IAEAInternational Atomic Energy
Agency
Radiation Protection in Paediatric Radiation Protection in Paediatric RadiologyRadiology
Standards and Guidelines in Standards and Guidelines in Radiological Procedures in Radiological Procedures in
Children Children
L08L08
IAEA 2Radiation Protection in Paediatric Radiology L08. Standards and guidelines
Educational Objectives
At the end of the programme, the participants
should become familiar with:• International standards & guidelines• Responsibilities of medical practitioners• How these standards are applied in
paediatric radiology
IAEA 3Radiation Protection in Paediatric Radiology L08. Standards and guidelines
Answer True or False
1. ICRP provides recommendations for use in diagnostic radiology for the protection of the patients and staff.
2. Dose limits apply to medical exposures of patients.
3. Radiologists need special training for paediatric radiology.
IAEA 4Radiation Protection in Paediatric Radiology L08. Standards and guidelines
Contents
• Why we do need standards and guidelines?
• International framework of radiation protection for medical exposures
• Application of basic principles of radiation protection in paediatric radiology
IAEA 5Radiation Protection in Paediatric Radiology L08. Standards and guidelines
Why do we need Standards and guidelines ?
• International Standards are a set of mandatory requirements agreed on by worldwide consensus
• Application of standards and guidelines ensures implementation of principles:• To minimize the occurrence
of stochastic effects• To avoid tissue reactions
• Children are recognized as a special case
IAEA 6Radiation Protection in Paediatric Radiology L08. Standards and guidelines
International framework for radiation protection
• Requirement that there be a clear delineation of responsibility extending from the level of the highest official body of the hospital or clinic involved, to the operational level
• Relies on three principles adopted in most regulatory systems throughout the world:• Justification of the activity or practice involved• Optimization of the activity in terms of risks,
costs, benefits etc.• Limitation of the doses received by various
groups including workers and the general public
IAEA 7Radiation Protection in Paediatric Radiology L08. Standards and guidelines
UNSCEAR
• UNSCEAR: United Nations Scientific Committee on the Effects of Atomic Radiation:•Assess and report
levels and effects of exposure to ionizing radiation
http://www.unscear.org/
IAEA 8Radiation Protection in Paediatric Radiology L08. Standards and guidelines
ICRP
• ICRP: International Commission on Radiological Protection•Provides
recommendations and guidance on all aspects of protection against ionizing radiation
http://www.icrp.org/
IAEA 9Radiation Protection in Paediatric Radiology L08. Standards and guidelines
IAEA
• IAEA: International Atomic Energy Agency•Establish standards of safety
for the protection of health and minimization of danger to life, in collaboration with the appropriate organs of the UN and the specialized agencies concerned, and provide for the application of these standards
http://www.iaea.org/
IAEA 10Radiation Protection in Paediatric Radiology L08. Standards and guidelines
International framework for radiation protection
IAEA 11Radiation Protection in Paediatric Radiology L08. Standards and guidelines
IAEA
SafetyGuides
SafetyPractices
TECDOCs
TechnicalReports
SafetyFundamentals and Standards
IAEA 12Radiation Protection in Paediatric Radiology L08. Standards and guidelines
“…marks the culmination of efforts that have continued over the past
several decades towards the
harmonization of radiation protection and safety standards internationally”
International Basic Safety Standard (BSS)
IAEA 13Radiation Protection in Paediatric Radiology L08. Standards and guidelines
Medical Exposure
Radiation doses incurred:
By patients as part of their own medical or dental diagnosis or treatment
By individuals (other than those occupationally exposed) knowingly exposed while voluntarily helping patients
By volunteers exposed for biomedical research purposes (must be under approved protocol; usually children may not participate, only exceptionally and for their own diagnosis or treatment)
IAEA 14Radiation Protection in Paediatric Radiology L08. Standards and guidelines
SupervisorMedical Practitioner
Worker
Responsibilities
• Principal responsibility for radiation protection•Legal person subject of authorization
(licensee) and employer
• Subsidiary responsibilities
Radiologists
IAEA 15Radiation Protection in Paediatric Radiology L08. Standards and guidelines
Advice of a qualified expert, medical physicist
Radiologist
Patient Protectio
n
Responsibilities
Training criteria
OptimizationEquipment
design and suppliers
Quality assurance
BSS
Justification
IAEA 16Radiation Protection in Paediatric Radiology L08. Standards and guidelines
Responsibilities for Medical Exposure
• Medical exposure has to be prescribed by a medical practitioner (justification)
• Medical practitioners are assigned the primary task and obligation of ensuring overall patient protection and safety in the prescription of, and during the delivery of, medical exposure
IAEA 17Radiation Protection in Paediatric Radiology L08. Standards and guidelines
Responsibility for Medical Exposure
• … training criteria are to be specified or be subject to approval, as appropriate, by the Regulatory Authority in consultation with relevant professional bodies (i.e., cardiology, radiology, interventional cardiology)
IAEA 18Radiation Protection in Paediatric Radiology L08. Standards and guidelines
Justification
