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This advanced course on fluoroscopy for APRNs in Oregon offers comprehensive training on safely performing fluoroscopic procedures in line with Oregon’s regulatory including radiation safety, procedural methodologies, and emergency management.  

The course aims to enhance patient and healthcare personnel safety, emphasizing the ALARA principle for minimizing radiation exposure and addresses the biological effects of radiation, protective measures, and the importance of documenting radiation dose data, ensuring adherence to state regulations and safety protocols. 

Introduction

The State of Oregon has established specific requirements for Advanced Practice Registered Nurses (APRNs) in the context of fluoroscopy, highlighting the guidelines that promote patient care and safety in medical and procedural imaging. 

Overview of Fluoroscopy 

The generation of conventional radiographs occurs by transmitting an X-ray beam through a patient and capturing the altered beam with an X-ray plate [1][3]. The formation of the resulting image occurs due to the varying densities within the human body and their capacity to diminish (attenuate) the X-ray beam [3].  

Fluoroscopy provides a continuous X-ray visualization, displaying real-time images on a monitor as an X-ray beam travels through the body. This technique allows for detailed observation of body parts, instruments, or contrast agents (“X-ray dye”) moving within the body, with the resulting images projected onto a monitor for in-depth analysis [4].  

Fluoroscopy has applications across multiple medical fields, such as orthopedics, urology, interventional radiology and cardiology, vascular surgery, and gastroenterology. With the increasing use of radiation, gaining a comprehensive knowledge of the risks associated with radiation exposure and the methods to minimize doses is becoming increasingly critical.  

Interventional fluoroscopy, which employs ionizing radiation to navigate small instruments including catheters through blood vessels or other internal pathways, offers a significant advantage over traditional surgery by requiring a minimal incision, diminishing the risk of infection, and facilitating a quicker recovery period compared to invasive surgical methods [23]. 

Fluoroscopic imaging occurs through two primary methods: capturing a single image using an image intensifier and receptor or generating an angiographic sequence of fluorographic images through multiple exposures [4] [5]. Often, these sequences derive by subtracting them from a reference (mask) image to produce subtraction angiographic images. 

The X-rays in fluoroscopy are polychromatic, spanning a broad spectrum of energy levels, unlike the monoenergetic rays, such as gamma-rays, emitted from nuclear radiation sources [4]. Fluoroscopy serves as an imaging technique that visualizes anatomical structures, organ motion, and the flow of contrast agents within blood vessels and organs, aiming to gather functional insights [5]. It transitioned from traditional fluoroscopy, which recorded images on film, to modern digital fluoroscopy (DF), where dynamic digital captures and stores images.  

Digital fluoroscopy operates in two modes: one employs an image intensifier connected to a digital imaging system, and the other utilizes digital flat-panel detectors (FPDs) for image capture [5]. Fluoroscopy offers several benefits, including reduced complications from less invasive procedures, shorter hospital stays, and lower healthcare costs [6]. To reduce radiation exposure, the management of fluoroscopy requires the minimal acceptable dose for the briefest duration required. 

Regulating Fluoroscopy Supervision by APRNs in Oregon  

In Oregon, the Oregon Board of Medical Imaging regulates the oversight of fluoroscopy by Advanced Practice Registered Nurses (APRNs) ORS 678.025 through a structured approach aimed at guaranteeing the safe and proficient application of this diagnostic imaging technique. [2]. The Oregon Board of Nursing, along with other regulatory bodies such as the Oregon Medical Board, outlines the scope of practice for APRNs and may provide specific stipulations regarding the use of fluoroscopy [2].  

In Oregon, APRNs aiming to operate fluoroscopy must obtain relevant training and certification. This entails completing an accredited program in fluoroscopy safety, covering topics such as radiation physics, radiation safety, the biological impacts of radiation, and strategies for managing radiation exposure. 

Advanced Practice Registered Nurses (APRN) interested in conducting specific fluoroscopic exams must complete 40 hours of clinical practice under supervision in a fluoroscopic suite [2]. A radiologist, a medical physicist, or a radiography instructor can provide this supervision.  

The variety and complexity of fluoroscopic exams available for achieving clinical competency will vary depending on the clinical environment and patient demographics [2]. 

Regarding fluoroscopy regulation: The Nursing Practice Act does not delegate the oversight of fluoroscopy to the Board of Nursing. 

In Oregon, for an APRN to conduct a procedure while a technician operates the fluoroscopy equipment, the following criteria is set by the Oregon Board of Medical Imaging (OBMI): 

• Obtain the necessary didactic experience 
• Gain the requisite clinical experience 
• Successfully complete the ARRT fluoroscopy examination 
• Obtain a limited fluoroscopy permit, which the OBMI restricts to supervised roles 

Purpose of the Law 

These regulations aim to protect patient health and safety and enhance the clinical application of fluoroscopy. By setting definitive guidelines for APRNs, the legislation guarantees that individuals conducting or overseeing fluoroscopic procedures possess comprehensive training in radiation safety, procedural methods, and emergency responses.  

This approach is vital for reducing radiation exposure among patients and healthcare personnel while maintaining superior care quality. 

Key Components of the Law 

Training and Certification: APRNs must undergo accredited training covering radiation safety principles, fluoroscopy usage, patient positioning, and radiation dose management. This training and education are essential for understanding the hazards linked to radiation and for the secure operation of fluoroscopic equipment. 

Supervision Requirements: The legislation outlines the circumstances that enable APRNs to conduct or oversee fluoroscopic procedures, detailing the requirement of direct physician supervision and defining the extent of independent operation permitted for APRNs, contingent on their certification and the procedure’s complexity. 

