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Radiation Dose Management for Fluoroscopically Guided
Interventional Medical Procedures issue 168 1st Edition
Ncrp Publications Digital Instant Download
Author(s): Ncrp Publications
ISBN(s): 9780982384367, 098238436X
Edition: 1
File Details: PDF, 3.64 MB
Year: 2011
Language: english
99107NCRP_Cover-R1 10/18/07 12:44 PM Page 1

156 NCRP REPORT No. 168

AND PROCEDURES FOR THEIR ASSESSMENT, DOSIMETRY AND TREATMENT

DEVELOPMENT OF A BIOKINETIC MODEL FOR RADIONUCLIDE-CONTAMINATED WOUNDS
RADIATION DOSE
MANAGEMENT FOR
FLUOROSCOPICALLY-
GUIDED INTERVENTIONAL
MEDICAL PROCEDURES
 NCRP REPORT No. 168

Radiation Dose
Management for
Fluoroscopically-Guided
Interventional Medical
Procedures

Recommendations of the
NATIONAL COUNCIL ON RADIATION
PROTECTION AND MEASUREMENTS

July 21, 2010

National Council on Radiation Protection and Measurements

7910 Woodmont Avenue, Suite 400 / Bethesda, MD 20814-3095
 LEGAL NOTICE
This Report was prepared by the National Council on Radiation Protection and
Measurements (NCRP). The Council strives to provide accurate, complete and use-
ful information in its publications. However, neither NCRP, the members of NCRP,
other persons contributing to or assisting in the preparation of this Report, nor any
person acting on the behalf of any of these parties: (a) makes any warranty or rep-
resentation, express or implied, with respect to the accuracy, completeness or use-
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damages resulting from the use of any information, method or process disclosed in
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U.S.C. Section 2000e et seq. (Title VII) or any other statutory or common law theory
governing liability.

Disclaimer
Any mention of commercial products within NCRP publications is for informa-
tion only; it does not imply recommendation or endorsement by NCRP.

Library of Congress Cataloging-in-Publication Data

Radiation dose management for fluoroscopically guided interventional medical

procedures.
p. ; cm. -- (NCRP report ; no. 168)
Includes bibliographical references and index.
ISBN 978-0-9823843-6-7 (alk. paper)
1. Fluoroscopy--Equipment and supplies. 2. Radiation--Dosage. 3. Radiation--
Safety measures. I. National Council on Radiation Protection and Measurements.
II. Series: NCRP report ; no. 168.
[DNLM: 1. Fluoroscopy--instrumentation. 2. Equipment Safety. 3. Radiation
Dosage. 4. Radiation Protection. 5. Radiography, Interventional--adverse effects.
WN 220]
RC78.5.R33 2011
616.07'572--dc22

2011002846

Copyright © National Council on Radiation

Protection and Measurements 2011
All rights reserved. This publication is protected by copyright. No part of this publica-
tion may be reproduced in any form or by any means, including photocopying, or
utilized by any information storage and retrieval system without written permission
from the copyright owner, except for brief quotation in critical articles or reviews.

[For detailed information on the availability of NCRP publications see page 314.]
Preface

This Report was developed under the auspices of Program Area

Committee 2 of the National Council on Radiation Protection and
Measurements, the committee that provides oversight for opera-
tional radiation safety.
Fluoroscopically-guided interventional medical procedures (e.g.,
diagnostic angiography, angioplasty, stent placement) are now
commonly performed in the United States, are often less invasive
and less costly, and result in shorter hospital stays than surgical
procedures. They are performed by radiologists and other medical
specialists (e.g., cardiologists, orthopedic surgeons) with the assis-
tance of medical support staff.
This Report will be of benefit to these physicians and the medi-
cal support staff, particularly those who currently participate in
fluoroscopically-guided interventional procedures but do not have
sufficient training in the practical radiation protection aspects
of the use of the equipment for the procedures (e.g., knowledge of
equipment operation, optimal imaging techniques, radiation dose
management for patients and medical staff, benefit-risk tradeoffs,
and the potential for early or late detrimental radiation effects). An
extensive bibliography is provided to facilitate access to the pri-
mary literature.
This Report is also intended for policymakers who can place
radiation-dose management requirements on those who conduct
fluoroscopically-guided interventional procedures with regard to:
• optimizing imaging protocols;
• managing procedure time;
• utilizing available radiation protective equipment and dose-
management features;
• tracking and trending radiation doses to patients and medi-
cal staff; and
• credentialing and privileging physicians to use the fluoro-
scopic equipment for these specialized procedures.