• Education and training of both referring physicians and radiologists plays a crucial role in ensuring that justification works well in practice
• The knowledge required for Justification includes: • Clinical history, including examinations already performed,• Potential benefits of the action,• Awareness of short term and long term consequences,
including the risks, • Up-to-date knowledge of any available alternative actions, • Knowledge of the consequences of not taking any action,
and • Knowledge of referral guidelines and/or appropriateness
criteria where they are available
IAEA 19Radiation Protection in Paediatric Radiology L08. Standards and guidelines
Justification of medical exposures and dose limits
• ICRP has recommended that dose limits not be applied to medical exposures
• Even with the higher radiation sensitivity of children, this recommendation is also applied to paediatrics
• It is based on the fact that the exposed individual will derive benefit from the procedure, provided it has been properly justified
IAEA 20Radiation Protection in Paediatric Radiology L08. Standards and guidelines
Responsibility for Medical Exposure
• … the imaging and quality assurance requirements of the Standards should be fulfilled with the advice of a qualified expert in … medical physics
• Optimization requirement on equipment design: ensure that whether imported into or manufactured in the country where it is used, the equipment conforms to applicable standards of the:• International Electrotechnical Commission (IEC) • International Organisation for Standardization (ISO) or
to equivalent national standards;
IAEA 21Radiation Protection in Paediatric Radiology L08. Standards and guidelines
Optimization
• Once justified, examinations must be optimised:
•Generic: for examination type and equipment and procedures involved
•Specific: for the individual patients
IAEA 22Radiation Protection in Paediatric Radiology L08. Standards and guidelines
Optimization
• Ensure that the appropriate equipment be used• The medical practitioner, the technologist or
other imaging staff select the relevant combination of parameters, that results in: •minimum patient exposure consistent with
acceptable image quality and the clinical purpose of the examination,
•paying particular attention to this selection for paediatric radiology and interventional radiology
IAEA 23Radiation Protection in Paediatric Radiology L08. Standards and guidelines
Diagnostic reference levels (DRL)
• Guidance for radiologists and other practitioners to help to achieve good examinations at reasonable dose levels
• In paediatric radiology, adoption and use of paediatric protocols
• If DRLs are exceeded regularly, the practice involved should be investigated.
• DRL for an examination is derived from a regional, national, or sometimes international, survey of the doses for that examination ( usually taken as the third quartile value for the dose distribution obtained in the survey)
IAEA 24Radiation Protection in Paediatric Radiology L08. Standards and guidelines
Dose constraints
• Dose constraints are used as an upper bound on the doses that individuals might expect to receive in comforting, caring for or assisting with immobilization of a patient
• Should not be applied as a dose limit • Exposure of comforters and carers is
considered as medical exposure (dose constraint is applied)
IAEA 25Radiation Protection in Paediatric Radiology L08. Standards and guidelines
Unintended exposure
• Unintended exposures of patients arise from failures in justification, failures in optimisation or errors
IAEA 26Radiation Protection in Paediatric Radiology L08. Standards and guidelines
Accidental Medical Exposures
• … any diagnostic exposure substantially greater than intended …
• Investigation required•Calculate or estimate doses received• Indicate corrective measures•Submit a report• Inform the patient and his/her doctor
about the incident
IAEA 27Radiation Protection in Paediatric Radiology L08. Standards and guidelines
Pregnancy issues
Special care should be observed with respect to:
• irradiation of pregnant or potentially pregnant occupationally exposed workers
• comforters and carers • members of the public
Pregnancy can occur in adolescent girls, thus precautions for this group should be followed for exposures which may involve a foetus
IAEA 29Radiation Protection in Paediatric Radiology L08. Standards and guidelines
Occupational
Protection
Responsibilities
Personal protective
devices
Individual exposure
monitoring
BSS
Pregnant workers
Workplace monitoring
Health surveillanc
e
IAEA 30Radiation Protection in Paediatric Radiology L08. Standards and guidelines
Dose limits for occupationally exposed workers and members of
the public
Type of limit Occupational Public
Effective dose 20 mSv/year 1 mSv/year
Annual equivalent dose
Lens of the eye 150 mSv 15 mSv
Skin 500 mSv 50 mSv
Hand and feet 500 mSv
ICRP 103
IAEA 31Radiation Protection in Paediatric Radiology L08. Standards and guidelines
Education and training
• Special education and training related to radiation protection in paediatric radiology, techniques and equipment used:•medical practitioners providing
radiological services•other professions including medical
physicists and technologists• Further, continuous professional
development allows professionals to continue to cope with new developments
IAEA 32Radiation Protection in Paediatric Radiology L08. Standards and guidelines
http://europa.eu.int/comm/environment/
radprot
http://rpop.iaea.org/RPOP/RPoP/Content/AdditionalResources/Training/1_TrainingMaterial/index.htm
IAEA 33Radiation Protection in Paediatric Radiology L08. Standards and guidelines
European Guidelines on Quality Criteria for Diagnostic Radiographic Images in Paediatrics, July 1996.