The degree of oversight (direct or indirect) needed for APRNs operating fluoroscopy varies based on the healthcare environment and the procedures undertaken [2]. Direct supervision entails the presence and immediate availability of a qualified physician during the fluoroscopy, while indirect supervision grants APRNs greater independence but necessitates that a supervising physician be accessible for consultation [2]. 

Scope of Practice: Specifies the limits for APRNs’ use of fluoroscopy, determined by specialty, level of training, and the clinical environment. This regulation guarantees that APRNs operate within their areas of expertise, upholding superior patient care standards.  

The scope of practice encompasses various essential aspects, including the permissions of APRN, required qualifications, and restrictions set forth by legal or regulatory standards [2]. 

Regulatory Oversight: The Oregon Board of Nursing, in collaboration with pertinent regulatory authorities, manages the enforcement of these statutes. The board oversees the establishment of criteria for training programs, certification of APRNs for fluoroscopy application, and monitoring adherence to the regulations. 

Continuing Education: APRNs must participate in continuous education and professional growth to keep their fluoroscopy supervision certification valid. This commitment helps them stay updated with the latest technological innovations, radiation safety standards, and field best practices. ​

Definitions 

Advanced Practice Registered Nurse (APRN): An APRN (Advanced Practice Registered Nurse) is a registered nurse who has earned a minimum of a master’s degree in nursing, along with advanced clinical training in a specific area of healthcare.  

This group encompasses nurse practitioners, clinical nurse specialists, nurse anesthetists, and nurse midwives. APRNs possess enhanced theoretical and practical education, expertise, abilities, and a broader scope of practice within the nursing field [54]. 

Air kerma: Represents the energy derived from an x-ray beam per unit mass of air within an irradiated air volume. Also quantified in grays (Gy), it indicates the dose imparted to a specific volume of air [59]. 

ALARA (As Low as Reasonably Achievable): A safety principle designed to minimize radiation exposure to the lowest level possible, considering economic and practical factors [60]. 

ALARP (As Low as Reasonably Practicable): Fulfilling the obligation to maintain risk levels at the lowest feasible point [61]. 

Biologic variation: The quantity of radiation needed to trigger a deterministic effect and in the degree of harm inflicted by identical radiation doses in humans [62]. 

C-arm fluoroscopy system: A medical imaging device that uses X-rays to provide real-time visualization of internal structures, featuring a C-shaped arm that allows for flexibility in positioning around the patient [63]. 

C-arm X-ray system: An X-ray system links the image receptor and the X-ray tube housing through a shared mechanical support. This setup enables altering the projection of the beam through the patient without needing to reposition the patient [63]. 

Dosimeter: Dosimeters are devices that measure cumulative radiation exposure [56]. 

Effective dose: The effective dose determines the entire body by summing the equivalent doses received by each organ and adjusting for the organ’s sensitivity to radiation. This cumulative measure expresses in millisieverts (mSv) [64]. 

Equivalent dose: The equivalent dose determines for specific organs, considering the absorbed dose by an organ, and adjusting for the radiation type’s effectiveness. This adjusted measure expresses in millisieverts (mSv) for each organ [64]. 

Fluoroscopy: A form of medical imaging that displays a real-time X-ray image on a screen, similar to an X-ray film in motion. Healthcare professionals utilize this technique to observe the motion of a body part, instrument, or a contrast agent as it moves through the body [55]. 

Fluoroscopic benchmark: A standard established from the average cumulative duration of fluoroscopy observed during a specific fluoroscopic procedure at a given location [67]. 

Fluoroscopic image: A single captured image produced through the use of an image intensifier or a digital flat panel serving as the image receptor. A digital angiographic loop is composed of a sequence of images obtained from fluorography [4]. 

Fluoroscopic imaging assembly: A subsystem that converts X-ray photons into a visible image includes image receptors including the image intensifier and spot-film device, any electrical interlocks, and the structural components that connect the image receptor to the diagnostic source assembly [63]. 

Image intensifier: A device, housed within a specific enclosure, which transforms an X-ray pattern into a related light image with a higher energy density [68]. 

Irradiation: The act of subjecting an object to radiation exposure [55]. 

Kilovoltage: Denotes the steady voltage level utilized within an X-ray system. The quantity of radiation that results in an energy deposition of 1 joule per kilogram (1 J kg 1) within the irradiated material [65].  

Leakage radiation: Leakage radiation refers to any radiation that originates from the diagnostic or therapeutic source assembly, excluding the intended or useful beam [69]. 

Milliamperes (mA): Milliamperes (mA) is a unit of electrical current measurement equal to one-thousandth of an ampere [57]. 

Millisievert (mSv): Unit of radiation dose that represents one-thousandth of a Sievert (Sv) [70]. 

Peak skin dose: Peak Skin Dose (PSD) is the maximum radiation dose received by any area of a patient’s skin throughout a medical procedure [65]. 

Radiation Absorbed dose (RAD): The absorbed dose refers to the amount of energy ionizing radiation deposits in a tissue at a particular location, quantified in grays (Gy). This quantity of radiation characterizes the deposition of 1 joule of energy per kilogram (1 J/kg) in the irradiated substance.1 Gray (Gy) is equivalent to 100 rads; 1 Gy also equals 1000 milligrays (mGy) [58] [64]. 

Roentgen Equivalent Man (rem): A measurement unit for the biological dose received by human tissues as a result of exposure to one or more types of ionizing radiation [64]. 

Scattered radiation: Radiation that diverges in various directions from a radiation beam upon interaction with a material, such as body tissue [66]. 

Sievert (Sv): A unit for measuring the dose of ionizing radiation, quantifying the energy absorbed per unit mass in a human’s body (J/kg) [70].  

