of a health screening programme for
asymptomatic populations shall be carried out by the health
authority in conjunction with appropriate professional
bodies.
3.159. Any radiological procedure on an asymptomatic
individual that is intended to be performed for the early
detection of disease, but not as part of an approved health
screening programme, shall require specific justification for
that individual by the radiological medical practitioner and
the referring medical practitioner, in accordance with the
guidelines of relevant professional bodies or the health
authority. As part of this process, the individual shall be
informed in advance of the expected benefits, risks and
limitations of the procedure.”
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Part 6. Medical Exposure
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Justification: BSS (2011) contd…
“ 3.160. The medical exposure of volunteers as part of a
programme of biomedical research is deemed to be not justified
unless:
 (a) It is in accordance with the provisions of the Helsinki
Declaration [20] and takes into account the guidelines
published by the Council for International Organizations of
Medical Sciences [21], together with the recommendations
of the ICRP [22];
 (b) It is subject to approval by an ethics committee (or other
institutional body that has been assigned similar functions by
the relevant authority), subject to any dose constraints that
may be specified (as required in paras 3.148(a)(ii) and
3.173), and subject to applicable national regulations and
local regulations.”
Nuclear Medicine
Part 6. Medical Exposure
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IAEA Training Material on Radiation Protection in Nuclear Medicine
Part 6. Medical Exposure
Protection of the Patient
Module 6.4. Optimization of
Examination
Otimization of
Patient Examination
Diagnostic Objective
Nuclear Medicine
Part 6. Medical Exposure
Medical Exposure
37
Optimization of Medical
Exposure in Nuclear Medicine
“3.162. For diagnostic radiological procedures and image guided
interventional procedures, the radiological medical practitioner, in
cooperation with the medical radiation technologist and the
medical physicist, and if appropriate with the radiopharmacist or
radiochemist , shall ensure that the following are used:


(a) Appropriate medical radiological equipment and software and
also, for nuclear medicine, appropriate radiopharmaceuticals;
(b) Appropriate techniques and parameters to deliver a medical
exposure of the patient that is the minimum necessary to fulfil the
clinical purpose of the procedure, with account taken of relevant
norms of acceptable image quality established by relevant
professional bodies and relevant diagnostic reference levels
established in accordance with paras 3.147 and 3.168.”
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Part 6. Medical Exposure
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Optimization contd...
“3.163. For therapeutic radiological procedures, the radiological
medical practitioner, in cooperation with the medical physicist
and the medical radiation technologist, shall ensure that for each
patient the exposure of volumes other than the planning target
volume is kept as low as reasonably achievable consistent with
delivery of the prescribed dose to the planning target volume
within the required tolerances.
3.164. For therapeutic radiological procedures in which
radiopharmaceuticals are administered, the radiological medical
practitioner, in cooperation with the medical physicist and the
medical radiation technologist, and if appropriate with the
radiopharmacist or radiochemist, shall ensure that for each
patient the appropriate radiopharmaceutical with the appropriate
activity is selected and administered so that the radioactivity is
primarily localized in the organ(s) of interest, while the
radioactivity in the rest of the body is kept as low as reasonably
achievable.”
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Part 6. Medical Exposure
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Optimization contd...
“3.165. Registrants and licensees shall ensure that the particular
aspects of medical exposures are considered in the optimization
process for:






(a) Paediatric patients subject to medical exposure;
(b) Individuals subject to medical exposure as part of a health
screening programme;
(c) Volunteers subject to medical exposure as part of a programme
of biomedical research;
(d) Relatively high doses to the patient;
(e) Exposure of the embryo or fetus, in particular for radiological
procedures in which the abdomen or pelvis of the pregnant woman
is exposed to the useful radiation beam or could otherwise receive
a significant dose;
(f) Exposure of a breast-fed infant as a result of a female patient
undergoing a radiological procedure with radiopharmaceuticals.
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Part 6. Medical Exposure
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Optimization of Medical Exposure
Radionuclide
Biokinetics
Patient
Administered
activity
Nuclear Medicine
Effective
dose
Quality of
equipment etc
Radiation risk
Image quality
Part 6. Medical Exposure
41
Radiopharmaceuticals
Considering that, according to the BSS, the activities listed
below also require authorization, regulatory authorities may
require the licensee of a nuclear medicine practice to
contract any of the following services only to enterprises
authorized by the Regulatory Authority:
 production, import, distribution, sale or transfer of
radioactive sources
 personal monitoring
 installation, maintenance of nuclear medicine
equipment
 disposal of radioactive sources
Use only radiopharmaceuticals from an authorized
manufacturer!
Nuclear Medicine
Part 6. Medical Exposure
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Radiopharmaceuticals
If more than one radiopharmaceutical can be used for a
procedure consideration should be given to physical,
chemical and biological properties.
Example:
Leucocytes labelled with
In-111
0.36 mSv/MBq
20 MBq  7.2 mSv
T1/2 = 2.8 days
Nuclear Medicine
Tc-99m
0.011 mSv/MBq
200 MBq  2.2 mSv
T1/2 = 6 hours
Part 6. Medical Exposure
43
Radiopharmaceuticals
Tl-201
25 mSv
Nuclear Medicine
Tc-99m
8 mSv
Part 6. Medical Exposure
44
Optimization of Image Quality
Image quality depends on:



Administered activity
Technical factors - equipment used
- acquisition protocol
- image processing & evaluation
- noise
- spatial resolution
- scatter
Patient factors
- size
- age
- disease
- movement
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Part 6. Medical Exposure
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Optimization of Administered
Activity
In general, doses should be maintained as low as reasonable
achievable but high enough to obtain the desired diagnostic
information. This means that exposures above clinically
acceptable maximum doses must be avoided as well as doses
below clinically acceptable minimum doses
Nuclear Medicine
Part 6. Medical Exposure
46
Optimization of Administered
Activity
Value of diagnostic information
There is a threshold below
which no useful information
can be expected
Above this threshold the
diagnostic quality increases
steeply with the administered
activity
Once an acceptable level has
been reached further increase
of activity will not improve
the result
Administered activity
Nuclear Medicine
Part 6. Medical Exposure
(ICRP 52)
47
Administered Activity to Children
Optimization is Necessary!
Administered activity (MBq)
120
100
80
60
40
20
0
0
4
8
12
16
20
24
Age (years)
Administered activity to children referred to DMSA scan in Swedish hospitals
Nuclear Medicine
Part 6. Medical Exposure
48
…..noting the special requirements for patients with impairment of
Organ Function
Kidney dose (mGy)
KIDNEY FUNCTION
(100 MBq Tc99m-DTPA)
50
40
30
20
10
0
1
normal
function
Nuclear Medicine
2
3
partially
obstructed
outflow
Part 6. Medical Exposure
4 obstructed
totally
outflow
49
Optimization
(ii) use of methods for blocking the uptake in
organs not under study and for accelerated
excretion when applicable;
• Blocking agents for thyroid
• Hydration and frequent
voiding of the urinary bladder
• Laxatives
• Catheterisation to empty the
bladder???
• Cholecystokinin (fatty meal)
for gallbladder emptying
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Part 6. Medical Exposure
50
Tc-99m-MAG3, Two different first voiding times, girl 7 years
Time between injection
and first void
Organ
30 min
Bladder wall (mGy/MBq)
Nuclear Medicine
2 hours
2h/30min
0,07
0,15
2,1
Gall bladder wall
0,099
0,01
1,0
Kidneys
0,0078
0,0081
1,0
Liver
0,0018
0,002
1,1
Red marrow
0,0018
0,0022
1,2
Ovaries
0,005
0,0086
1,7
Testes
0,0045
0,0082
1,8
Effective dose (mSv/MBq)
(Eleonor Westergren)
0,0062
0,011
1,8
Part 6. Medical Exposure
51
Optimization
(iii) appropriate image acquisition and processing;
Equipment used:
•Single head/dual head
camera
•Collimator used
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Part 6. Medical Exposure
52
Aquisition Protocol
Static?
Tomographic?
Dynamic?
Nuclear Medicine
Part 6. Medical Exposure
53
Acquisition Protocol
Static imaging
Dynamic imaging
Tomographic imaging
Nuclear Medicine
- matrix size
- number of counts
- projections, zoom
- matrix size
- time/frame
- number of groups
- 180o or 360o
- matrix size
- number of angles
- time/angle
Part 6. Medical Exposure
54
Image Processing & Evaluation
Static
Dynamic
Tomographic
Nuclear Medicine
- smoothing
- image filtering
- quantification
- applications programme
- regions of interest (ROI)
- time-activity curves
- application programme
- attenuation correction
- reconstruction method
- image filtering
- slices displayed
- application programme
Part 6. Medical Exposure
55
Noise



Random variations in the number of counts (N) in a pixel,
ROI or in a point in a time-activity curve
 true uptakes may not be seen
 false uptakes may occur
 uncertainty in quantitative values
Lower noise requires more administered activity or longer
acquisition times
Noise
Nuclear Medicine
100

N
SD %
Part 6. Medical Exposure
56
Noise
1000000 counts
Nuclear Medicine
Part 6. Medical Exposure
100000 counts
57
Phantom: Different number of counts
50 k
Nuclear Medicine
250 k
Part 6. Medical Exposure
1000 k
58
Thyroid Scintigraphy,
different acquisition times
1 min
2 min
4 min
8 min
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Part 6. Medical Exposure
59
The noise level versus activity levels for an adult, CBF
9
8
7
CV (%)
6
5
4
3
2
1
0
0
500
1000
1500
2000
2500
3000
3500
4000
Activity (MBq)
Eleonor Westergren
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Part 6. Medical Exposure
60
Spatial Resolution


