IAEA Training Material on Radiation Protection in Nuclear Medicine
Part 8
Radiation Protection in
Radionuclide Therapy
Objective
To be able to apply the principle of optimization of radiation
protection to therapeutic procedures including design,
operational consideration, quality control and clinical dosimetry.
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Contents





Basic requirements
Administration of therapy
The radioactive patient. Dose constraints
The hospitalized patient
Emergency procedures
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IAEA Training Material on Radiation Protection in Nuclear Medicine
Part 8
Optimization of Protection in
Medical Exposure
Module 8.1 Basic Requirements
Justification of Medical Exposure
(BSS: Interim Edition, 2011)
“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.”
Use WHO guidelines
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Responsibilities
(BSS: Interim Edition)
”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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Dosimetry (BSS: Interim Edition)
“3.167. Registrants and licensees shall
ensure that dosimetry of patients is
performed and documented by or under the
supervision of a medical physicist, using
calibrated dosimeters and following
internationally accepted or nationally
accepted protocols, including dosimetry to
determine the following:


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…..
(c) For therapeutic medical exposures, absorbed
doses to the tissues or organs for individual
patients, as determined to be relevant by the
radiological medical practitioner.”
Part 8. Therapy
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Medical Physicist
A qualified medical physicist should be responsible for
measurement of radionuclide activity, identification of
radionuclides and internal radiation dosimetry
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Absorbed Dose-Administered Activity
I-131
Example of method to calculate administered activity from
Prescribed absorbed dose to the thyroid
Thyroid mass (g)
Prescibed dose (Gy)
30
100
Activity (MBq)=
Uptake measurements
Time
(h)
0
2
24
48
144
Standard
(cpm)
21736
18286
17165
13171
Patient
(cpm)
5521
12338
10565
5754
Bg
(cpm)
100
100
100
100
Effective half-life (d):
Activity to administer (MBq):
Uptake
(%)
73,5
25,1
67,3
61,3
43,3
23.4*mass(g)*dose (Gy)
uptake at t=0 (%)*Teff (d)
4,0
240
Berg GEB et al, J Nucl Med 1996; 37:228-232
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Uptake Measurement
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Gamma Camera Examination
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Gamma Camera Examination
Used to determine the size of the organ
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Factors Affecting Safety in
Radionuclide Therapy
Safe handling of
radionuclides
•
•
•
•
•
•
ordering
receipt and unpacking
storage
dispensing
internal transports
radioactive waste
Safe administration
•
•
•
Identification
pregnancy
breastfeeding
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Patient preparation
The radioactive patient and dose
constraints
The hospitalized patient
•instructions to nursing staff
•visitors instructions
•discharge of the patient
•decommissioning of hospital ward
•radioactive waste
Emergency procedures
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Ordering, Receipt & Unpacking
•The hospital routines for ordering radionuclides should
be followed.
•When ordering, be sure the delivery service knows where
in the hospital to deliver the material.
•Make sure that the package is expected and that no unauthorized person will open it upon arrival.
•Before unpacking, check the package. In case of damage,
contact your RPO.
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Storage of I-131
•The radionuclide should be stored in a controlled
area, according to national regulations and local
rules.
•The radionuclide should always be stored in a lead
container and preferably in a fridge to prevent evaporation
•To reach an acceptable external dose rate,
a thickness of 1-4 cm lead is generally required.
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Dispensing
• Protective clothing
• Lead shields (bench top shield,
vial shield, syringe shield)
• Keep the vial in the fume hood
and on a tray with lips, lined with
plastic backed absorbent pads.
• Handle the vial with forceps or
similar long handled instruments.
• Cover the vial with lead after use.
• Check the activity
• Fill in the necessary records
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Internal Transport
If the administration of radiopharmaceutical to the patient takes
place far from the dispensing room, use a transport container with
absorbent pads.
Make sure that a warning sign is on the container together
with patient name, activity and date.
Travel by the most direct route avoiding more heavily
occupied areas
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Radioactive Waste
Shall be collected, segregated and disposed
of according to national regulations and local
rules.
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IAEA Training Material on Radiation Protection in Nuclear Medicine
Part 8
Optimization of Protection in
Medical Exposure
Module 8.2 Administration of Therapy
Precautions Before
Administration
• Be prepared for an emergency situation.