Threshold dose: Threshold dose refers to the lowest level of radiation required for a specific deterministic effect to manifest [65].  

Components of Standard Fluoroscopy Units  

Generating X-ray images in a standard fluoroscopy unit requires three key components: the X-ray generator, the X-ray tube, and the image intensifier [7]. 

X-Ray Generator 

The X-ray generator produces X-rays by applying an electrical current. It serves as the central control unit for the fluoroscopy system, regulating the flow of current into the X-ray tube. This device adjusts the voltage differential and current within the X-ray tube to optimize image contrast and brightness.  

Several types of generators utilized in fluoroscopy include single phase, three phase, constant potential, and high frequency [8]. Among these, high-frequency generators stand out for their consistent exposure quality, compact size, cost-effectiveness, and lower maintenance expenses [8]. 

X-Ray Tube 

An X-ray tube operates as a specialized energy converter, transforming electrical energy into two distinct forms: X-radiation (1%) and heat (99%) [9]. The generation of X-radiation involves harnessing the energy from electrons and transforming it into photons. This precise conversion of energy occurs within the X-ray tube. 

X-Ray Tube Housing 

The lead-lined housing contains an X-ray beam filter, the beam collimator, and thermal switch [10]. The collimator restricts the size of the X-ray beam, while the thermal switch monitors the tube’s temperature and shuts it down if it overheats to prevent damage. 

The housing acts as a protective shield against X-rays. Under FDA regulations, the level of X-rays that leak from the tube housing—referred to as “leakage X-rays”—must not exceed a radiation exposure rate of 0.1 roentgen (milliroentgens) per hour at a distance of 1 meter from the X-ray source over a period of 1 hour, even when the tube is operating at its maximum voltage and current [11] [12]. 

X-Ray Beam Filter  

The x-ray tube comes equipped with beam filters, made of aluminum or copper, to produce a more refined and effective beam. These filters eliminate lower energy rays that do not contribute to generating the diagnostic image. Different tissues absorb the filtered, higher energy beams that penetrate the patient [13].  

Collimator 

The x-ray beam can never be wider than the image intensifier’s diameter, and the purpose of the collimator is to fit the x-ray beam exiting the tube to the image intensifier. X-ray beam collimation in radiography and fluoroscopy is essential for minimizing patient radiation exposure and enhancing image quality by focusing the beam on the area of interest, which reduces scatter and improves contrast [14]. While collimation decreases image brightness and necessitates a slight increase in the patient’s radiation dose, it does not elevate the dose to the extent seen with electronic magnification, as the reduction in beam size maintains constant minification gain [14]. 

The Image Intensifier 

In a fluoroscopy unit, the image intensifier assembly includes an anti-scatter grid that minimizes the influx of scattered x-rays into the unit. Reducing scattered radiation at the image intensifier enhances the clarity of the image due to less interference at the entrance phosphor [15]. ​

Good Use Fluoroscopy Principles  

Prioritize ultrasound and utilize fluoroscopy whenever feasible. Make low-dose fluoroscopic modes the default. Operating in high-dose fluoroscopic mode can expose the operator to radiation levels exceeding 10 mSv/h [16]. Switching from a low-dose to a high-dose or cine fluoroscopic mode can amplify the radiation exposure to staff by factors of 2.6 and 8.2 [16] [17].  

Therefore, the use of fluorography techniques, including spot images, digital subtraction angiography, and cine imaging, should be limited due to their potential to increase radiation exposure, with cine acquisition modes possibly surpassing 50 mSv/h. Fluoroscopic operators are advised to employ lower dose modes with the ipsilateral orientation at angles of 32° or less to minimize the radiation exposure risk to both patients and staff [17] [18]. 

Steeper angles, larger patient sizes, changes in frame rate, not using the store fluoroscopy mode, and the inclusion of patient extremities in the field of view can all lead to a significant increase in radiation dose, without impacting the duration of fluoroscopy [18]. To reduce radiation exposure, operators should opt for the lowest effective pulse and frame rates, adjusting the standard fluoroscopic frame rate to 2 to 7.5 frames per second to decrease radiation while maintaining diagnostic quality [16]. 

It is preferable to use intermittent fluoroscopy instead of continuous or spot imaging, focusing on analyzing the last-image-hold or previously saved loops [19]. Implementing breath-holds and administering certain medications, like sedation or glucagon, can also diminish motion artifacts caused by patient or bowel movements, thereby decreasing the need for increased frame rates and additional imaging sessions [18][19] [20].  

Enhancing the knowledge of healthcare team members regarding radiation exposure and the implementation of correct radiation safety practices is key to reducing both long-term and immediate adverse effects among patients and healthcare providers [15]. This encompasses various strategies including collimation, the use of barriers and shielding, optimal patient positioning, adjusting image acquisition settings and promoting effective communication within the team [15]. 

Eliminate Unnecessary Radiation Exposure 

Collimation minimizes radiation exposure for both the patient and operator while enhancing image contrast [14]. During procedures such as digital subtraction angiography and cone-beam CT, advise staff members to leave the room or maintain a greater distance from the patient.  

Recommend using a power injector for efficiency when feasible [21]. Operators should also ensure they do not place their hands within the radiation field to avoid exposure. 

Judicious Use of Use Magnification  

Using both geometric and electronic magnification leads to a higher radiation dose for the patient; therefore, apply magnification only when it enhances diagnostic efficiency. Solid-state detectors can offer electronic magnification benefits with a smaller increase in dose compared to traditional image intensifiers [16] [22].  

Specific Considerations when Administering Iodinated Contrast Medium 

Patients who have a history of heart conditions, such as previous cardiac arrests or chest pain, are at a higher risk of experiencing more frequent and severe cardiovascular side effects after receiving contrast medium.  

