CT Scans - What can I do as a Radiologist?

"Child-size” the radiation delivered to your patients

Radiologists play a key role as healthcare providers for children. Radiology  and CT scanning is  critical in diagnosing illness in children and impacting their treatment and improving patient outcomes. By logging onto this website, you have already shown your commitment to improve radiation protection for kids. It is the responsibility of radiologists and all members of the healthcare team to ensure that every imaging study in pediatric patients is thoughtful, appropriate and indicated for  each and every child. As a radiologist in a busy practice with many adult patients, it may be difficult to “kid-size” the protocols used every day. This website provides simple educational resources to inform radiology practices what can be done to improve radiation management for children.

Medical imaging (with CT scans as the largest contributor) approaches background radiation as the single largest source of radiation for humans (NCRP, April 2007). Research is clear… children are more vulnerable to radiation, moreover, they  and have a lifetime to manifest potential radiation effects. 

Here are 5 simple steps to improve patient care in your everyday practice: 

1. Increase awareness for the need to use the appropriate amount of radiation dose for children during CT scanning. Protocol development recommendations are offered under What can I do? or directly here.
2. Be committed to make a change in your daily practice by working as a team with your technologists, medical physicist, referring doctors and parents to use only the necessary radiation dose! Sign the pledge! Click on the link on the home page to join the image gently campaign today.
3. Contact your medical physicist to review your adult CT protocols and then use the simple CT protocols on this website to “right-size” the protocols for kids. More is not necessarily better….adult size KV and mAs are not necessary for small bodies.
4. Single phase scans are usually adequate. Pre- and post contrast, and delayed CT scans rarely add additional information in children yet can double or triple the dose! Consider reviewing and removing multi-phase scans from your daily protocols.
5. Scan only the indicated area. For example, if a patient has a possible viewing in the chest, there is rarely need to scan the through to below the adrenal glands. “Child-size” the scan and only scan the area required to obtain the necessary information.
   
   Donald P. Frush, MD, Alliance Chair
   Pediatric Radiologist 
   Past President, The Society for Pediatric Radiology
   
   Marilyn J. Goske, MD, Alliance Chair Emeritus
   Pediatric Radiologist
   Past President, The Society for Pediatric Radiology

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Fluoroscopy - What can I do as a Radiologist?

• FAQs - Fluoroscopy - Medical Professionals
• Fluoroscopy and Radiation Safety Content for Radiologists

IR - What can I do as a Radiologist?

• Click here for a downloadable Procedure Checklist to use prior to every pediatric IR procedure.
• Click here for a comprehensive document Steps for Radiation Safety.
• Click here for an IR Patient Brochure to share with your patients.
• Click here for access to the Slide Presentation, made available by the Society for Pediatric Radiology. You may use this presentation to educate your colleagues locally and you may develop a shorter presentation by selecting from the slides. We do ask that you not alter the slides and that you attribute the SPR in any presentation.   

“Child- size” the radiation delivered to your patients. Pediatric and interventional radiologists play a key role as healthcare providers for children. Interventional radiology is a critical medical service which saves lives and improves patient outcomes. By logging onto this website, you have already shown your commitment to improve radiation protection for kids. It is the responsibility of radiology providers and all members of the healthcare team to ensure that every interventional radiology procedure in pediatric patients is thoughtful, indicated and appropriately performed for each and every child. As a practitioner in a busy practice with many adult patients, it may be difficult to “kid-size” the protocols used every day. This website provides a simple review of “child-size” IR practices which can be used now to improve radiation protection for children.
 
Soon medical imaging (with IR as the third largest contributor, after CT and nuclear medicine) will approach or potentially exceed background radiation as the single largest source of radiation for humans (NCRP, March 2009). Children are more sensitive to radiation and have a lifetime to manifest those changes. Studies from the atomic bomb indicate that radiation at low levels can cause random injury at the DNA level and genetic changes that impact children’s future health.

Here are 5 simple steps to improve patient care in your everyday practice:

1. Increase awareness within your medical team and within the institution for the need to decrease radiation dose to children during IR procedures. Procedure recommendations are offered here.
2. Be committed to make a change in your daily practice by working with your technologists, physicist, referring doctors and parents to decrease the radiation dose! Sign the pledge! Click on the link on the home page to join the image gently campaign today.
3. Contact your physicist and manufacturer to review your adult angiography and CT protocols and to “down-size” the protocols for kids. More is not better… adult techniques are not necessary for small bodies.
4. During the procedure, “step lightly” on the fluoroscopy pedal, using the least amount of radiation needed to safely and effectively perform the procedure. Remember to take other common sense steps to reduce dose, such as planning runs in advance, using pulse fluoroscopy, using US or MRI for guidance when possible, and minimizing use of magnification.
5. Remember that reducing patient dose reduces dose to personnel in the room: as you work to reduce dose to children, you will also help your healthcare team.