This Report was prepared by Scientific Committee 2-3 on Radi-

ation Safety Issues for Image-Guided Interventional Medical Pro-
cedures. Serving on Scientific Committee 2-3 were:

iii
iv / PREFACE

Stephen Balter, Chairman

Columbia University Medical Center
New York, New York
Vice Chairmen
Beth A. Schueler Donald L. Miller
Mayo Clinic Uniformed Services University
Rochester, Minnesota of the Health Sciences
Bethesda, Maryland

Members
Jeffrey A. Brinker Cynthia H. McCollough
Johns Hopkins Hospital Mayo Clinic
Baltimore, Maryland Rochester, Minnesota
Charles E. Chambers Keith J. Strauss
Pennsylvania State College Harvard Medical School
of Medicine Boston, Massachusetts
Hershey, Pennsylvania
Kenneth F. Layton Louis K. Wagner
Baylor University Medical University of Texas Medical
Center School
Dallas, Texas Houston, Texas
M. Victoria Marx
University of Southern
California Medical Center
Los Angeles, California
Consultants
John F. Angle Norman J. Kleiman
University of Virginia Columbia University
Charlottesville, Virginia New York, New York
Lionel Desponds John W. Hopewell
GE Healthcare Green Templeton College
Buc, France University of Oxford
Oxford, United Kingdom
Andrew Einstein Matthew Williams
Columbia University Medical Columbia University
Center New York, New York
New York, New York

NCRP Secretariat
Marvin Rosenstein, Staff Consultant
Cindy L. O’Brien, Managing Editor
David A. Schauer, Executive Director
 PREFACE / v

The Council expresses its appreciation to the Committee mem-

bers for the time and effort devoted to the preparation of this
Report. NCRP gratefully acknowledges the financial support pro-
vided by the National Cancer Institute (NCI) under Grant Number
R24 CA074296-10. The contents of this Report are the sole respon-
sibility of NCRP, and do not necessarily represent the official views
of NCI, National Institutes of Health.

Thomas S. Tenforde
President
Contents
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

1. Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
1.1 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
1.2 Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

2. General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

2.1 Scope and Applicability of this Report . . . . . . . . . . . . . . . .10
2.2 Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
2.2.1 Definition of a Fluoroscopically-Guided
Interventional Procedure . . . . . . . . . . . . . . . . . . .11
2.2.2 Types of Procedures . . . . . . . . . . . . . . . . . . . . . . . .11
2.2.3 Temporal Trends . . . . . . . . . . . . . . . . . . . . . . . . . .14
2.2.4 Individuals Performing Interventional Procedures
(interventionalists) . . . . . . . . . . . . . . . . . . . . . . . .16
2.3 Efficacy, Effectiveness, Benefit-Cost Analyses . . . . . . . . .17
2.3.1 Diagnostic Procedures . . . . . . . . . . . . . . . . . . . . . .17
2.3.2 Therapeutic Procedures . . . . . . . . . . . . . . . . . . . .18
2.4 Justification, Appropriateness, and Benefit-Risk
Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18
2.4.1 Patient Benefit-Risk Analysis Models . . . . . . . . .19
2.4.1.1 Diagnostic Studies . . . . . . . . . . . . . . . . .19
2.4.1.1.1 Benefit . . . . . . . . . . . . . . . . . .19
2.4.1.1.2 Procedure Risk . . . . . . . . . . . .20
2.4.1.1.3 Radiation Risk . . . . . . . . . . . .20
2.4.1.2 Therapeutic Procedures . . . . . . . . . . . . .20
2.4.1.2.1 Benefit . . . . . . . . . . . . . . . . . .20
2.4.1.2.2 Procedure Risk . . . . . . . . . . . .21
2.4.1.2.3 Radiation Risk . . . . . . . . . . . .21
2.4.2 Applying Benefit-Risk Analyses . . . . . . . . . . . . . .23
2.4.3 Risks to Interventionalists and Staff . . . . . . . . . .25
2.4.3.1 Radiation Risk . . . . . . . . . . . . . . . . . . . .25
2.4.3.2 Medical Risks . . . . . . . . . . . . . . . . . . . . .26
2.4.3.2.1 Ergonomic Risks to
Interventionalists. . . . . . . . . .26
2.4.3.2.2 Economic Benefit to Operator
and Staff . . . . . . . . . . . . . . . . .27
2.4.4 Benefit to Society . . . . . . . . . . . . . . . . . . . . . . . . . .27
2.4.5 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28
2.5 Physics and Dosimetry . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