The procedures that pose the highest risk for such adverse cardiovascular outcomes, including arrhythmias, tachycardia, hypotension, and congestive heart failure, are pulmonary angiograms and injections into the intracardiac coronary arteries [20][24][25].  

Studies on the safety of using contrast media during breastfeeding, including both iodinated and gadolinium-based agents, have shown that current guidelines indicate no need to stop breastfeeding or take any specific measures following the intravenous use of these contrast agents [36]. 

Metformin Interaction 

In patients with type 2 diabetes who are on metformin therapy, the administration of iodinated radioactive contrast material can lead to an accumulation of metformin causing biguanide-induced lactic acidosis, characterized by symptoms such as vomiting, diarrhea, and drowsiness [28]. While metformin-associated lactic acidosis can be fatal in about 50% to 83% of cases, it is important to note that this condition is rare in patients who have normal kidney function [26]. 

Patients with an estimated glomerular filtration rate (eGFR) greater than 30 mL/min/1.73 m^2 and without signs of acute kidney injury (AKI) can continue their metformin regimen while undergoing contrast media (CM) procedures, in line with the guidelines set forth by the American College of Radiology (ACR) for individuals with an eGFR of 30 mL/min/1.73 m^2 or higher [27].  

For patients with normal kidney function and without other known health issues, it is not necessary to stop taking metformin before using iodinated radiographic contrast, nor is there a need to monitor creatinine levels after the imaging procedure [27]. However, for those with kidney problems, pause metformin on the day of the imaging study and avoid taking it for 48 hours afterwards. Conduct a creatinine test 48 hours post-procedure, and restart metformin once confirming normal kidney function [29]. 

Contrast-Induced Nephropathy 

Contrast-induced nephropathy (CIN) manifests as a deterioration in kidney function, marked by either a 25% increase in serum creatinine from its baseline value or a rise of 0.5 mg/dL (44 µmol/L) in the absolute serum creatinine level, happening within 48-72 hours after administering intravenous contrast [30]. This type of kidney damage is acute, manifesting within 2-3 days of contrast exposure.  

Nonetheless, experts suggest classifying any renal impairment appearing within seven days after receiving contrast as CIN, provided other causes of kidney failure cannot explain it, indicating a direct temporal association [30]. Following the administration of contrast, serum creatinine levels peak within two to five days and return to baseline levels within 14 days [30].  

While CIN often results in temporary kidney damage, it can evolve into severe, lasting renal dysfunction, end-stage renal failure (ESRF), and negative cardiovascular effects. Identifying patients at risk of CIN before the administration of contrast is difficult [31].  

Present strategies focus on preventing dehydration, stopping the use of nephrotoxic medications, and reducing the amount of contrast [31]. 

Extravasation  

Contrast media extravasation (CMEX) occurs when intravenous contrast agents, such as iodine or gadolinium-based solutions, leak into adjacent soft tissues. The severity of this complication can range from mild redness and discomfort to severe outcomes including compartment syndrome, skin ulceration, and necrosis [32]. Numerous manufacturers have created Extravasation Detection Accessories (EDA), which are sensors designed to identify and halt automatic injections if an extravasation occurs [32]. 

Side effects of extravasation of iodinated radiographic contrast materials are the result of hyperosmolality and include pain, edema, swelling, and cellulitis [32]. These side effects may peak in the inflammatory response within 48 hours. Compartment syndrome can occur secondary to mechanical compression as a result of tissue edema and cellulitis [32].  ​

Procedures following a contrast media extravasation event differ based on each radiology department’s guidelines and may encompass:  

• Stop the injection and scan, categorizing the incident as mild, moderate, or severe. 
• Ensure thorough documentation, outline the impacted area, and notify the attending physician. 
• For mild cases: elevate the affected limb, apply ice packs, and conduct checks on the patient Q 2-4 hours.  
• Obtain radiographic evidence for moderate to severe cases through two orthogonal views or cross-sectional imaging to evaluate the degree of compartmentalization and the extravasation’s spread. 
• Enter the extravasation as an adverse event in both the radiology report and the facility’s incident reporting system. 
• Provide the patient with an information leaflet about the incident. 
• Schedule a follow-up appointment if deemed necessary. 
• In cases of suspected severe injury (such as neurovascular compromise, compartment syndrome, or tissue necrosis) consult a plastic surgeon. 
• Advise a surgical assessment for cases where the extravasation volume exceeds 150 ml. ​

Adverse Reactions 

The incidence of allergic-like and physiologic reactions to the intravascular use of iodinated contrast media (ICM) is low and has declined due to the shift from using ionic high-osmolality contrast media (HOCM) to nonionic low-osmolality contrast media (LOCM) [20]. The vast majority of adverse reactions to LOCM are mild and not life-threatening, often requiring just observation, reassurance, and supportive care [33].  

Severe and life-threatening reactions are still rare and unpredictable, with most critical incidents happening within the first 20 minutes following the injection of the contrast medium [20]. 

Adverse drug reactions (ADRs) from the intravascular use of iodinated contrast media (ICM) fall into two main categories: hypersensitivity (allergic-like) reactions and chemo-toxic reactions [33]. The American College of Radiology (ACR) Manual on Contrast Media outlines three severity levels of ADRs: “mild” (where limited symptoms do not progress), “moderate” (symptoms are more intense and require medical intervention), and “severe” (symptoms are potentially life-threatening and can lead to permanent damage or death without proper management) [20]. Mild and moderate reactions can escalate to severe if not addressed. 

Healthcare professionals responsible for administering intravascular contrast media must equip themselves to 1) identify the range of possible adverse reactions post-ICM administration, and 2) implement the necessary actions to address these reactions. These actions encompass alerting the overseeing radiologist (or their proxy), monitoring the patient, providing specific medications, and/or summoning additional help (such as emergency services or a “code team”). 