• Careful identification of the patient (hospital routines
shall be followed).
• Questions to the patient:
-Pregnant?
-Breastfeeding?
-Incontinent?
-Nausea?
-Living conditions?
-Type of work?
-Public transportation back home?
• Verbal and written individual instructions to the patient.
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Pregnancy (BSS: Interim Edition)

“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 3.156) and in the optimization of
protection and safety (para. 3.165).”
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Radioiodine Therapy and
Pregnancy
Radioiodine easily crosses the
placenta and therapeutic doses can
pose significant problems for the
fetus, particularly permanent
hypothyroidism.
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Radioiodine Therapy
As a rule, a pregnant woman should not be treated
with a radioactive substance unless the therapy is
required to save her life: in that extremely rare
event, the potential absorbed dose and risk to the
fetus should be estimated and conveyed to the
patient and the referring physician.
Considerations may include terminating the
pregnancy.
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Radioiodine Therapy
In women, thyroid carcinoma comprises over 80%
of cancer of the head and neck diagnosed between
the ages of 15-45 years. Thyroid cancers are
relatively unaggressive compared to most other
cancers. As a result both surgical and radio-iodine
treatment are often delayed until after pregnancy. In
general, if any therapy is to be performed during
pregnancy, it will be surgery during the second or
third trimester.
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Inadvertent Administration of Therapy Dose
Menstrual history is often not adequate to ensure that a
patient is not pregnant. In most developed countries, it is
common practice to obtain a pregnancy test prior to highdose 131 I scanning or therapy for women of childbearing
age unless there is a clear history of prior tubal ligation or
hysterectomy precluding pregnancy.
In spite of the above, it still happens that pregnant women
are treated, either because of false histories or because the
pregnancy is at such an early stage that the pregnancy test
is not yet positive.
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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.
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Pregnancy after Therapy
Radiopharmaceutical
All activities
up to (MBq)
Au-198 colloid
10000
I-131 iodide (thyroid ca)
5000
I-131 iodide (thyrotoxicosis)
800
I-131 MIBG
5000
P-32 phosphate
200
Sr-89 chloride
150
Y-90 colloid (arthritic joints) 400
Y-90 colloid (malignancy)
4000
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Part 8. Therapy
Avoid pregnancy
(months)
2
4
4
4
3
24
0
1
27
Breast Feeding (BSS: Interim Edition)

“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).”
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Breast Feeding
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Patient Information Needed:
•Nausea
•Living conditions
•Type of work
•Public transport
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-intravenous administration to
be considered?
-number of people in house?
-children?
-separate room?
-working close to other people?
-working with children?
-pregnant coworkers?
-time?
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Administration of Therapy:
Calibration of Sources (BSS)
“3.166. In accordance with para. 3.153(d) and (e), the medical
physicist shall ensure that:
 (a) All sources giving rise to medical exposure are calibrated
in terms of appropriate quantities using internationally
accepted or nationally accepted protocols;
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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Safe Administration
•
•
•
•
•
I-131 should be administered in a controlled area (hot lab or the
patient’s hospital bedroom).
A plastic bag for contaminated items should be available as well as
paper tissues.
The patient is asked to sit at a table covered with adsorbent pads and
the floor beneath the patient should also be covered by adsorbent
pads.
If the I-131 is administered in capsules they should be transferred to
the patient mouth by tipping from a small shielded (>1 cm Pb)
container.
I-131 administered in an oral solution (50 ml) should be sucked up
through a straw from the shielded vial by the patient. The vial should
be flushed with water several times. The patient should drink several
glasses of water to clean the mouth.
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Safe Administration
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Safe Administration
Procedure for intravenous administration:
•
•
•
•
•
Dispense the radionuclide into a shielded syringe
Put the radionuclide in an infusion bottle
Line the bottle to the patient using an intravenous catheter
Keep the patient in bed until the bottle is empty
Remove the bottle and the catheter and dispose of them as
radioactive waste
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IAEA Training Material on Radiation Protection in Nuclear Medicine
Part 8
Optimization of Protection in
Medical Exposure
Module 8.3 The Radioactive
Patient: Dose Constraints
Shall the Patient be Hospitalized?