vii
viii / CONTENTS

2.6 Radiation Health Effects . . . . . . . . . . . . . . . . . . . . . . . . . . 33

2.6.1 Demographic Factors . . . . . . . . . . . . . . . . . . . . . . 33
2.6.2 Medical History Factors . . . . . . . . . . . . . . . . . . . . 34
2.6.3 Cancer Risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
2.6.3.1 Worker Cancer Risk . . . . . . . . . . . . . . . 37
2.6.3.2 Patient Cancer Risk . . . . . . . . . . . . . . . 37
2.6.3.3 Stochastic Risk-Related Aspects of
Dosimetry . . . . . . . . . . . . . . . . . . . . . . . 38
2.6.4 Deterministic Effects . . . . . . . . . . . . . . . . . . . . . . 41
2.6.4.1 Tissue Reactions: Skin and Hair . . . . . 43
2.6.4.2 Tissue Reactions: Lens of the Eye . . . . 44
2.6.5 In Utero Irradiation . . . . . . . . . . . . . . . . . . . . . . . 49
2.6.6 Heritable Effects . . . . . . . . . . . . . . . . . . . . . . . . . . 50

3. Fluoroscopy Equipment and Facilities . . . . . . . . . . . . . . . . 51

3.1 Equipment Configurations . . . . . . . . . . . . . . . . . . . . . . . . 53
3.1.1 General Considerations . . . . . . . . . . . . . . . . . . . . 53
3.1.2 Specific Equipment Components . . . . . . . . . . . . . 58
3.1.3 Specific Equipment Components for Pediatric
Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
3.2 Room Design and Structural Radiation Protection . . . . . 61

4. Protection of the Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

4.1 Patient Dose Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
4.1.1 Cardiac Procedures . . . . . . . . . . . . . . . . . . . . . . . . 69
4.1.2 Other Interventional Procedures . . . . . . . . . . . . . 70
4.1.3 Pediatric Interventional Procedures . . . . . . . . . . 74
4.2 Patient Radiation Dose-Management Program . . . . . . . . 86
4.2.1 Radiation History . . . . . . . . . . . . . . . . . . . . . . . . . 86
4.2.2 Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
4.2.3 Type of Procedure . . . . . . . . . . . . . . . . . . . . . . . . . 87
4.2.4 General Principles of Radiation Dose
Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
4.2.4.1 Patient Dose Monitoring. . . . . . . . . . . . 89
4.2.4.2 Optimizing Patient Dose. . . . . . . . . . . . 90
4.2.4.3 Managing Peak Skin Dose . . . . . . . . . . 93
4.3 Sample Patient Radiation Dose-Management Process . . 94
4.3.1 Preprocedure Planning . . . . . . . . . . . . . . . . . . . . . 94
4.3.2 Fluoroscopic Set-Up and Configuration . . . . . . . 94
4.3.3 Intraprocedural Management . . . . . . . . . . . . . . . 95
4.3.3.1 Radiation Dose Management . . . . . . . . 96
4.3.3.2 Monitoring Patient Radiation Dose . . . 97
4.3.3.3 Use of Radiation-Level Information
During the Procedure . . . . . . . . . . . . . . 99
4.3.4 Post-Procedure Management . . . . . . . . . . . . . . . . 99
 CONTENTS / ix