Describes how a point source is reproduced
 small details are not seen
 uptakes seem to be lower
Improved spatial resolution can be achieved by
changing to a collimator with higher resolution
but:
 lower sensitivity requires more administered
activity or longer acquisition times
Nuclear Medicine
Part 6. Medical Exposure
61
Appropriate Image Acquisition
Close
Nuclear Medicine
15 cm
Part 6. Medical Exposure
Wrong setting
of energy window
62
Patient Factors
Size
increased scatter
spatial resolution
Age & Disease
radiopharmaceutical distribution
movement artifacts
Nuclear Medicine
Part 6. Medical Exposure
63
Image Quality
Patient Movement
Movement
Nuclear Medicine
Corrected
Part 6. Medical Exposure
64
Staff and Procedures
•Well trained staff with access to manuals
and other documentation.
• Quality control program.
• Regular maintenance of equipment
Nuclear Medicine
Part 6. Medical Exposure
65
IAEA Training Material on Radiation Protection in Nuclear Medicine
Part 6. Medical Exposure
Protection of the Patient
Module 6.5. Reference Levels of
Activity
Diagnostic Reference Levels
(BSS)
“3.168. Registrants and licensees shall ensure that:
(a) Local assessments, on the basis of the measurements required
in para. 3.167, are made at approved intervals for those
radiological procedures for which diagnostic reference levels have
been established (para. 3.147);
(b) A review is conducted to determine whether the optimization
of protection and safety for patients is adequate, or whether
corrective action is required if, for a given radiological procedure:
(i) typical doses or activities exceed the relevant diagnostic
reference level; or
(ii) typical doses or activities fall substantially below the
relevant diagnostic reference level and the exposures do not
provide useful diagnostic information or do not yield the expected
medical benefit to the patient.”
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Part 6. Medical Exposure
67
Reference Levels of Activity
Examination
Bone scan
Brain scan
CBF
Thyroid imaging
Thyroid imaging
Parathyroid
Lung perfusion
Lung ventilation
Lung ventilation
Lung ventilation
Liver & spleen
Myocardium
Myocardium
Kidneys
Kidneys
Kidneys
Tumours
Tumour
Tumour
Nuclear Medicine
Radionuclide
Chemical form
Tc-99m
Tc-99m
Tc-99m
Tc-99m
I-123
Tl-201
Tc-99m
Tc-99m
Kr-81m
Xe-133
Tc-99m
Tl-201
Tc-99m
Tc-99m
Tc-99m
I-123
Ga-67
I-123
I-131
phosphonate
pertechnetate
HMPAO
pertechnetate
iodide
chloride
MAA
aerosol
gas
gas
colloid
chloride
isonitriles
DMSA
DTPA
hippuran
citrate
MIBG
MIBG
Part 6. Medical Exposure
Guidance level
(MBq)
600
500
500
200
20
80
100
80
6000
400
80
100
600
160
350
20
300
400
20
Effective dose
(mSv)
4.8
2.7
5.5
2.6
3.4
18
1.2
0.6
0.2
0.4
0.6
23
4.2
2.5
2.2
0.3
36
7.2
4
68
Reference Levels
How to establish:
1. Elimination of outliers
2. State-of-the practice (good practice)
3. State-of-the art (optimal practice)
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Part 6. Medical Exposure
69
Distribution of Administered Activities
Log-normal distributions
Number of patients
Activity
Optimized?
Guidance level
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Part 6. Medical Exposure
70
Activity, MBq
900
Max
800
700
IAEA guidance level
600
Mean and
range of mean
(Sweden,
1995)
500
400
Optimized?
300
200
100
0
0
1
Bone scintigraphy
Nuclear Medicine
Part 6. Medical Exposure
71
IAEA Training Material on Radiation Protection in Nuclear Medicine
Part 6. Medical Exposure
Protection of the Patient
Module 6.6. Dose Constraints:
Volunteers and Comforters
Dose Constraints
“3.151. Registrants and licensees shall ensure that
no individual incurs a medical exposure as part of a
programme of biomedical research unless the
exposure has been approved by an ethics
committee (or other institutional body that has been
assigned similar functions by the relevant authority)
as required in para. 3.160 and a radiological medical
practitioner has assumed responsibility as specified
in para. 3.153(a). Registrants and licensees shall
ensure that the requirements specified in para. 3.173
are met for the optimization of protection and safety
for persons subject to exposure as part of a
programme of biomedical research.”
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Part 6. Medical Exposure
73
Biomedical Research
ICRP and WHO categorization of risk
Trivial
Risk Category:
I
I.A.
I.
III
Total detriment
~ 10-6 or
less
~ 10-5
~ 10-4
~ 10-3 or
more
Range of effective
doses (adults), mSv
< 0.1
0.1 - 1
1 - 10
> 10a
Anticipated level of
benefit to Society
Minor
Intermediate to
moderate
a
Minor to
Intermediate
Moderate
Level of Risk:
Substantial
To be kept below deterministic thresholds except for therapeutic experiments.
Nuclear Medicine
Part 6. Medical Exposure
74
Research on Pregnant
Patients
 Radiation
research
involving
pregnant
patients should
be discouraged
Nuclear Medicine
Part 6. Medical Exposure
75
Dose Constraints
“3.152. Registrants and licensees shall ensure that
no individual incurs a medical exposure as a carer
or comforter unless he or she has received, and
has indicated an understanding of, relevant
information on radiation protection and
information on the radiation risks prior to
providing care and comfort to an individual
undergoing a radiological procedure. Registrants
and licensees shall ensure that the requirements
specified in para. 3.172 are met for the optimization
of protection and safety for any procedure in which
an individual acts as a carer or comforter.”
Nuclear Medicine
Part 6. Medical Exposure
76
Dose Constraints
..The dose shall be constrained so that it is unlikely that his or
her dose will exceed 5 mSv during the period of a patient’s
diagnostic examination or treatment. The dose to children
visiting patients who have ingested radioactive materials should
be similarly constrained to less than 1 mSv
Nuclear Medicine
Part 6. Medical Exposure
77
NM patient with pregnant family
member at home
For most diagnostic nuclear medicine
procedures, the total decay dose at 0.5
meter from the patient ranges from .02-0.25
mGy and at 1 meter from the patient the
dose is 0.05-0.10 mGy. This poses no
significant risk to pregnant family members.
Nuclear Medicine
Part 6. Medical Exposure
78
IAEA Training Material on Radiation Protection in Nuclear Medicine
Part 6. Medical Exposure
Protection of the Patient
Module 6.7. Examination of
Children, Pregnant and Lactating
Women
Optimization
“3.165. Registrants and licensees shall ensure that the particular aspects of
medical exposures are considered in the optimization process for:
 (a) Paediatric patients subject to medical exposure;
 ……..
 (e) Exposure of the embryo or fetus, in particular for radiological
procedures in which the abdomen or pelvis of the pregnant woman is
exposed to the useful radiation beam or could otherwise receive a
significant dose;
 (f) Exposure of a breast-fed infant as a result of a female patient
undergoing a radiological procedure with radiopharmaceuticals.”
Nuclear Medicine
Part 6. Medical Exposure
80
Nuclear Medicine
Part 6. Medical Exposure
81
Radiation Risks
16
LIFE-TIME RISK (%/Sv)
14
12
10
8
6
4
2
0
0
5
15 25 35 45 55 65 75 85 95
AGE AT EXPOSURE
Nuclear Medicine
Part 6. Medical Exposure
82
Activity to Children
The amount of activity administered to an
adult can for children be reduced by one of
the following methods:



Nuclear Medicine
body weight/70 kg
body surface area/1.73 m2
height/174 cm
Part 6. Medical Exposure
83
Fraction of the Adult Activity
Fraction of adult activity
1,2
1,0
0,8
0,6
BW
H
BSA
0,4
0,2
0,0
0
Nuclear Medicine
4
8
12
Age (years)
Part 6. Medical Exposure
16
20
24
84
European Association of
Nuclear Medicine (EANM)
1
Fraction of adult activity
0,9
0,8
0,7
0,6
0,5
0,4
0,3
0,2
0,1
0
0
10
20
30
40
50
60
Body Weight (kg)
Nuclear Medicine
Part 6. Medical Exposure
85
…...noting the special requirements for
Children
Local rules for administered activities to children should be
available. Recommendations from international professional
organizations should be followed.
Nuclear Medicine
Part 6. Medical Exposure
86
Pregnancy
Nuclear Medicine
Part 6. Medical Exposure
87
Example of justified use of CT in a pregnant
female who was in a motor vehicle accident
ribs
Fetal
skull
Blood
outside
uterus
Fetal dose 20 mGy
Nuclear Medicine
Part 6. Medical Exposure
88
3 minute CT exam and taken to the operating
room. She and the child survived
Free blood
Kidney ripped off aorta
(no contrast in it)
Nuclear Medicine
Part 6. Medical Exposure
Splenic laceration
89
Introduction
Thousands of pregnant women are
exposed to ionizing radiation each year
 Lack of knowledge is responsible for
great anxiety and probably unnecessary
termination of pregnancies
 For most patients, radiation exposure is
medically appropriate and the radiation
risk is minimal

Nuclear Medicine
Part 6. Medical Exposure
90



In some circumstances, the exposure is
inappropriate and the unborn child may be at
increased risk.
Prenatal doses from most properly done
diagnostic procedures present no measurably
increased risk of prenatal death,
malformation, mental impairment.
Higher doses such as those from therapeutic
procedures can result in significant fetal
harm.
Nuclear Medicine
Part 6. Medical Exposure
91
An example of media nonsense
Nuclear Medicine
Part 6. Medical Exposure
92
Pregnant Women
“3.175. Registrants and licensees shall ensure that there
are procedures in place for ascertaining the pregnancy
status of a female patient of reproductive capacity before
the performance of any radiological procedure that could
result in a significant dose to the embryo or fetus, so that
this information can be considered in the justification for
the radiological procedure (para. 3.154) and in the
optimization of protection and safety (para. 3.165).”
Nuclear Medicine
Part 6. Medical Exposure
93
Situation Analysis





Number of females getting exposed every
week without knowing that they are pregnant:
Inadvertent radiation exposure of early
conceptus
Planned Exposures:
 patients needing nuclear medicine
examinations or even therapy while
pregnant
Accidental exposure in pregnancy
Occupational exposures in pregnancy
Exposure of female of reproductive capacity
Nuclear Medicine
Part 6. Medical Exposure
94
How Sensitive is Early
Conceptus?
Threshold dose
deterministic effects
100 - 200 mSv
Mental retardation
40 % /Sv
Cancer and leukemia
before 10 years of age
lifetime
2 % /Sv
15 % /Sv
Hereditary effects
1 % /Sv
Nuclear Medicine
Part 6. Medical Exposure
95
Irradiation of Fetus Results
from:

Placental transfer


distribution of activity in fetal organs
 not much data available
 I-131 as iodide Tc-99m pertechnetate
External radiation from activity present
in the mothers organs and tissues

radiopharmaceuticals eliminated via the
kidneys
Nuclear Medicine
Part 6. Medical Exposure
96
Absorbed Dose to the Fetus
Examination
fetus
Bone (Tc99m)
Brain (CBF)
Lung (Tc99m-MAA)
Kidneys (MAG3)
Tumour or abscess (Ga-67 citrate)
Heart (Tc99m-MIBI)
Heart (Tl-201)
Thyroid (Tc99m)
Thyroid (I-131)
Activity
Dose to
(MBq)
(mSv)
600
500
160
100
300
300
100
100
100
4
4
0.4
2
28
5
10
1
7
4
0.02
Kidney clearance (Cr-51-EDTA)
(Data from Russell, Stabin et al Radiation dose to the embryo/fetus from
radiopharmaceuticals Draft, 1997
Nuclear Medicine
Part 6. Medical Exposure
97
Absorbed Dose to the Fetus
0,3
I-131 iodide
Tc-99m-MAG3
mGy/MBq
0,2
0,1
0,0
Early
3 months
6 months
9 months
Pregnancy month
(Data from Russell, Stabin et al Radiation dose to the embryo/fetus from
radiopharmaceuticals Draft, 1997
Nuclear Medicine
Part 6. Medical Exposure
98
Risk of childhood cancer from mother’s
diagnostic procedure in NM




The risk to an embryo or fetus from absorbing 1 mSv of
radiation dose - an increased risk of developing childhood
cancer of 6 in 100,000 (3 of which would be fatal)
Natural risk of complications of pregnancy or of birth anomalies
is approximately 4,000 in 100,000
Natural risk of the incidence of childhood cancer – 150 in
100,000
Fetal doses from diagnostic procedures in NM – max. tens of
mSv ( 67Ga, 131I)
Nuclear Medicine
Part 6. Medical Exposure
99
Prevention of Inadvertent
Exposure in Pregnancy
When a female of reproductive age presents for
an examination ask:
 Is she likely to be pregnant? Is period over-due?
 This should be recorded at appropriate place in the

form
Females under 16?
Depending upon answer
 No possibility of pregnancy
 Proceed with the examination
Nuclear Medicine
Part 6. Medical Exposure
100
IF YOU THINK THAT
YOU MIGHT BE
PREGNANT , NOTIFY
STAFF BEFORE
TREATMENT
Nuclear Medicine
Part 6. Medical Exposure
103
Before Examination is Performed
•Many patients incorrectly assume that irradiation from a
nuclear medicine examination begins when the gamma camera
begins imaging,
•Therefore, before radiopharmaceutical administration, it is
necessary to
consider as pregnant any woman of reproductive age
presenting for a nuclear medicine examination at a time when a
menstrual period is overdue or missed, unless
•there is information that precludes pregnancy (e.g.,
hysterectomy or tubal ligation).
•If the menstrual cycle is irregular, and a non-technetium or
therapeutic radiopharmaceutical is being administered, a
pregnancy test may be indicated before proceeding.
Nuclear Medicine
Part 6. Medical Exposure
104
Informed Consent and
Understanding



The pregnant patient has a right to know the
magnitude and type of potential radiation
effects that might result from in-utero
exposure
Communication should be related to the level
of risk. Verbal communication may be
adequate for low dose procedures.
If fetal doses are above 1 mGy, usually a
more detailed explanation is given
Nuclear Medicine
Part 6. Medical Exposure
105
If an examination of a pregnant
woman is judged to be necessary




Choice of radiopharmaceutical
Is it possible to reduce the administered
activity?
Prolonged acquisition times?
For radiopharmaceuticals eliminated via the
kidneys:
 Partially filled urinary bladder at the time
of administration
 Hydration and frequent voiding
Nuclear Medicine
Part 6. Medical Exposure
106
During the Examination
Using smaller administered activities
and longer imaging times can reduce
the absorbed dose to the fetus. This is
feasible if the patient is not too sick
and is able to remain still
Nuclear Medicine
Part 6. Medical Exposure
107
During the Examination
The sequence of the examinations can be adjusted
to reduce radiation dose.
•e.g. a ventilation-perfusion lung scan ordered on a
pregnant patient to exclude a pulmonary embolus.
• Many laboratories will perform the ventilation scan
first and then do the perfusion scan.
•In the specific case of a suspected pulmonary
embolus, the perfusion scan can be performed first,
and if it is normal, a ventilation scan is not needed at
all.
Nuclear Medicine
Part 6. Medical Exposure
108
During the Examination (contd.)
• There will be much smaller fetal dose
with Xenon-133
• If one does ventilation scans using
99mTc-DTPA aerosol, this will be
absorbed and excreted via the kidneys,
and while in the bladder it will contribute
to fetal dose
Nuclear Medicine
Part 6. Medical Exposure
109
Dose reduction after procedure has
been performed
Can the dose be reduced after the
procedure has been performed?
• Yes, by accelerating voiding,
bladder dose
• Not possible in radiology and RT
Nuclear Medicine
Part 6. Medical Exposure
110
Termination of Pregnancy



