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Radiation Safety in the Cath LabCardiovascular Interventions 2019
La Jolla, California
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David G. Rizik, M.D., F.A.C.C., M.S.C.A.I.David G. Rizik, M.D., F.A.C.C., M.S.C.A.I.Chief Scientific OfficerChief Scientific Officer
Director of Structural and Coronary InterventionDirector of Structural and Coronary InterventionHonorHealth Medical CenterHonorHealth Medical Center
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Cen
ter DisclosuresDisclosures
•• Abbott Vascular: Medical Advisory Board.Abbott Vascular: Medical Advisory Board.
•• CordisCordis/Cardinal: Medical Advisory Board./Cardinal: Medical Advisory Board.
•• BiotronikBiotronik: Medical Advisory Board.: Medical Advisory Board.
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•• Boston Scientific: Executive Physician Council;Boston Scientific: Executive Physician Council;Grant/Research Support; Consulting/Proctor;Grant/Research Support; Consulting/Proctor;License Fees/Royalties.License Fees/Royalties.
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Occupational Health Hazards in theInterventional Laboratory
Time for a Safer Environment
Occupational Health Hazards in theInterventional Laboratory
Time for a Safer Environment
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““The Interventional Laboratory Poses WorkplaceThe Interventional Laboratory Poses WorkplaceHazards to Interventional Physicians”Hazards to Interventional Physicians”
KleinKlein etet alal:: OnOn behalfbehalf ofof thethe MultiMulti--SpecialtySpecialty OccupationalOccupational HealthHealth GroupGroup
CathCath andand CVCV InterventIntervent 20092009;; 7373::432432/J/J VascVasc InterventIntervent RadiolRadiol 20092009;; 2020::147147
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Radiation Scatter Patterns: Primary and SecondaryRadiation Scatter Patterns: Primary and Secondary
Primary Beam Rad Source
Main Scatter Source = PatientBigger Patient = More Scatter
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Schueler, Tech Vasc Interv Radiol. 2010;13:167-71
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Cen
ter Causes of Occupational InjuriesCauses of Occupational InjuriesCauses of Occupational InjuriesCauses of Occupational Injuries
X-RayImagingX-Ray
Imaging
RadiationRadiationRadiationRadiation
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Radiation
Exposure
Radiation
Exposure
RadiationInjury
RadiationInjury
OrthopedicInjury
OrthopedicInjury
RadiationProtectionRadiationProtection
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“The chronic bearing ofheavy leaded protectiveaprons is implicated asan important factorcontributing to whatappears to be anepidemic of orthopedic
The Cath Lab: An Unhealthy Work EnvironmentKlein, Goldstein et al Cath CV Intervent 2004
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epidemic of orthopediccomplications… resultingin missed days of work,surgery, or, in some cases,curtailed careers.”Current methods only partially protect operators
from hazardous radiation exposure
Long-term lead apron use causes orthopedicproblems
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Cen
ter MODERN INTERVENTIONAL ERAMODERN INTERVENTIONAL ERAMODERN INTERVENTIONAL ERAMODERN INTERVENTIONAL ERA
•• VOLUME OF CASES/OPERATORVOLUME OF CASES/OPERATOR
•• VOLUME OF CASES/Lab (affects techs/nurses)VOLUME OF CASES/Lab (affects techs/nurses)
•• FLUORO & APRON TIME/CASEFLUORO & APRON TIME/CASE
•• VOLUME OF CASES/OPERATORVOLUME OF CASES/OPERATOR
•• VOLUME OF CASES/Lab (affects techs/nurses)VOLUME OF CASES/Lab (affects techs/nurses)
•• FLUORO & APRON TIME/CASEFLUORO & APRON TIME/CASE
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•• COMPLEXITY OF CASESCOMPLEXITY OF CASESCTO’s/StructuralCTO’s/Structural
•• IMAGESIMAGES
Radiation & Ortho ExposureRadiation & Ortho Exposure
•• COMPLEXITY OF CASESCOMPLEXITY OF CASESCTO’s/StructuralCTO’s/Structural
•• IMAGESIMAGES
Radiation & Ortho ExposureRadiation & Ortho Exposure
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Operator Dose Higher with Radial v Femoral Access
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Cen
ter Cath Lab Occupational Health Hazards
Radiation Exposure
Cataracts
Cancers
Cath Lab Occupational Health Hazards
Radiation Exposure
Cataracts
Cancers
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Cancers
Orthopedic Injuries: Lead Apron Burden
Spine (>50%)
Hips, Knees, Ankles >30%
Cancers
Orthopedic Injuries: Lead Apron Burden
Spine (>50%)
Hips, Knees, Ankles >30%
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Biologic Effects of RadiationBiologic Effects of RadiationBiologic Effects of RadiationBiologic Effects of Radiation
Deterministic injuriesDeterministic injuries•• When large numbers of cells are damagedWhen large numbers of cells are damaged
and die immediately or shortly afterand die immediately or shortly afterirradiation. Units of Gy.irradiation. Units of Gy.