4.3.4.1 Dose Documentation . . . . . . . . . . . . . . .99

4.3.4.2 Substantial Radiation Dose Level . . . .101
4.3.4.3 Interventionalist Responsibilities . . . .103
4.3.4.4 Patient Follow-Up. . . . . . . . . . . . . . . . .104
4.3.5 Radiation Dose-Management Processes . . . . . . .105
4.3.5.1 Diagnostic Radiography and Diagnostic
Reference Levels. . . . . . . . . . . . . . . . . .106
4.3.5.2 Fluoroscopy-Guided Interventional
Procedures and Advisory Data . . . . . .107
4.3.5.3 Example of Using an Advisory Data Set
to Evaluate a Facility . . . . . . . . . . . . . .108
4.3.5.4 Further Research and Data
Collection . . . . . . . . . . . . . . . . . . . . . . .114

5. Protection of Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .115

5.1 Review of Staff Exposure . . . . . . . . . . . . . . . . . . . . . . . . .116
5.2 Essential Radiation Protection Knowledge . . . . . . . . . . .116
5.3 Pregnant or Potentially-Pregnant Workers . . . . . . . . . . .117
5.4 Radiation Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120
5.5 Personal Radiation Protective Equipment . . . . . . . . . . .125
5.5.1 Lead and Other Attenuating Materials
(lead-equivalent thickness) . . . . . . . . . . . . . . . . .125
5.5.2 Protective Garments . . . . . . . . . . . . . . . . . . . . . .126
5.5.3 Thyroid Shields . . . . . . . . . . . . . . . . . . . . . . . . . .128
5.5.4 Protective Glasses . . . . . . . . . . . . . . . . . . . . . . . .128
5.5.5 Protective Gloves . . . . . . . . . . . . . . . . . . . . . . . . .130
5.5.6 Movable Shielding . . . . . . . . . . . . . . . . . . . . . . . .131
5.6 Situational Awareness . . . . . . . . . . . . . . . . . . . . . . . . . . .133
5.7 Personal Monitoring and Risk Assessment . . . . . . . . . . .134
5.7.1 Occupational Dose Limits . . . . . . . . . . . . . . . . . .134
5.7.2 Dose-Monitoring Policy Considerations . . . . . . .137
5.7.3 Operational Dose Monitoring . . . . . . . . . . . . . . .138
5.7.4 Investigation of Personal-Dosimeter Readings .142
5.7.5 Investigation of High Occupational Dose . . . . . .144

6. Administrative and Regulatory Considerations . . . . . . .146

6.1 Human Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .148
6.1.1 Principals (physicians and other authorized
independent operators) . . . . . . . . . . . . . . . . . . . .148
6.1.2 Routine Direct-Support Staff . . . . . . . . . . . . . . .148
6.1.3 Occasional Direct-Support Staff . . . . . . . . . . . . .148
6.1.4 Indirect-Support Staff . . . . . . . . . . . . . . . . . . . . .149
6.1.5 General-Support Staff . . . . . . . . . . . . . . . . . . . . .149
6.1.6 Administrative and Management Staff . . . . . . .149
6.1.7 Visitors to the Procedure Room . . . . . . . . . . . . .149
x / CONTENTS

6.2 Education and Training . . . . . . . . . . . . . . . . . . . . . . . . . . 152

6.2.1 Physicians and Other Authorized Independent
Operators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
6.2.2 Routine and Occasional Direct-Support Staff . . 154
6.2.3 Indirect-Support Staff . . . . . . . . . . . . . . . . . . . . 156
6.2.4 General-Support Staff . . . . . . . . . . . . . . . . . . . . 156
6.2.5 Administrative and Management Staff . . . . . . . 157
6.2.6 Visitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
6.3 Radiation Safety Credentials and Clinical Privileges . . 157
6.3.1 Physicians and Other Independent Operators
(interventionalists) . . . . . . . . . . . . . . . . . . . . . . 157
6.3.2 Routine Direct-Support Staff . . . . . . . . . . . . . . . 158
6.3.3 Medical Physicists, Medical Health Physicists,
Radiation Safety Officers . . . . . . . . . . . . . . . . . 158
6.4 Purchase, Configuration, and Technical Quality
Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
6.4.1 Equipment Economics Overview . . . . . . . . . . . . 159
6.4.2 Initial Activities . . . . . . . . . . . . . . . . . . . . . . . . . 159
6.4.3 Technical Quality-Control Program . . . . . . . . . 160

7. Summary and Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . 162

Appendix A. Benefit-Cost Analyses . . . . . . . . . . . . . . . . . . . . . . 165