Reactions to the injection of iodinated contrast media (ICM) span from minor chemo-toxic effects to critical, life-threatening emergencies [33]. Adverse responses to low-osmolality ICM are mild, necessitating monitoring or administration of oral H1-antihistamines.  

For minor hypersensitivity reactions like itching, H1 antihistamines are adequate, but severe anaphylaxis requires intramuscular epinephrine [33]. The initial treatment involves administering 0.01 mg/kg of body weight, up to a maximum of 0.5 mg, of epinephrine at a 1:1000 concentration, injected into the thigh’s lateral side [33][34]. Management of severe adverse reactions includes adhering to advanced cardiovascular life support guidelines, including airway management, oxygen administration, mechanical ventilation, external cardiac massage, and electrical cardiac defibrillation [33][34]. 

Non-immediate hypersensitivity reactions (NIHR), often presenting as maculopapular exanthema that range from mild to moderate in severity and tend to resolve without treatment [33]. Severe NIHR instances, such as acute generalized exanthematous pustulosis (maculopapular drug eruption), drug reaction with eosinophilia and systemic symptoms, Stevens–Johnson syndrome, and toxic epidermal necrolysis, necessitate specialist referral. Treatment for these severe reactions involves systemic corticosteroids and hospital admission [35].  

A meta-analysis determined that the likelihood of experiencing a severe adverse reaction was greater with high-osmolality iodinated contrast media (ICM) than nonionic ICM [32]. The incidence of anaphylaxis caused by iodinated contrast media (ICM) was 0.06%, with over half of these cases occurring in individuals without risk factors for adverse drug reactions (ADRs) and no history of ADRs from previous ICM administrations, and the likelihood of anaphylaxis varied based on the type of ICM, as indicated by a higher odds ratio (OR) [34]. 

Allergic-Like Hypersensitivity vs. Chemo-Toxic Reactions  

Mild Reactions 

Allergic /Hypersensitivity: This category includes limited urticaria (hives) or pruritis (itching), swelling of the skin, a mild itchy or scratchy throat, nasal congestion, and symptoms like sneezing, conjunctivitis, or a runny nose [33]. 

Chemo-Toxic: Symptoms encompass mild nausea or vomiting, temporary feelings of flushing, warmth, or chills, headaches, dizziness, anxiety, changes in taste, mild hypertension, and vasovagal reactions that resolve on their own [33]. 

Moderate Reactions 

Allergic /Hypersensitivity: Symptoms escalate to widespread urticaria or pruritis, diffuse erythema with stable vital signs, facial swelling without difficulty breathing, throat tightness or hoarseness without shortness of breath, and mild wheezing or bronchospasm without significant oxygen deprivation [33]. 

Chemo-Toxic: Includes prolonged nausea or vomiting, a state of hypertensive urgency, isolated instances of chest pain, and vasovagal reactions needing and responding to treatment [33]. 

Severe Reactions 

Allergic-Like/Hypersensitivity: These reactions are more serious and include widespread swelling or facial swelling with difficulty breathing, widespread redness with low blood pressure, swelling of the larynx with stridor and/or lack of oxygen, severe wheezing, or bronchospasm with significant lack of oxygen, and anaphylactic shock characterized by low blood pressure and rapid heartbeat [33]. 

Chemo-Toxic: Severe symptoms comprise vasovagal reactions that do not respond to treatment, arrhythmias, convulsions or seizures, and hypertensive emergencies [33]. 

No premedication strategy can prevent severe reactions to contrast agents. Healthcare professionals can prescribe corticosteroids (such as prednisone) and antihistamines [37]. This method has proven to lower the occurrence of adverse reactions in individuals who have reacted to high-osmolar contrast agents in the past. The need for prophylactic treatment before administering low-osmolar, non-ionic contrast agents remain uncertain.[37]. 

Nephrogenic Systemic Fibrosis 

The use of gadolinium-based contrast agents links to the subsequent development of nephrogenic systemic fibrosis in patients with pre-existing renal disease, but the risk remains low with the small doses administered [38]. Gadolinium-based contrast agents (GBCAs) serve as substitutes in fluoroscopic guided procedures for patients with allergies to iodine contrast, reporting an adverse reaction rate of 0.06% [39.]  

Nephrogenic systemic fibrosis (NSF) is a condition that causes widespread fibrosis of multiple organs and is attributable to the use of gadolinium-based contrast agents (GBCAs) [38]. Nephrogenic systemic fibrosis is a fibrosing disease affecting the skin and subcutaneous tissues, heart, lungs, esophagus, and skeletal muscle [38].  

Individuals with acute or chronic severe renal disease exhibit a higher incidence of nephrogenic systemic fibrosis (NSF). It is advisable to avoid high-risk gadolinium-based contrast agents (GBCAs) when the estimated glomerular filtration rate (eGFR) falls below 30 mL/min/1.73 m^2. Effective management of NSF necessitates a coordinated effort from the entire healthcare team [38]. 

Radiation Use and Safety 

The ionization of water molecules within cells by radiation leads to the creation of reactive free radicals, which in turn can damage vital macromolecules like DNA, resulting in biological effects [71]. The Maximum Permissible Dose (MPD) establishes the maximum radiation exposure limit safely receivable without incurring serious adverse effects. For healthcare providers, the annual limit for whole-body radiation exposure is set at 50 milliSieverts (mSv) or 5 rem [72].  

