Professional Documents
Culture Documents
Part 8
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
q q q q q
Basic requirements Administration of therapy The radioactive patient. Dose constraints The hospitalized patient Emergency procedures
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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.
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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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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 Uptake (%) 73,5 25,1 67,3 61,3 43,3
4,0 240
Uptake Measurement
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ordering receipt and unpacking storage dispensing internal transports radioactive waste Identification pregnancy breastfeeding
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
Safe administration
Emergency procedures
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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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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?
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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
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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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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Safe Administration
I-131 should be administered in a controlled area (hot lab or the patients 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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0.5
0.1
0.06
0.03 mSv/h
0.5
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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
Generally larger than the derived limits for contamination given by ICRP (publ 57)
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Sm-153
26
3Sv/h* GBq
0 3 Sv /h* GBq , 0 m
0,5
1m
0 0 1 2 3 4 5
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Restrictions
Patient with Iodine-131
Activity of I-131 administered (MBq) 30-200 200-400 400-600 600-800 Behaviour restriction Period of restrictions (d) Stay at least 1 metre away from all members 5 9 12 14
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
15 -
21 -
25 4 -
27 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 th row is 5 mSv ird The fourth row only covers on single event whereas the other ategories assume daily contact. c
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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
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
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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
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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 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
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
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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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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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Isolation Ward
Areas are covered with plastic Areas are covered with plastic backed absorbent material. backed absorbent material.
Warning Signs
Radiation sign posted on door and on Patient Chart
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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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 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 patients room Do not touch the toilet or sink in the patients 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 Sv/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
T ypical Graph Showing the Percentage of I-131that is Retained in the Body of a Patient Adm inistered with 5.5 GBq
100 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%)
140 120 100 80 60 40
Number of Patients
(16%)
31
(4%)
20 0
(5%)
10 3 4 5
0 1 2
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
Furniture and telephone sets are surveyed. Areas suspected to be contaminated are surveyed.
Monitoring
Are or ite a m Toilet Washroom floor Sink and Faucets Shower Bed Arm chair Bedroom floor TV/Telephone Bedside table Doorknobs Lam switches p Initial (Bq/cm2) Afte cle r aning (Bq/cm2)
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A Radiation Safe sign is posted at the door after decontamination and clearing of room
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 patients 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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HELP!
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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)
R adio nu clide I-131 Y-90 colloid A u-198 colloid P-32 S r-89 B urial 400 2000 400 2000 2000 C rem ation 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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sessions
qFurther
s
readings
IAEA, International Basic Safety Standards for Protection Against Ionizing Radiation and for the Safety of Radiation Sources Safety Series No.115, Interim Edition (2011) s IPEM, Medical and Dental Guidance Notes. A good practice guide to implement ionising radiation protection legislation in the clinical environment s IAEA/WHO Manual on Radiation Protection in Hospitals and General Practice, Volume 4, Nuclear Medicine s IAEA, Manual on therapeutic use of iodine-131. Practical Radiation Safety Guide
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