A.1 Diagnostic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
A.2 Therapeutic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . 166
A.2.1 Percutaneous Coronary Intervention . . . . . . . . 166
A.2.2 Uterine Fibroid Embolization . . . . . . . . . . . . . . 167
A.2.3 Endovascular Aneurysm Repair . . . . . . . . . . . . 168

Appendix B. Benefit-Risk Analysis . . . . . . . . . . . . . . . . . . . . . . 171

B.1 Diagnostic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
B.2 Therapeutic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . 173
B.2.1 Interventions in the Central Nervous System . 174
B.2.2 Interventions in the Heart . . . . . . . . . . . . . . . . . 175
B.2.2.1 Percutaneous Coronary Interventions 175
B.2.2.2 Electrophysiology Procedures. . . . . . . 179
B.2.3 Interventions in the Abdomen and Pelvis . . . . . 183
B.2.3.1 Uterine Fibroid Embolization. . . . . . . 183
B.2.3.2 Endovascular Aneurysm Repair . . . . 184
B.2.4 Pediatric Interventional Radiology . . . . . . . . . . 185
B.2.4.1 Central Venous Access . . . . . . . . . . . . 185
B.2.4.2 Angiography and Vascular
Intervention. . . . . . . . . . . . . . . . . . . . . 186
B.2.4.3 Treatment of Vascular Anomalies . . . 186
B.2.4.4 Biopsies and Drainages . . . . . . . . . . . 186
B.2.4.5 Gastrointestinal Intervention . . . . . . 187
 CONTENTS / xi

Appendix C. Medical Risks to Interventionalists and Staff .188

Appendix D. Physics and Dosimetry . . . . . . . . . . . . . . . . . . . . .190

D.1 Dosimetry Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . .190
D.2 Fluoroscopic Radiation Beams . . . . . . . . . . . . . . . . . . . . .198

Appendix E. Lens of the Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . .202

E.1 Lens of the Eye Anatomy and Pathology . . . . . . . . . . . . .202
E.2 Epidemiology of Radiation Effects on the Lens of the
Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .203
E.3 Protocol for a Slit-Lamp Examination . . . . . . . . . . . . . . .204

Appendix F. Tissue Reactions: Skin and Hair . . . . . . . . . . . . .206

F.1 Biological Factors Influencing Skin Reactions . . . . . . . .206
F.2 Biology of Radiation Injuries . . . . . . . . . . . . . . . . . . . . . .207
F.3 Initiating Dose and Subsequent Time Course of Radiation
Injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .209
F.3.1 Prompt Reactions (less than two weeks) . . . . . .210
F.3.2 Early Reactions (two to eight weeks) . . . . . . . . .211
F.3.3 Mid-Term Reactions (6 to 52 weeks) . . . . . . . . .215
F.3.4 Long-Term Reactions (>40 weeks) . . . . . . . . . . .216

Appendix G. Graded Examples of Skin Reactions to

Radiation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .217

Appendix H. Theory of Operation of Equipment . . . . . . . . . .225

H.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .225
H.2 Workflow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .226
H.3 Main Acquisition Modes . . . . . . . . . . . . . . . . . . . . . . . . . .228
H.4 Interventional Suite Layout . . . . . . . . . . . . . . . . . . . . . . .229
H.5 Interventional Image Chain . . . . . . . . . . . . . . . . . . . . . . .232
H.6 Patient Support and Image-Chain Gantry . . . . . . . . . . .235
H.6.1 Patient Support . . . . . . . . . . . . . . . . . . . . . . . . . .235
H.6.2 Image-Chain Gantry . . . . . . . . . . . . . . . . . . . . . .236
H.7 Automatic Exposure-Rate Control Devices . . . . . . . . . . .238
H.8 Interventional Image Processing . . . . . . . . . . . . . . . . . . .240
H.9 Anatomical Programming . . . . . . . . . . . . . . . . . . . . . . . . .242
H.9.1 Anatomical Program Selection: Fluorography
(image recording mode) . . . . . . . . . . . . . . . . . . . .243
H.9.2 Anatomical Program Selection: Fluoroscopy . . .245

Appendix I. Pediatric Equipment Considerations . . . . . . . . .246

Appendix J. Example of Information for Informed Consent

for Radiation Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .248
xii / CONTENTS