Radiation doses quantify in three distinct manners. The absorbed dose, representing the amount of radiation deposited within an object, measures in milligrays (mGy). The equivalent dose considers the specific exposure of an organ to radiation and its radiation sensitivity, measuring in millisieverts (mSv) [40]. The effective dose aggregates the equivalent doses from individual organs across the entire body and also measures in millisieverts (mSv) [40].  

Table 1. Annual Maximum Target Organ permissible Radiation Dose [15]. 

Table 2. Minimum Radiation to Produce Side Effects [15].  

The threshold of radiation required to induce specific effects varies, starting from 200 rads for cataract formation to between 5,000 and 10,000 rads for causing cerebral edema [41]. The human fetus is vulnerable to radiation from 8 to 15 weeks of gestation, a time when DNA proliferation in the brain peaks. The highest allowable radiation dose to the fetus is 0.5 rem or 5 millisieverts (mSv) [42].  

Biological effects of radiation exposure appear in two forms: deterministic effects and Stochastic events [43]. Non-stochastic effects, where the likelihood and intensity of an outcome change according to the dose and depend on surpassing a threshold, also go by the name of deterministic effects, emerging once exposure exceeds a specific level. The International Atomic Energy Agency (IAEA) defines a deterministic effect as a health impact that occurs after ionizing radiation reaches a certain level of exposure [44].  

Documented deterministic effects observed in interventional radiology, cardiology, and radiation therapy include conditions such as radiation-induced thyroiditis, dermatitis, and hair loss [44]. Deterministic effects depend on the total radiation dose an organ or tissue accumulates over time, known as the lifetime equivalent dose.  

Stochastic effects, or dose-dependent probabilities, indicate outcomes with a certain probability but without a precise initiation threshold. Defined by their random or statistical nature—hence the term ‘stochastic’—these effects characterize the likelihood of occurrence in relation to the dose, without a specific threshold, focusing on probability rather than the severity of the outcome.  

Stochastic effects from radiation exposure, including cancer, manifest years after the initial exposure during a latent period, with the severity being unrelated to the received dose [44]. While the probability of experiencing a stochastic effect rises with the number of x-rays a patient undergoes, the cumulative lifetime radiation dose does not influence the occurrence of stochastic effects [44]. Recent studies indicate that exposure to medical radiation could lead to a slight elevation in the risk of developing cataracts, cancer, and the potential for genetic disorders [44]. 

Clinical Significance 

Reducing radiation exposure hinges on three main factors: the length of exposure time, the proximity to the radiation source, and the use of protective shielding [44]. To minimize exposure time, technicians or physicians should plan necessary images in advance to prevent needless and repetitive radiation. Since using magnification can raise radiation levels for the patient, apply it with caution [44].  

While continuous or live fluoroscopy can enhance the understanding of anatomy during procedures, it generates 35 images per second, leading to higher exposure [44]. An alternative method to reduce exposure is employing pulsed fluoroscopy, which produces around five images per second, thus lowering radiation exposure without compromising image quality [45].  

Minimizing radiation exposure can also occur by increasing the distance between the x-ray beam and the targeted imaging area [44]. Positioning the image intensifier or x-ray plate as close to the patient as feasible, while keeping the x-ray tube at the maximum practical distance helps in reducing exposure without compromising the quality of the image [44][46]. This principle also benefits medical staff by reducing exposure. Surgeons, interventional radiologists, and operating room personnel encounter scattered radiation during fluoroscopy-assisted procedures, which diminishes with distance from the x-ray source, adhering to the inverse square law [47].  

Several types of personal protective equipment (PPE) can provide physical protection from radiation. Many fluoroscopy rooms come with ceiling-mounted lead acrylic shields, which can lower radiation doses to the head and neck area by a factor of 1 [44]. Portable rolling shields offer a flexible solution for staff in operating rooms and interventional environments, without needing permanent installation. Using these movable shields can cut down the effective radiation dose received by staff by over 90%. [44].  

When the use of a physical barrier for shielding is impractical, all staff members should utilize leaded aprons for their protection. These aprons, mandated in most jurisdictions, are available in thicknesses of 0.25 mm, 0.35 mm, and 0.5 mm [48]. Professionals prefer aprons designed to encircle the body over those that only cover the front, due to their greater area of coverage [48]. Lead aprons, offering shielding effectiveness comparable to a lead barrier of 0.25–0.5 mm, serve to attenuate, or reduce, radiation exposure. They are capable of absorbing 90%–95% of the scattered radiation that comes into contact with them [49]. It is imperative to use leaded aprons in conjunction with thyroid shields for optimal protection [48].  

Personal protective equipment (PPE) not only safeguards healthcare workers but also protects patients, who should receive protective gowns covering areas not subject to imaging during procedures such as plain radiography, fluoroscopy, or CT scans. Inspect lead protective clothing every six months to ensure they remain in good condition and hang up leaded aprons instead of folding them to prevent damage and cracking [44]. 

Medical personnel participating in fluoroscopy-guided procedures are at risk of developing radiation-induced cataracts, making it essential to monitor lens doses [50]. It is crucial to extend radiation protection to the fullest extent possible to safeguard against such risks. Leaded eyeglasses should have a minimum lead equivalence of 0.25 mm to offer sufficient protection for the eyes’ lenses [50].  

Despite their importance, healthcare professionals report the least utilization of lead glasses as a form of personal protective equipment (PPE), with adherence rates in numerous studies ranging between 2.5% and 10% [50][51]. Frequent use of leaded eyeglasses can lower the radiation exposure to the eye’s lens by up to 90%. [44] [78].  

Healthcare providers should place dosimeters, which are practical, affordable, and effective at enhancing awareness of their radiation exposure, over personal protective equipment at shoulder level to monitor lens and thyroid exposure [51]. A dual-badge system, featuring one dosimeter outside and another inside the protective apron, offers a more precise estimate of eye and body radiation doses. [55].  