Termination of pregnancy at fetal doses of
less than 100 mGy is NOT justified based
upon radiation risk
At fetal doses in excess of 100 mGy, there
can be fetal damage, the magnitude and type
of which is a function of dose and stage of
pregnancy
In these cases decisions should be based
upon individual circumstances
Nuclear Medicine
Part 6. Medical Exposure
111
Becoming Pregnant after Irradiation
• ICRP has recommended that a woman not become
pregnant until the potential fetal dose from
remaining radionuclides is less than 1 mGy.
• This is not usually a consideration except for
radiopharmaceuticals labelled with 59Fe (for
metabolism studies) or 75Se (for adrenal imaging).
• As a result of the long physical half-lives of these
radionuclides and their long residence times in the
body, it is recommended that pregnancy be avoided
for 6 and 12 months respectively.
Nuclear Medicine
Part 6. Medical Exposure
112
Nuclear Medicine
Part 6. Medical Exposure
113
Mothers in Lactation
Nuclear Medicine
Part 6. Medical Exposure
114
Optimization: Breast Feeding
“3.176. Registrants and licensees shall ensure that
there are arrangements in place for establishing
that a female patient is not breast-feeding before
the performance of any radiological procedure
involving the administration of a
radiopharmaceutical that could result in a significant
dose to an infant being breast-fed, so that this
information can be considered in the justification for
the radiological procedure (para. 3.154 and 3.156 )
and in the optimization of protection and safety
(para. 3.165).”
Nuclear Medicine
Part 6. Medical Exposure
115
Irradiation of breastfed child
results from:



Nuclear Medicine
Activity in milk
External radiation from the mother
Possible contamination
Part 6. Medical Exposure
116
Recommendations for Cessation
of Breast Feeding
Radiopharmaceutical
Tc -99m DTPA
Tc -99m MAA
Tc -99m Pertechnetate
Tc -99m DISIDA
Tc -99m glucoheptonate
Tc -99m HAM
Tc -99m MIBI
Tc -99m MDP
Tc -99m PYP
Tc -99m RBC's in vivo
labelling
Tc -99m RBC's in vitro
labelling
Tc -99m Sulphur Colloid
Tc -99m DTPA Aerosol
Tc -99m WBC's
Tc -99m MAG3
Nuclear Medicine
Administered activity
(MBq)
740
148
185
300
740
300
1110
740
740
740
Counseling?
740
no
444
37
185
370
no
no
yes
no
Part 6. Medical Exposure
no
yes
yes
no
no
no
no
no
no
yes
Advice
12 hr
4 hr
12 hr
48 hr
117
Recommendations for Cessation
of Breast Feeding
Radiopharmaceutical
Ga-67 Citrate
I-131 NaI
Cr-51 EDTA
In-111 WBC's
I-123 NaI
I-123 OIH
I-123 mIBG
I-125 OIH
I-131 OIH
Tl-201
Xe-133 gas
Nuclear Medicine
Administered activity
(MBq)
185
5550
1.85
20
15
74
370
0.37
11.1
111
Part 6. Medical Exposure
Counseling?
Advice
yes
yes
no
no
yes
no
yes
no
no
yes
no
Cessation
Cessation
Cessation
48 hr
96 hr
118
IF YOU ARE BREASTFEEDING, PLEASE
NOTIFY THE STAFF
Nuclear Medicine
Part 6. Medical Exposure
119
IAEA Training Material on Radiation Protection in Nuclear Medicine
Part 6. Medical Exposure
Protection of the Patient
Module 6.8. Records
Records
“3.182. Registrants and licensees shall maintain for a period as specified by
the regulatory body and shall make available, as required, the following
personnel records:
(a) Records of any delegation of responsibilities by principal parties
(as required in para. 3.153(f));
(b) Records of training of personnel in radiation protection (as required
in para. 3.149(b)).
3.183. Registrants and licensees shall maintain for a period as specified by
the regulatory body and shall make available, as required, the following
records of calibration, dosimetry and quality assurance:
(a) Records of the results of the calibrations and periodic checks of the
relevant physical and clinical parameters selected during treatment of
patients;
(b) Records of dosimetry of patients, as required in para. 3.167;
(c) Records of local assessments and reviews made with regard to
diagnostic reference levels, as required in para. 3.168;
(d) Records associated with the quality assurance programme, as
required in para. 3.170(d).”
Nuclear Medicine
Part 6. Medical Exposure
121
Records
“3.184. Registrants and licensees shall maintain for a period
as specified by the regulatory body and shall make available,
as required, the following records for medical exposure:
…….
(c) For nuclear medicine, the types of
radiopharmaceutical administered and their activity;
…….
(e) Exposure records for volunteers subject to medical
exposure as part of a programme of biomedical research;
(f) Reports on investigations of unintended and
accidental medical exposures (as required in para.
3.180(d).”
Nuclear Medicine
Part 6. Medical Exposure
122
Records and Documents:
Medical Exposures
•Administered radiopharmaceutical
and activity (each patient)
•Route of administration (each patient)
•Incident and accident investigation reports
•Absorbed doses to patients
•Calibration certificate (activity meter)
•Quality control of equipment
(gamma camera & activity meter)
•Maintenance and repair work
•Audits and reviews of radiation safety programme
•Training provided:
initial
refresher
Nuclear Medicine
Part 6. Medical Exposure
123
IAEA Training Material on Radiation Protection in Nuclear Medicine
Part 6. Medical Exposure
Protection of the Patient
Module 6.9. Local Rules
Local Rules:
Medical Exposures
Activity to adults in nuclear medicine examinations
Activity to children in nuclear medicine examinations
Rules for pregnant women
Rules for lactating women
Preparation and dispensation of radiopharmaceuticals
Procedure manual, activity meter
Patient identification and information
Administration of radiopharmaceuticals
Procedure manual, gamma camera examinations
Procedures in case of misadministrations
Procedures in case of accidents
Records
Nuclear Medicine
Part 6. Medical Exposure
125
Local Rules
Department of Nuclear Medicine
Radiation Protection Manual
PROTECTION OF THE PATIENT
Nuclear Medicine
Activity to Adults
Children & Young people
Pregnant women
Lactating women
Radiopharmaceuticals
Activity measurement
Misadministration
Examination
Proceedure Manuals
Patient Identification
Part 6. Medical Exposure
126
Questions?
Nuclear Medicine
Part 6. Medical Exposure
127
Disccussion
• Increase the activity for elderly patients and patients with
pain to reduce the examination time?
• Increase the activity for all patients in order to increase
the throughput of patients?
• Increase the activity for paediatric patients in order to
avoid sedation or general anaesthesia?
• Increase the activity to cancer patients who are
nevertheless going to receive radiotherapy?
Nuclear Medicine
Part 6. Medical Exposure
128
Discussion
A patient is referred to a bone scan. It is
obvious from the information on the request
that this is the wrong type of examination to
get the right diagnosis. The examination is
done anyway. Who is responsible for this non
justified exposure?
Nuclear Medicine
Part 6. Medical Exposure
129
Discussion
Discuss how to handle the problem when it is
necessary to to examine or treat a woman who
is pregnant.
Nuclear Medicine
Part 6. Medical Exposure
130
Where to Get More Information