Appendix K. Example of Post-Procedure Patient Discharge

Instructions for a Substantial Radiation Dose Level . . . 249

Appendix L. Equipment Acquisition and Testing . . . . . . . . . 250

Appendix M. List of Practical Actions to Reduce Unnecessary

Radiation Exposure to Patients and Staff During FGI
Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253

Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254

Acronyms and Symbols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265

The NCRP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305

NCRP Publications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314

1. Executive Summary

1.1 General

The “fluoroscope” is defined as an instrument used chiefly in

industry and in the practice of medicine for observing the internal
structure of objects (such as the living body) by means of the
shadow cast by the object examined upon a fluorescent screen when
placed between the screen and a source of x rays.
The simple “fluoroscopic screen” referred to in this definition
has been replaced in current medical practice by vacuum-tube
image intensifiers and solid-state detectors. These devices are col-
lectively called “image receptors.”
Conventional radiography in medicine is preferred for the
acquisition of static images (e.g., chest radiography). Medical fluo-
roscopy is normally reserved for the observation of moving objects.
Fluoroscopes have two main modes of operation:

• fluoroscopy: intended to observe moving objects for rela-

tively long periods of time (seconds to minutes) without the
intent of preserving the images; and
• fluorography: intended to record images of moving objects for
a few seconds at a time (e.g., cinefluorography of the heart).

The production of fluorographic images requires air-kerma

rates (incident on the patient’s skin) that are usually 10 to 100
times higher than for fluoroscopic images of the same patient
and anatomical view. Traditionally, fluoroscopic, fluorographic, and
radiographic images were acquired and managed using somewhat
different technologies. At present, a state-of-the-art fluoroscopic
system is able to produce all three classes of images using a single
image-acquisition and image-processing chain. The production
of the different classes of images is determined by the selection of
technical factors in the imaging system. The boundary between flu-
oroscopy and fluorography has been further blurred in those sys-
tems that offer the possibility of retrospectively storing the last
several seconds of fluoroscopy. This can reduce total patient dose by
eliminating the need for fluorographic documentation in those sit-
uations where the previous fluoroscopic sequence meets clinical
requirements.

1
2 / 1. EXECUTIVE SUMMARY

These state-of-the-art fluoroscopic systems are now extensively

used to conduct diagnostic or therapeutic interventional medical
procedures performed via percutaneous or other access routes in
order to:
• localize or characterize a lesion, diagnostic site, or treat-
ment site;
• to monitor the procedure; or
• to control and document therapy.

The term fluoroscopically-guided interventional (FGI) procedure is

used to describe this practice of medicine.
This Report is focused on the use of fluoroscopic systems as a tool
for guiding diagnostic and therapeutic procedures because higher
radiation doses (compared to conventional radiography and fluoros-
copy) are received regularly from some types of FGI procedures and
occasionally from many other types of FGI procedures. Other med-
ical applications of fluoroscopy (e.g., examination of the gastrointes-
tinal system, guiding open surgical procedures) are outside the
scope of this Report. Computed-tomography-guided interventional
(CTGI) procedures are not discussed in detail due to continuing
changes in the technology driven by the evolution of multi-slice
computed tomography (CT) detectors. However, the principles pre-
sented in this Report are generally applicable to these domains.
Most of the recommendations contained in this Report should be
applied in all settings where fluoroscopic guidance is used.
Within the context of radiation dose management, the goal of
this Report is to supply information that helps optimize patient
outcomes without compromising worker safety. However, radiation
is not the only risk to which patients and workers are exposed. In
many cases, radiation is a minor component of overall risk. In these
situations, too great a focus on radiation safety (e.g., the use of
unnecessarily thick lead aprons) may reduce the overall safety
of patients or workers.
Some beneficial, clinically-justified FGI procedures, even when
optimized for radiation protection, deliver substantial doses of radi-
ation to patients. This puts the patient at risk for radiogenic sto-
chastic effects and occasionally induces radiogenic deterministic
effects. However, a complete risk analysis usually identifies many
other procedural hazards and will often conclude that radiation is
one of the lesser hazards from FGI procedures. While the decision
to conduct an FGI procedure assumes that the use of ionizing radi-
ation is warranted by the disease state for which the patient under-
goes treatment, the benefits, risks, and alternative procedures that
do not require the use of ionizing radiation should be considered.
 1.2 RECOMMENDATIONS / 3