Compliance with dosimeter guidelines offers staff precise insights into their radiation exposure levels and supports the evaluation of safety practices and promotes a stronger culture of safety awareness [44]. 

Radiation Protection & Safety 

Radiation safety is a critical issue affecting patients, physicians, and staff across various departments, such as radiology, interventional cardiology, and surgery. The highest levels of radiation exposure to medical personnel stem from fluoroscopic procedures [15]. In the fluoroscopic suite, there are three primary sources of radiation exposure: the main X-ray beam, along with leakage and scatter from X-ray beams [15].  

The X-ray beam, along with leakage and scattered X-ray beams, presents a challenge in radiology. As X-rays journey from their source to the patient, a considerable number of particles do not reach the image detector; they are either absorbed, attenuated, or scattered [15] [74]. The scattered X-rays, resulting from incoherent scattering, are a concern for healthcare providers due to their major contribution to occupational radiation exposure [15] [74].  

When primary X-ray particles interact with these atoms, they generate scattered X-ray photons, leading to the emission of new photons in random directions. This randomness poses a significant hazard to healthcare workers [74]. As a result, healthcare professionals view not just the path of the primary beam but the entire radiologic suite as a potential zone for significant radiation exposure. 

In comparison, the radiation exposure from diagnostic imaging techniques, including computed tomography, mammography, and nuclear imaging, contributes less to the overall radiation dose received by healthcare workers [44]. The foundation of radiation safety stands on three fundamental principles: justification, optimization, and dose limitation [43]. 

Justification necessitates a grasp of the pros and cons associated with using radiation in medical treatments or procedures [43]. The application of radiation must always have medical justification, confirming that the patient’s advantages from its use surpass the potential risks of exposure. This requires a thorough evaluation of the patient’s health status, the availability of non-radiation diagnostic alternatives, and the anticipated results of the procedure [43]. 

The second principle, dose limitation, entails establishing and following specific limits for radiation exposure and reducing the duration of fluoroscopy exposure and utilizing pulsed fluoroscopy methods. [43]. Radiation levels require minimization to the lowest achievable extent (ALARA principle and sufficient to gather the required diagnostic data [43]. The third principle, optimization, focuses on developing a comprehensive strategy to reduce radiation exposure to the lowest possible levels [43].  

Occupational exposure to radiation is subject to established dose limits, and it is critical to ensure that healthcare professionals stay within these boundaries. Implementing protective strategies, such as wearing lead aprons, thyroid shields, lead glasses, and utilizing shielding barriers, is a critical part of an extensive radiation protection plan [73] [78]. 

The As Low as Reasonably Achievable (ALARA) principle, established by federal regulations, aims to ensure that all steps to minimize radiation exposure, while acknowledging the essential role of radiation in diagnosing and treating patients [43][60].  

Exposure to any level of radiation heightens the risk of stochastic effects and the likelihood of cancer development post-exposure. These effects follow a linear model, indicating no precise threshold exists to reliably cancer development [44]. The radiology community advocates for protective measures adhering to the ALARA principle [60]. 

Three principles for radiation safety: time, distance, and shielding.  

Radiation exposure accumulates with the duration of exposure. During procedures involving C-arm fluoroscopy, the amount of time spent operating the device impacts the level of radiation exposure [73].  

Moving further away from the radiation source reduces radiation exposure, with the decrease in exposure being proportional to the square of the distance from the source [73] Thus, maintaining a greater distance grom the X-ray generator serves as a vital radiation safety strategy.  

Regarding shielding, numerous protective devices are available for mitigating radiation exposure during C-arm fluoroscopy-guided procedures, including caps, lead glasses, thyroid shields, aprons, and radiation-reducing gloves [73]. Using protective shielding for the patient also reduces the level of radiation administered, as well as the overall amount of radiation scatter, thereby minimizing the exposure experienced by occupational personnel [46].  

Implementing techniques including collimation, oblique views, and intermittent fluoroscopy to prevent hand exposure to the beam leads to reduced radiation doses for both the patient and the operator [75]. 

Biological Effects of Radiation 

Fluoroscopy presents certain risks due to radiation exposure. The x-rays generated in fluoroscopy are a type of ionizing radiation capable of causing significant biological effects [76]. Even low doses of ionizing radiation can lead to molecular changes that might evolve into cancer over the years [76]. 

Experts deem the impact of low doses of ionizing radiation as minor, as biological cells possess inherent mechanisms for DNA repair [76]. Nonetheless, it is crucial to acknowledge that individual responses to radiation exposure vary, resulting in diverse deterministic effects or varying intensities of effects. This biological variation can be spontaneous or influenced by various patient-specific factors, such as health condition and previous exposures.  

In the current medical landscape about 48% of the radiation exposure experienced by the average American comes from medical procedures [76]. Cells have three known techniques for addressing radiation injury: repairing DNA, attacking reactive oxygen species, and eliminating mutated or unstable cells [77].  

We can categorize radiation impacts into deterministic and stochastic types. Stochastic effects, such as the development of cancer, cataracts, and genetic mutations, do not depend on the dose and manifest after a prolonged latency period compared to deterministic effects [44]. These outcomes result from free radical damage to DNA [78].  

On the other hand, deterministic effects, or tissue reactions, are related to the dose and emerge once radiation exposure surpasses a certain threshold, leading to conditions like radiation dermatitis, skin necrosis, and hair loss [15][44]. The biologic effects of ionizing radiation are proportional to the time of radiation exposure, and radiation exposure is inversely proportional to the square of the distance from the radiation source [44]. This implies that the greater the distance between the radiation source and a person, the lower the exposure.  