EUR 16261 EN
Free PDF version available at:
http://www.cordis.lu/fp5-euratom/src/lib_docs.htm
Applying standards in practice
IAEA 35Radiation Protection in Paediatric Radiology L08. Standards and guidelines
Quality Criteria List
IAEA 38Radiation Protection in Paediatric Radiology L08. Standards and guidelines
Criteria related to images
• The Image Criteria for paediatric patients presented for a particular type of radiograph are those deemed necessary to produce an image of standard quality
• No attempt has been made to define acceptability for particular clinical indications
• The image criteria allow an immediate evaluation of the image quality, with respect to: • the smaller body size, the age-dependent body
composition, lack of co-operation and other functional differences
IAEA 39Radiation Protection in Paediatric Radiology L08. Standards and guidelines
Criteria related to images
• A lower level of image quality may be acceptable for certain clinical indications
• An inferior image quality, however, cannot be justified unless it is set for clinical indication to reduce radiation dose
• The fact that the X-Ray was taken from a non-cooperative paediatric patient (anxious, crying, heavily resisting) is not an excuse for producing an inferior quality image which is often associated with an unnecessary dose (due to the need for a repeat exam)
IAEA 40Radiation Protection in Paediatric Radiology L08. Standards and guidelines
http://rpop.iaea.org/RPOP/RPoP/Content/InformationFor/HealthProfessionals/1_Radiology/Standards.htm
IAEA 41Radiation Protection in Paediatric Radiology L08. Standards and guidelines
Summary
• Radiation protection system has an international framework
• Radiology of children is different from adult radiology• The special requirements that arise apply to all
aspects of the radiation protection system, including:• justification• optimization, including the use of DRL
• All persons directing and conducting medical radiation exposure of children, including radiologists and technologists, should have received recognised education and training in their discipline
IAEA 42Radiation Protection in Paediatric Radiology L08. Standards and guidelines
Answer True or False
1. ICRP provides recommendations for use in diagnostic radiology for the protection of the patients and staff.
2. Dose limits apply to medical exposures of patients.
3. Radiologists need special training for paediatric radiology.
IAEA 43Radiation Protection in Paediatric Radiology L08. Standards and guidelines
Answer True or False
1. True – ICRP’s principles of justification, optimization and dose limitation and specific recommendations in different conditions are available for the protection of the patients and staff.
2. False – There are no regulatory dose limits that apply to medical exposures of patients. However, DRLs are available.
3. True – In view of peculiar situations in paediatric radiology, specific training is required.
IAEA 44Radiation Protection in Paediatric Radiology L08. Standards and guidelines
References
• INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION, Radiological Protection in Medicine, Publication 105, Elsevier, Oxford (2008).
• INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION, Recommendations of the ICRP, Publication 60, Pergamon Press, Oxford (1991).
• INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION, Recommendations of the ICRP, Publication 103, Elsevier, Oxford (2008).
• FOOD AND AGRICULTURE ORGANIZATION OF THE UNITED NATIONS, INTERNATIONAL ATOMIC ENERGY AGENCY, INTERNATIONAL LABOUR ORGANIZATION, OECD NUCLEAR ENERGY AGENCY, PAN AMERICAN HEALTH ORGANIZATION, WORLD HEALTH ORGANIZATION, International Basic Safety Standards for Protection Against Ionizing Radiation and for the Safety of Radiation Sources, Safety Series No. 115, IAEA, Vienna (1996).
• EUROPEAN COMMISION, Council Directive 1997/43/Euratom on health protection of individuals against ionizing radiation in relation to medical exposure, Off. J. Eur. Commun. L. 180, 22–27 (1997).
• EUROPEAN COMMISSION, Referral Guidelines for Imaging, Luxembourg, Radiation Protection 118, Office for Official Publications of the European Communities, Luxembourg (2001) and Update Mars 2008
• EUROPEAN COMMISSION, Guidelines on Education and Training in Radiation Protection for Medical Exposures. Radiation Protection 116, Office for Official Publications of the European Communities, Luxembourg, (2000).
• EUROPEAN COMMISSION, European Guidelines on Quality Criteria for Diagnostic Radiographic Images in Paediatrics, Rep. EUR 16261, Office for Official Publications of the European Communities, Luxembourg Communities, Luxembourg, (1996).