FGI procedures should only be performed when there is the

expectation of a benefit to the patient. At present, many medically
necessary x-ray image-guided procedures (including FGI proce-
dures using fixed or mobile equipment and CTGI procedures) can
only be performed by physicians and support staff positioned adja-
cent to the patient. These individuals are unavoidably irradiated
while performing their duties. Provided that appropriate radiation
protection methods are applied, staff occupational exposure is jus-
tified if the procedure is itself justified, and the occupational expo-
sure adheres to the as low as reasonably achievable (ALARA)
principle. The ALARA principle should be applied without compro-
mising either patient safety or the clinical procedure and without
unacceptably increasing workers’ nonradiation risks (e.g., spinal
injuries related to wearing inappropriately heavy lead aprons). In
this context, worker irradiation is considered to be an unavoidable
part of the social cost of providing FGI procedures.
Sections 2 through 6 of this Report are organized by the follow-
ing topics:

• general information (Section 2) (includes scope, FGI proce-

dures, efficacy and benefit-cost, justification and benefit-
risk, physics and dosimetry, radiation biology);
• fluoroscopy equipment and facilities (Section 3);
• protection of the patient (Section 4);
• protection of staff (Section 5); and
• administrative and regulatory considerations (Section 6).

This material is intended to provide background information for

readers, including facility administrative and management execu-
tives, professionals participating in or supporting FGI procedures,
and regulatory officials. The contents of many of the sections are
supplemented by materials in the appendices. Because of the diver-
sity of FGI procedures it is impracticable to supply a complete
handbook on this topic.

1.2 Recommendations

The National Council on Radiation Protection and Measure-

ments (NCRP) recommendations in this Report are listed in
Table 1.1 for ready reference. The recommendations are consecu-
tively numbered in the order they appear in the text of this Report,
and the subsection in which each statement appears and is discussed
is noted in the right-hand column. The recommendations should not
be read in isolation. The reader should consult the indicated subsec-
tions for more complete explanations and further information.
Other documents randomly have
different content
 Neuroscience - Field Notes
Second 2022 - University