Other sessions




Further readings






Part 7 Optimization of protection in Nuclear Medicine Examinations
Part 8 Optimization of protection in Nuclear Medicine therapy
Part 11 Potential exposure and accidental medical exposure
IAEA Basic Safety Standards: Interim Edition (2011)
IAEA Safety Guide on Radiological Protection for Medical Exposure
IAEA Model regulations on radiation safety in nuclear medicine
WHO. Manual on Radiation Protection in Hospitals and General
Practices. Volume 4: Nuclear Medicine
ICRP publication 84
Practical session

Simulated inspection
Nuclear Medicine
Part 6. Medical Exposure
131
Local Rules 1
Department of Nuclear Medicine
Radiation Protection Manual
PROTECTION OF THE PATIENT
ADULTS
Examination
Bone scan
Radiopharmaceutical
Activity (MBq)
Tc99m DPD
400
Thyroid
Tc99m-pertechnetate
100
Kidney
Tc99m-MAG3
75
Note: For not listed examinations consult the nuclear medicine specialist
Nuclear Medicine
Part 6. Medical Exposure
132
Local Rules 2
Department of Nuclear Medicine
Radiation Protection Manual
PROTECTION OF THE PATIENT
CHILDREN & YOUNG PEOPLE
Examination
Bone scan
Radiopharmaceutical
Tc99m DPD
Activity (MBq)
Age 0-14
Age 15-18
BW x 3
BW x 6
Thyroid
Tc99m-pertechnetate
BW x 0.5
BW x 1
Kidney
Tc99m-MAG3
BW x 0.5
BW x 1
Note: For not listed examinations consult the nuclear medicine specialist
Nuclear Medicine
Part 6. Medical Exposure
133
Local Rules 3
Department of Nuclear Medicine
Radiation Protection Manual
PROTECTION OF THE PATIENT
PREGNANT WOMEN
•If a female patient is pregnant or think that she might be, the responsible
physician shall always make a decision whether the examination shall be
done or shall be postponed either until after delivery or to the latter half of
the pregnancy, carefully considering the use of other diagnostic methods.
• If there is uncertainty concerning pregnancy, either because the period is
known to be overdue or for other reasons, the woman shall be treated as
pregnant until otherwise proved.
• The administered activity shall be in proportion to body weight using 70%
of the normal adult activity for the required examination
Nuclear Medicine
Part 6. Medical Exposure
134
Local Rules 4
Department of Nuclear Medicine
Radiation Protection Manual
PROTECTION OF THE PATIENT
LACTATING WOMEN
No counseling of breastfeeding for the following radiopharmaceuticals:
51Cr-EDTA, 99mTc-DMSA, 99mTc-DTPA, 99mTc-MDP, 99mTc-glycoheptonate
99mTc-HMPAO, 99mTc-MIBI, 99mTc-colloids, 99mTc-MAG3(<100MBq),
201Tl-chloride (<80MBq) and 111In-leucocytes (<20MBq).
table
For other radiopharmaceuticals, see attached
For not listed radiopharmaceuticals, consult the nuclear medicine specialist
Nuclear Medicine
Part 6. Medical Exposure
135
Local Rules 4:1
Department of Nuclear Medicine
Radiation Protection Manual
PROTECTION OF THE PATIENT
LACTATING WOMEN
Counseling of breastfeeding
Radiopharmaceutical
99mTc-pertechnetate
4h
99mTc-MAA
12h
201Tl-chloride
96h
67Ga-citrate
Cessation
………
Nuclear Medicine
Advice
…..
Part 6. Medical Exposure
136
Local Rules 5
Department of Nuclear Medicine
Radiation Protection Manual
PROTECTION OF THE PATIENT
RADIOPHARMACEUTICALS
Preparation
Dispensing
Injection
Nuclear Medicine
Part 6. Medical Exposure
137
Local Rules 5:1
Department of Nuclear Medicine
Radiation Protection Manual
PROTECTION OF THE PATIENT
PREPARATION OF RADIOPHARMACEUTICALS
Name:
DPD (CIS bio)
Composition 13 mg 3,3-diphosphono-1,2-propanedicarboxylic acid, tetrasodium salt (DPD) 0.23 mg
tin(II)oxide
Usage:
Bone scintigraphy
Preparation: Use a transparent vial shield. Put the kit vial in the shield. Dispense 5 ml pertechnetate
(3000 MBq) in a shielded syringe. Add the solution to the vial containing the freeze dried
kit.
Remove an equal volume of gas to equalize the pressure. Shake the vial gently for 10 s.
Store the preparation for 5 min. Temporarily remove the vial from the shield and measure
the activity.
Use a forceps when moving the vial. Put a label on the shield. The label shall contain: Name