•• Threshold doseThreshold dose for visible post procedurefor visible post procedureinjury from erythema to skin necrosis.injury from erythema to skin necrosis.
Deterministic injuriesDeterministic injuries•• When large numbers of cells are damagedWhen large numbers of cells are damaged
and die immediately or shortly afterand die immediately or shortly afterirradiation. Units of Gy.irradiation. Units of Gy.
•• Threshold doseThreshold dose for visible post procedurefor visible post procedureinjury from erythema to skin necrosis.injury from erythema to skin necrosis.
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Stochastic injuriesStochastic injuries•• Post radiation damage, cell descendants arePost radiation damage, cell descendants are
clinically important. Higher dose, the moreclinically important. Higher dose, the morelikellikel the process, and therefore based uponthe process, and therefore based uponprobabilityprobability
•• Linear nonLinear non--threshold dosethreshold dose identifiable foridentifiable forradiationradiation--induced neoplasm and heritableinduced neoplasm and heritablegenetic defects (genetic defects (SvSv).).
Stochastic injuriesStochastic injuries•• Post radiation damage, cell descendants arePost radiation damage, cell descendants are
clinically important. Higher dose, the moreclinically important. Higher dose, the morelikellikel the process, and therefore based uponthe process, and therefore based uponprobabilityprobability
•• Linear nonLinear non--threshold dosethreshold dose identifiable foridentifiable forradiationradiation--induced neoplasm and heritableinduced neoplasm and heritablegenetic defects (genetic defects (SvSv).).
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Risk of Cataract Among interventionalRisk of Cataract Among interventionalCardiologists and Catheterization Lab StaffCardiologists and Catheterization Lab Staff
A systematic review and MetaA systematic review and Meta‐‐analysisanalysis
Catheter CV Intervent 2017; 90: 1-9
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Catheterization and Cardiovascular Interventions
Lens changes found in either or both eyes in >51%
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Occupational Radiation Exposure Linked to Left-sided Brain TumorsOccupational Radiation Exposure Linked to Left-sided Brain Tumors
• Brain tumors in 31 interventionistsGlio 55%, Astro 17%, Mening16%
• Worked in cath lab for prolonged periodMean latency period=23.5 years
• Brain tumors in 31 interventionistsGlio 55%, Astro 17%, Mening16%
• Worked in cath lab for prolonged periodMean latency period=23.5 years
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Roguin A et al, et al Am J Cardiol 2013
• Cancer on Left side of Brain in 85% of cases• Cancer on Left side of Brain in 85% of cases
“Given that the brain is relatively unprotected and the left side of thehead more exposed to radiation than the right, these findingssuggest the possibility of a causal relationship to occupationalradiation exposure”
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Work-Related Musculoskeletal Pain by Job (Mayo)Work-Related Musculoskeletal Pain by Job (Mayo)
Survey: N=1,543N=1,042 Exposedvs501 Unexposed
Back Pain>50%
Age Related
Not just MD’s
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Orme N, et al. JACC 2015
Age>50,Working>15 years= >50% have symptoms!
Yrs Working
Not just MD’sNurses and Techs Suffer too!