Prepared by: Teaching Assistant Garcia

Date: August 12, 2025

Introduction 1: Interdisciplinary approaches

Learning Objective 1: Experimental procedures and results
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 1: Diagram/Chart/Graph]
Learning Objective 2: Study tips and learning strategies
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Learning Objective 3: Critical analysis and evaluation
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Learning Objective 4: Critical analysis and evaluation
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Learning Objective 5: Assessment criteria and rubrics
• Research findings and conclusions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Important: Comparative analysis and synthesis
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
[Figure 6: Diagram/Chart/Graph]
Remember: Literature review and discussion
• Experimental procedures and results
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Important: Case studies and real-world applications
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Critical analysis and evaluation
• Assessment criteria and rubrics
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Example 9: Practical applications and examples
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Discussion 2: Comparative analysis and synthesis
Remember: Ethical considerations and implications
• Fundamental concepts and principles
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Note: Literature review and discussion
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 12: Diagram/Chart/Graph]
Key Concept: Ethical considerations and implications
• Experimental procedures and results
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Remember: Fundamental concepts and principles
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Assessment criteria and rubrics
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 15: Diagram/Chart/Graph]
Key Concept: Fundamental concepts and principles
• Fundamental concepts and principles
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Key terms and definitions
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Important: Experimental procedures and results
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Current trends and future directions
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Best practices and recommendations
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
[Figure 20: Diagram/Chart/Graph]
Methodology 3: Research findings and conclusions
Note: Critical analysis and evaluation
• Learning outcomes and objectives
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
Definition: Research findings and conclusions
• Problem-solving strategies and techniques
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Example 22: Interdisciplinary approaches
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 23: Diagram/Chart/Graph]
Key Concept: Study tips and learning strategies
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Key Concept: Problem-solving strategies and techniques
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Best practices and recommendations
• Problem-solving strategies and techniques
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Interdisciplinary approaches
• Current trends and future directions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Literature review and discussion
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Research findings and conclusions
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Critical analysis and evaluation
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
[Figure 30: Diagram/Chart/Graph]
Review 4: Research findings and conclusions
Example 30: Theoretical framework and methodology
• Assessment criteria and rubrics
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
Definition: Interdisciplinary approaches
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 32: Theoretical framework and methodology
• Problem-solving strategies and techniques
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 33: Diagram/Chart/Graph]
Remember: Comparative analysis and synthesis
• Research findings and conclusions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Key Concept: Learning outcomes and objectives
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Key Concept: Ethical considerations and implications
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 36: Diagram/Chart/Graph]
Remember: Research findings and conclusions
• Experimental procedures and results
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
[Figure 37: Diagram/Chart/Graph]
Key Concept: Key terms and definitions
• Problem-solving strategies and techniques
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Note: Key terms and definitions
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Important: Theoretical framework and methodology
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 40: Diagram/Chart/Graph]
Introduction 5: Key terms and definitions
Definition: Key terms and definitions
• Research findings and conclusions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Practice Problem 41: Research findings and conclusions
• Key terms and definitions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 42: Diagram/Chart/Graph]
Remember: Ethical considerations and implications
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Remember: Case studies and real-world applications
• Key terms and definitions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Experimental procedures and results
• Problem-solving strategies and techniques
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 45: Diagram/Chart/Graph]
Important: Fundamental concepts and principles
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Definition: Learning outcomes and objectives
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
[Figure 47: Diagram/Chart/Graph]
Remember: Literature review and discussion
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Example 48: Current trends and future directions
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Example 49: Critical analysis and evaluation
• Experimental procedures and results
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 50: Diagram/Chart/Graph]
Conclusion 6: Study tips and learning strategies
Example 50: Assessment criteria and rubrics
• Key terms and definitions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Important: Assessment criteria and rubrics
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Practice Problem 52: Study tips and learning strategies
• Assessment criteria and rubrics
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Example 53: Learning outcomes and objectives
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
[Figure 54: Diagram/Chart/Graph]
Definition: Critical analysis and evaluation
• Key terms and definitions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
[Figure 55: Diagram/Chart/Graph]
Remember: Learning outcomes and objectives
• Problem-solving strategies and techniques
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
Remember: Problem-solving strategies and techniques
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
[Figure 57: Diagram/Chart/Graph]
Definition: Current trends and future directions
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Important: Literature review and discussion
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 59: Fundamental concepts and principles
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
Exercise 7: Literature review and discussion
Practice Problem 60: Literature review and discussion
• Assessment criteria and rubrics
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Example 61: Practical applications and examples
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Key terms and definitions
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Important: Experimental procedures and results
• Case studies and real-world applications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Comparative analysis and synthesis
• Key terms and definitions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 65: Assessment criteria and rubrics
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
[Figure 66: Diagram/Chart/Graph]
Key Concept: Literature review and discussion
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
[Figure 67: Diagram/Chart/Graph]
Note: Interdisciplinary approaches
• Key terms and definitions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Important: Experimental procedures and results
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Definition: Key terms and definitions
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Chapter 8: Current trends and future directions
Remember: Comparative analysis and synthesis
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Key Concept: Research findings and conclusions
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
[Figure 72: Diagram/Chart/Graph]
Remember: Key terms and definitions
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 73: Diagram/Chart/Graph]
Key Concept: Problem-solving strategies and techniques
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Important: Comparative analysis and synthesis
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Remember: Fundamental concepts and principles
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Learning outcomes and objectives
• Learning outcomes and objectives
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Note: Theoretical framework and methodology
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 78: Diagram/Chart/Graph]
Key Concept: Case studies and real-world applications
• Problem-solving strategies and techniques
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 79: Diagram/Chart/Graph]
Example 79: Literature review and discussion
• Experimental procedures and results
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Part 9: Problem-solving strategies and techniques
Remember: Research findings and conclusions
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Note: Practical applications and examples
• Case studies and real-world applications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Example 82: Research findings and conclusions
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 83: Diagram/Chart/Graph]
Example 83: Critical analysis and evaluation
• Problem-solving strategies and techniques
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 84: Diagram/Chart/Graph]
Important: Statistical analysis and interpretation
• Learning outcomes and objectives
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Practice Problem 85: Best practices and recommendations
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
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