“Child-size” the Radiopharmaceutical Doses Administered to Your Patients

Nuclear medicine tests are often essential in diagnosing illness in children, impacting their treatment and improving outcomes. As the nuclear medicine physician or radiologist, you play a key role as an advocate for children. By logging onto this website, you have already demonstrated your commitment to improve radiation protection for kids. It is the collective duty of all members of the healthcare team to ensure that every imaging study in pediatric patients is thoughtful, appropriate and indicated. This website provides simple educational resources to radiology and nuclear medicine practices for improving radiation protection for children.

Be Every Child’s Advocate

There is now a growing awareness of the opportunities to lower radiation dose in children without compromising the diagnostic quality. Encourage parents to ask questions and then direct them to this website.

5 Simple Steps to Improve Patient Care in Your Daily Practice

• Perform only appropriate exams. Discussing the clinical situation with the referring physician can often be beneficial to choose the right exam for each patient. Embedded decision support in electronic ordering may also reduce inappropriate imaging.

• Increase awareness within the imaging facility and the institution for the need of lowering radiation dose to children during nuclear medicine procedures.

• Be committed to make a change in your daily practice by working as a team with your technologists, physicist, referring doctors and parents to decrease the radiation dose!

• As you work to decrease the administered dose to children, you also reduce the dose to the personnel in the room, thus promoting safety for the entire health care team!

• Follow expert guidelines:

2014 Update of North American Consensus Guidelines for Pediatric administered Radiopharmaceutical activities

 

Patient Preparation

• Appropriate patient preparation is crucial for image quality. Any measure that can calm the child prior to start of imaging will help keep the child quiet and still during the imaging study.

• Different imaging studies warrant certain protocols; please see the following references below for more details.
  

Treves ST (2007). Introduction. In Treves ST (Ed.), Pediatric Nuclear Medicine/PET, 3rd Edition (pp 1-15). New York: Springer.

Kaste SC (2004). Issues specific to implementing PET CT for pediatric oncology: what we have learned along the way. Pediatr Radiol, 34(3), 205-213.

Alessio, A. M., Kinahan, P. E., Manchanda, V., Ghioni, V., Aldape, L., & Parisi, M. T. (2009). Weight-based, low-dose pediatric whole-body PET/CT protocols. J Nucl Med, 50 (10), 1570-1577

SNM and combined SNM and ACR practice guidelines

List of procedures
Procedure checklist
Optimal imaging protocols and post processing (prepared by Adam Alessio PhD, DABSNM)

 

Radiation Dose and Risk

• Radiation dose may be different in children as compared to adults due to patient size, organ size and orientation and organ distribution of administered radiopharmaceutical.
• Estimates of critical organ and effective dose in common pediatric nuclear medicine procedures are listed in the table below. However please note that these estimates are averages over a wide range of patients at each age and do not take into consideration individual differences in anatomy and physiology from the standard models.
• Assessing the risk associated with exposure to ionizing radiation involves applying models that use both epidemiologic and biologic data to extrapolate from the available data to the dosimetric region of interest. Such extrapolation is not straightforward.
• Much of the current understanding about the risk of exposure to ionizing radiation for humans is based on the Life Span Study of the survivors of the bombings of Hiroshima and Nagasaki as reported by the Radiation Effects Research Foundation.
• The consensus is to assume that the risk at the lower doses with medical radiation can best be estimated by a linear extrapolation from higher doses for radiation protection purposes.
• It has become increasingly more important that nuclear medicine practitioners—including physicians, physicists, technologists, and other members of patient care teams effectively communicate with the referring providers and with patients and families about the medical use of radiation, the level of radiation exposure, and the potential risk.

Further Reading
 Outline: Radiation Dose and Risk in Pediatric Nuclear Medicine -  Frederic H. Fahey, DSc, S. Ted Treves, MD and S. James Adelstein
 Minimizing and Communicating Radiation Risk in Pediatric Nuclear Medicine - Fahey FH, Treves ST, Adelstein SJ. J Nucl Med. 2011; 52:1240-1251.

Additional Reading Material and Resources
 SNM and combined SNM and ACR practice guidelines 
    The Society for Pediatric Radiology (SPR)
 American College of Radiology pediatric imaging appropriateness criteria
 Society of Nuclear Medicine and Molecular Imaging (SNMMI)
 International Atomic Energy Agency (IAEA) 
 Radiology Info
 National Council on Radiation Protection and Measurements (NCRP) 
 Image Wisely- Radiation safety in adult medical imaging