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Rate Of Health Problems By Years Of WorkRate Of Health Problems By Years Of Work
Survey: N=466 Exposed vs 280 UnexposedSurvey: N=466 Exposed vs 280 Unexposed
Ortho Illness
CataractsSkin Lesions
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Andreassi et al. Circ Cardiovasc Interv. 2016;9:
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Cen
ter Cath Lab Orthopedic EpidemicCath Lab Orthopedic Epidemic
Ortho Issues in 48%
ACC SurveyNagelhout CardioSurve 2016;40
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Caused/Worsened by Work in 70%
Retire or cut Back in 50%
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In What Modern Rationale WorkplaceIn What Modern Rationale WorkplaceWould Laborers Subject Themselves toWould Laborers Subject Themselves to
Harm on a Daily Basis?Harm on a Daily Basis?
In What Modern Rationale WorkplaceIn What Modern Rationale WorkplaceWould Laborers Subject Themselves toWould Laborers Subject Themselves to
Harm on a Daily Basis?Harm on a Daily Basis?
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Harm on a Daily Basis?Harm on a Daily Basis?Harm on a Daily Basis?Harm on a Daily Basis?
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We are Like Football Players with Leather Helmets and No Face Masks
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How to Improve Safety and HealthHow to Improve Safety and Healthin the Catheterization Labin the Catheterization Lab
How to Improve Safety and HealthHow to Improve Safety and Healthin the Catheterization Labin the Catheterization Lab
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Mitigating Orthopedic ComplicationsMitigating Orthopedic Complications
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Multifactorial Spine Injury: Posture is Important!Multifactorial Spine Injury: Posture is Important!
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• Head-Forward & upward gaze= highestpressure on C-spine
• Neutral gaze is 11 degrees down• Pressure injures discs, facets, &
neuroforamina• Cervical > lumbar injury
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Posture!!!Posture!!!
• Sternum Up and out
• Shoulders down and back
• Feet Width of Shoulders
• Sternum Up and out
• Shoulders down and back
• Feet Width of Shoulders
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• Feet Width of Shoulders
• Pelvis tilted up
• Stretch Hamstrings
• Feet Width of Shoulders
• Pelvis tilted up
• Stretch Hamstrings
Military Bearing, Not Cro Magnon!
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ter Measures to Reduce Back Pain
Exercises, Strengthen Core and PostureMeasures to Reduce Back Pain
Exercises, Strengthen Core and Posture
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How to Improve Safety and HealthHow to Improve Safety and Healthin the Catheterization Labin the Catheterization Lab
How to Improve Safety and HealthHow to Improve Safety and Healthin the Catheterization Labin the Catheterization Lab
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Minimizing Radiation ExposureMinimizing Radiation Exposure
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Radiation Exposure ReductRadiation Exposure Reductiionon“Simple Methods” with Systems in Place“Simple Methods” with Systems in PlaceRadiation Exposure ReductRadiation Exposure Reductiionon
“Simple Methods” with Systems in Place“Simple Methods” with Systems in Place
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Marked Reduction in Operator Radiation DoseMarked Reduction in Operator Radiation Doseby Reducing Frame rate 15 to 7.5 FPSby Reducing Frame rate 15 to 7.5 FPS
Marked Reduction in Operator Radiation DoseMarked Reduction in Operator Radiation Doseby Reducing Frame rate 15 to 7.5 FPSby Reducing Frame rate 15 to 7.5 FPS
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Abdelaal E, et al. JACC Interv 2014;7:567.
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Not Much has ChangedNot Much has ChangedPosition shield betweenpatient and operator
Radiation safety glasseswith side panels
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25
with side panels
Lead skirt, vest andThyroid collar at all times
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Impact of Accessory Lead Shielding on Radiation ExposureAmong Nurses and Technologists
Impact of Accessory Lead Shielding on Radiation ExposureAmong Nurses and Technologists
We are not the only stakeholders
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Madder RD, et al. JACC Cardiol Intv 2018;11(2):20612
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Not Much has ChangedNot Much has ChangedPosition shield betweenpatient and operator
Radiation safety glasseswith side panels
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with side panels
Lead skirt, vest andThyroid collar at all times
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Novel Systems for Occupational HealthNovel Systems for Occupational Health
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Protego