of radiopharmaceutical, activity and activity concentration as well as date and time. Check
the label against the vial. Same radiopharmaceutical? Record the preparation and sign.
The preparation can be used for 5 patient examinations within 6 h from time of
preparation.
Storage:
Kit in fridge
Radiopharmaceutical in the shielded container and protected from light
Nuclear Medicine
Part 6. Medical Exposure
138
Local Rules 5:2
Department of Nuclear Medicine
Radiation Protection Manual
PROTECTION OF THE PATIENT
DISPENSING RADIOPHARMACEUTICALS
1.
2.
3.
4.
5.
Check the label on the vial shield. Is it the required
radiopharmaceutical?
Calculate the volume to dispense from the decay corrected activity
concentration and the requested activity for the intended
examination.
Dispense the calculated volume using a shielded syringe.
Temporarily remove the syringe shield and measure the activity.
Write a label and put it on the syringe shield. The label shall contain
patient name and id number, radiopharmaceutical, activity, date and
time. The label shall be signed.
Nuclear Medicine
Part 6. Medical Exposure
139
Local Rules 5:3
Department of Nuclear Medicine
Radiation Protection Manual
PROTECTION OF THE PATIENT
IDENTIFICATION OF PATIENT
INJECTION OF RADIOPHARMACEUTICALS
1.
2.
3.
4.
5.
6.
7.
8.
9.
Ask the patient about name and birth date or identification number.
Ask a female patient about pregnancy.
Ask a female patient if she is breastfeeding a child.
If necessary, inform the patient about any restrictions according to
the local rules.
Read the request
Check the label on the syringe shield.
Is it the correct radiopharmaceutical and activity for the requested
examination?
Inject according to the local rules for intravenous injections
The radiopharmaceutical and the injected activity.shall be recorded
Nuclear Medicine
Part 6. Medical Exposure
140
Local Rules 6
Department of Nuclear Medicine
Radiation Protection Manual
PROTECTION OF THE PATIENT
ACTIVITY MEASUREMENT
The activity of the radiopharmaceutical shall always be measured after
preparation and before and after injection.
1.
2.
3.
4.
5.
6.
Select the isotope
Check the background reading and make a background adjustment
Put the syringe or the vial in the holder using a forceps
Put the holder into the chamber
Read the activity
Remove the holder and put the syringe or vial back into the shield
Nuclear Medicine
Part 6. Medical Exposure
141
Local Rules 7
Department of Nuclear Medicine
Radiation Protection Manual
PROTECTION OF THE PATIENT
MISADMINISTRATION
The following are defined as misadministrations: Administration to the wrong patient, administration of the
wrong radiopharmaceutical, administration of wrong activity (>15% from prescribed activity in therapy and
>75% in diagnostic examinations) and wrong route of administration.
In case of misadministration:
1.
2.
3.
4.
5.
6.
Inform the nuclear medicine specialist
Inform the patient and the referring physician
Inform the medical physicist (phone ……), who shall calculate and report the
patient dose
The responsible technician shall write a report about the event and try to
explain the causes.
The nuclear medicine specialist shall send the report to the Head of the
Department who shall decide if the event shall be reported to the authorities.
All members of the staff shall be informed
Nuclear Medicine
Part 6. Medical Exposure
142
Local Rules 8
Department of Nuclear Medicine
Radiation Protection Manual
PROTECTION OF THE PATIENT
Study name:
Preparation of patient:
Radiopharmaceutical:
Route of administration:
Activity:
Start of measurement:
Type of examination:
Views:
Scanning speed:
Collimator:
Window setting:
Positioning of patient:
Presentation of result:
Nuclear Medicine
Bone scan
Empty bladder
Tc99m-DPD
iv injection
400 MBq
3h post injection
Whole body scan
AP, PA
10 cm/min
LEHR
140+/-20% keV
Supine
Images in BW on film.
Part 6. Medical Exposure
143