Can the patient leave?
Any restrictions?
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Dose Constraints
(BSS: Interim Edition)
“3.172. Registrants and licensees shall ensure
that relevant dose constraints (para.
3.148(a)(i)) are used in the optimization of
protection and safety in any procedure in
which an individual acts as a carer or
comforter.”
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Dose Limitation for Comforters
and Visitors of Patients
..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
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Exposures From Patient
Contamination
External
saliva
perspiration
breath
urine
0.5
0.1
0.06
0.03 mSv/h
1000 MBq
I-131
0
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0.5
Part 8. Therapy
1
2m
39
Biodistribution of I-131
(MIRD)
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Excretion of I-131
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Contamination
Administered activity: 1000 MBq I-131
Excretion
Concentration
Saliva
<2 MBq/g
Perspiration <20 Bq/cm2
Breathing
100 Bq/l
Urine
< 500 kBq/ml
Contamination
utensils
2 kBq
surfaces 10 Bq/cm2
air
1 Bq/l
toilet
2 kBq/cm2
Generally larger than the derived limits for contamination
given by ICRP (publ 57)
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Exposures from Patient
6 μSv /h* GBq , 0 m
Sm-153
26
0
3 μSv /h* GBq , 0 m
9
0,5
3μSv/h* GBq
1m
Activity concentration in urine: 0.3 MBq/ml*GBq
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External Exposure from Patient
Sm-153
Dose rate at 0.5 m
Mean dose rate (Sv/h*GBq)
10
8
6
4
2
0
0
1
2
3
4
5
Time after injection (h)
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Restrictions
Patient with Iodine-131
Activity of I-131 administered (MBq)
30-200
200-400
400-600
Behaviour restriction
Period of restrictions (d)
Stay at least 1 metre away from all members
5
9
12
of the household except for very brief periods
(a few minutes every day)
Restrict close contact (“cuddling” with all
members of the household to less than 15
minutes per day, and sleep separately from
them
Sleep separately from “comforters and cares”
600-800
14
15
21
25
27
-
-
4
-
8
1
Avoid prolonged close contact (more than 3
hours at <1 metre) with other adults
NOTE THAT:
The restriction times in the first two rows run concurrently e.g. for 30-200MBq category, a child should only be
cuddled for brief periods for 5 days, then cuddling must be restricted to 15 min per day for a further 10 days.
The dose constraint for the third row is 5 mSv
The fourth row only covers on single event whereas the other categories assume daily contact.
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Restrictions
Patient with Iodine-131
Public travel
allowed per day
Activity 1:st w 2:nd w
(MBq)
(h)
(h)
200
3,5
24
400
1,5
14
600
1
9
800
0,5
7
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Off
work
(d)
0
3
6
8
Sleep apart
from partner
pregn.
no
(d)
(d)
15
1
20
8
24
11
26
13
Part 8. Therapy
Restricted close contact
with children
<2 y
2-5 y
5-11 y
(d)
(d)
(d)
15
11
5
21
16
11
25
20
14
27
22
16
46
Therapy Patient
The dose to a family member staying at a distance of
0.5 meters from the patient until the radioactivity
totally decays (about 10 weeks) is about 1.3 mGy
from a hyperthyroid patient and 6.8 mGy from a
thyroid cancer patient.
These patients must also be careful not to transfer
radio-iodine contamination to family members by
direct contact or through indirect means
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Measurements
25 patients who received 220-600 MBq I-131
Husband/wife
Children
220-3100 μSv
110- 700 μSv
No correlation between administered activity and
doses to members of the family.
University Hospital, Gothenburg, Sweden
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Therapy Patient
I-131
The patient should be kept at
least 2h, and if possible one day
in the hospital.
In the case of cancer treatment,
the patient should generally be
hospitalized for several days.
In all cases, the dose rate at 1 m
from the patient should be down
to an acceptable level
established by the RPC.
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Patient Survey
Typical Graph of the Exposure Rate at 1 m from the Patient
Administered with of 5.5 GBq I-131
14
Exposure Rate (mR/hr)
12
10
8
6
4
2
0
1
2
3
4
5
Days of Isolation
Abdalla Al-Haj
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Guidance level for maximum activity for
patients in therapy on discharge from hospital
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Hospitalization or Not?
I-131
1100 MBq
stay in hospital
stay in hospital or
discharged with individual restrictions
600 MBq
discharged with individual restrictions
150 MBq
discharged, general restrictions
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Instructions to Out-patients
•
•
•
•
•
•
No eating and drinking during the first hour after treatment.
During the following two days you should drink more than usual.
Use only a WC and flush 2-3 times. Keep the toilet and the floor clean.
Wash your hands frequently and take a shower every day.
Avoid close contact with members of the family, children and pregnant
women according to the time table attached
Avoid solid waste
Contact the Nuclear medicine department in case of problems
or questions. Phone: …………
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Avoiding Solid Waste
Sensitive detectors at sanitary landfills and solid waste
transfer and processing sites have identified contaminated
articles from nuclear medicine patients.
• Do not use paper plates or disposable cups or flatware.
• Use regular dishes, glasses and utensils. Wash them in the sink
or dishwasher.
• Tissues and paper napkins should go in the toilet, not the
garbage.
• Food residues should be avoided during the first week (apple
cores, chicken bones etc).
• Articles contaminated with body fluids that cannot be washed
clean or disposed of in the toilet should be stored for decay.
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IAEA Training Material on Radiation Protection in Nuclear Medicine
Part 8
Optimization of Protection in
Medical Exposure
Module 8.4
The Hospitalized Patient
Hospitalized Patient
•
•
•
•
•
•
separate room with toilet and shower
patient instructions (verbal and written)
local rules for nursing the patient
local rules for visitors
local rules for decontamination
local rules for emergency situations
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Room for Iodine Therapy
(controlled area)
• only one patient in the room
• easily cleanable surfaces
and utensils
• extra lead shields
• door closed
• warning sign outside
• restrictions for visitors
• decontamination equipment
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Isolation Ward
Bed shield is positioned
Areas are covered with plastic
backed absorbent material.
King Faisal Specialist Hospital and Research Center, Riyadh
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Warning Signs
Radiation sign posted on door
and on Patient Chart
King Faisal Specialist Hospital and Research Center, Riyadh
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Patient Instructions
•
•
•
•
Stay in the room.
Drink as much as possible.
Eat lemon slices.
Use only the private toilet and flush 3 times. (Men
should sit down to avoid splashing.)
• Wash hands well in soapy water after using toilet.
• Wear footwear when leaving the bed.
• In event of vomiting or incontinence notify the nurse
immediately.
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Instructions to Nursing Staff
• Reduce time spent with patient by planning ahead and working
efficiently.
• Work as far from patient as possible.
• Practice preventative measures against contamination.
-wear impermeable protection gloves
-wear shoe covers
-wear a protective gown
• Remove protection clothing before leaving the room.
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Visitors Warning Card
The patient you are about to visit has received a therapeutic dose
of radioactive iodine. It is in your own best interest to protect yourself
as much as possible from receiving more radiation than is necessary.
To assist you in meeting that end we offer the following recommendations:
•
•
•
•
•
•
•
Visitors are discouraged for a 48 hour period after the patient receives
the treatment.
Pregnant women and children under the age of 18 are not permitted to
visit.
You should keep your visit short (<30 min).
Keep a reasonable distance (e.g. 2 m) away from the patient.
Do not kiss the patient.
Do not eat, drink or smoke in the patient’s room
Do not touch the toilet or sink in the patient’s room
If you have any questions, please ask the nursing staff.
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Discharge of Patient
The patient may leave the hospital when his/her radiation level
has dropped below the equivalent activity level specified by the
Regulatory Authority or the dose constraints specified by the
local RPC. E.g. 20 μSv/h which corresponds to an activity of
about 500 MBq
The patient should be instructed about the general precautions
for out-patients
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Discharge of Patient
Typical Graph Showing the Percentage of I-131that
is Retained in the Body of a Patient
Administered with 5.5 GBq
100
Percentage of I-131 in Body
90
80
70
60
50
40
30
20
10
0
1
2
3
4
5
Day of Isolation
Abdalla Al-Haj
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Discharge of Patient
Graph Showing the Number of Patients (5GBq) and
the Number of Days of Isolation
(Year 2000 Statistics)
160
142 (75%)
140
Number of Patients
120
100
80
60
(16%)
31
40
(5%)
(4%)
8
20
10
0
0
1
2
3
4
5
Number of Days of Isolation
Abdalla Al-Haj
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Decontamination
The RPO should supervise the removal of
contaminated waste, the decontamination of the room
and equipment and should make a documented final
survey of the room.
Monitoring and decontamination must be done prior to
entry of nursing and housekeeping staff to prepare the
room for the next patient.
When survey and decontamination procedures are
complete, the RPO will remove the radiation warning
sign and notify the nursing and housekeeping staff that
the room is now clear for general use.
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Monitoring
Areas suspected to be
contaminated are surveyed.
Furniture and telephone sets
are surveyed.
King Faisal Specialist Hospital and Research Center, Riyadh
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Monitoring
Area or item
Initial
(Bq/cm2)
After cleaning
(Bq/cm2)
Toilet
Washroom floor
Sink and Faucets
Shower
Bed
Armchair
Bedroom floor
TV/Telephone
Bedside table
Doorknobs
Lamp switches
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Derived limit: 3 Bq/cm2
METHODS
• wipe testing
• direct surveying
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Ready for a New Patient
A “Radiation Safe” sign
is posted at the door
after decontamination
and clearing of room
King Faisal Specialist Hospital and Research Center, Riyadh
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Radioactive Waste
• Faeces, urine and other liquids should be
disposed of via the toilet.
• Contaminated clothing, linen, food items
etc which can not go into the toilet should
be stored in a separate plastic bag
labeled ’RADIOACTIVE’, and should be
removed daily to the designated
radioactive waste storage facility.
• Disposable cutlery and dishes should be
used. If not, they should be washed in the
patient’s room and reused by the patient.
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Radioactive Waste
All patient radioactive wastes
are placed in a plastic bag and
the bag is properly tagged.
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IAEA Training Material on Radiation Protection in Nuclear Medicine
Part 8
Optimization of Protection in
Medical Exposure
Module 8.5 Emergency Procedures:
Death of Patient
HELP!
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Safety Assessment
Contingency Plan
A safety assessment will reveal the possible
situations where emergency actions have to be taken:
•Loss or damage of radioactive material
•Spillage of radioactive material
•Fire
•Medical emergencies
•...
A detailed contingency plan covering actions to
be taken in any foreseeable accident should be
available.
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Death of Patient
In the event of death of a patient who has recently received
a therapeutic dose of a radionuclide care has to be taken to
ensure that personnel receive as low a dose as possible at
all stages prior to the burial or cremation.
Activity (MBq)
Radionuclide
I-131
Y-90 colloid
Au-198 colloid
P-32
Sr-89
Burial
400
2000
400
2000
2000
Cremation
400
70
100
30
200
(UK)
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Death of Patient
Precautions that should be given are depending on the residual activity
and the expert advice provided by the RPO and may involve the
following:
• preparation for burial or cremation should be controlled by a
competent person,
• relatives should be prevented from coming into close contact with the
body,
• people should not be allowed to linger in the presence of the coffin,
• all personnel involved in handling the corpse should be instructed by
the RPO and monitored if appropriate,
• all objects, clothes, documents etc that might have been in contact
with the deceased must be tested for contamination,
• it may be expedient to wrap the cadaver in waterproof material
immediately after death to prevent spread of contaminated body fluids,
• embalming of cadavers should, if possible, be avoided,
• autopsy of highly radioactive cadavers should be restricted to the
absolute minimum
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Questions?
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Discussion
Discuss the advantages/disadvantages of giving
the patient a standard activity of I-131 in a capsule
or giving a carefully calculated activity based on a
prescribed dose to the thyroid.
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Discussion
1. Who should prescribe a thyroid treatment with I-131?
2. Who should perform the treatment?
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Discussion
Define some emergency situations or other
hazardous events that can occur in an isolation
ward and how to handle the situations.
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Where to Get More Information
Other
sessions
Part 6 Medical exposure
 Part 5 Occupational exposure
 Part 4 Design

Further
readings
IAEA, International Basic Safety Standards for Protection Against
Ionizing Radiation and for the Safety of Radiation Sources Safety
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