Biological tissues respond to radiation influenced by the radiation’s nature. Scientists classify radiation into ionizing and non-ionizing forms [80]. While both can harm human tissues, ionizing radiation, possessing higher energy, poses a greater risk of damage. It can harm human cells by triggering chemical reactions and modifying molecules within the cellular framework, affecting proteins and other large molecules that make up deoxyribonucleic acid (DNA) [79] [80]. 

Research divides ionizing radiation into direct and indirect ionizing categories. Indirect ionizing radiation, such as electromagnetic radiation (gamma photons), does ionize molecules via direct mechanism [79]. Instead, these photons lose their energy through various interactions, creating a charged particle that then interacts with a target molecule in biological tissues. Charged particles (alpha and beta particles) interact with biological tissues via direct mechanism, Indirect ionizing radiation is more harmful to tissues compared to direct ionizing radiation [79]. 

Ionizing radiation examples encompass x-rays, gamma rays, and rays at the extreme ultraviolet (UV) end of the electromagnetic spectrum. Non-ionizing radiation examples include radio waves and sunlight exposure (UV-A and UV-B) [79].  

In order to forecast the biological effects of various radiation types, we translate the rad unit (measuring the absorbed dose of ionizing radiation) into roentgen equivalent man (rem) or sieverts (Sv) in the International System of Units [58]. This translation involves multiplying the rad or gray (Gy) by a quality factor that is specific to the kind of radiation involved [58].  

Damage from radiation to the body occurs through direct cellular damage and indirect damage via creation of reactive oxygen species. Direct cellular damage is more in cells in the G1 or M phases of the cell cycle [81]. During the M stage, cells compact DNA into chromosomes, increasing the risk of a double-strand DNA break [81]. The repair process is complete in one to two hours, so more time between radiation doses improves cell survival [81] [82].  

Indirect cellular damage results from water hydrolysis, leading to reactive oxygen species production. Two-thirds of radiation-induced DNA damage comes from hydroxyl radicals [82]. A reactive oxygen species may react with protein, leading to loss of enzymatic activity in the cell. Antioxidants that scavenge free radicals are important for reducing this damage [82]. 

Biological tissue is rich in macromolecules that determine the cellular response to radiation exposure. Endogenous reactive oxygen species, more than three times as likely as natural background radiation, can cause DNA double strand breaks [83]. These macromolecules include innate antioxidant enzymes (superoxide dismutase) and dietary antioxidants. The oxidative stress triggered by radiation kick-starts enzyme systems to restore balance in the cell’s microenvironment and activates various signaling pathways [83].  

Radiation exposure also leads to the activation or suppression of numerous genes at doses lower than those causing mutagenesis [84]. Research reveals non-DNA effects and coordinates tissue responses from cells not hit by radiation, a phenomenon known as bystander effects [84]. These effects can either damage DNA or trigger protective responses in non-irradiated cells. With low radiation doses, the number of cells exhibiting bystander activation exceeds those exposed, heightening concerns over potential delayed DNA damage effects [82][82][84].  

Radiation and Pregnancy 

Epidemiological research on groups exposed to sudden, intense doses of ionizing radiation has been a method to evaluate cancer and other disease risks associated with radiation. These studies reveal that developing organisms are susceptible, though the impact of ionizing radiation on an embryo or fetus varies with the dose received and the gestational period [79]. Protecting pregnant or individuals with the potential to get pregnant and radiology personnel is of utmost importance in medical environments.  

The risk to the fetus from medical radiation is minor compared to the general population’s rates of spontaneous miscarriage (15%), genetic disorders (4% to 10%), and malformations (2% to 4%) [85]. Investigators refer to the fetal radiation dose as a tissue dose, and it does not distribute evenly through various mechanisms. Research supports the notion that fetal exposure to radiation below 50 mSv is inconsequential, as doses under 50 mGy do not impact pregnancy outcomes differently from those observed in control groups [85].  

The fetal risk from radiation is dose-dependent and varies with the pregnancy stage, being highest in the first trimester during organ formation and lowest in the last trimester. Healthcare providers should postpone diagnostic tests involving radiation until post-pregnancy or substitute them with non-radiative alternatives [43][86]. Healthcare providers should postpone diagnostic tests involving radiation until post-pregnancy or should substitute them with non-radiative alternatives. 

The estimated fetal radiation dose from diagnostic procedures changes with the procedure type and pregnancy stage. A pelvic x-ray may result in a 1.5 mSv dose [87]. A lumbar spine x-ray at three months of gestation exposes the fetus to 2 mSv, which increases to 9 mSv closer to term. A CT scan of the mother’s head exposes the fetus to less than 0.005 mSv, whereas an abdominal CT scan can result in an 8 mSv exposure.  

In the United States, experts estimate that annual whole-body background radiation exposure totals 3.1 mSv (310 mrem) [87]. United States Nuclear Regulation Commission (USNRC) advises keeping total fetal exposure during pregnancy below 5.0 mSv (500 mrem) [87]. Fetal radiation doses under 50 mGy are safe without causing harm [87]. The Center for Disease Control (CDC) considers radiation doses from 50 mGy to 100 mGy as having an unclear impact on the fetus. However, empirical data recognize doses over 100 mGy, exceeding 150 mGy, as levels at which adverse fetal effects occur [87]. Most diagnostic procedures conducted during pregnancy remain below this risk threshold [87]. 

The gestational age at the time of exposure influences the fetus’s vulnerability to radiation [87]. The embryo/fetus is sensitive during organogenesis (2 to 7 weeks gestational age) and the first trimester, whereas it exhibits greater resistance in the second and third trimesters [87]. A dose ranging from 0.05 to 0.5 Gy poses no harm to the fetus in the latter stages of pregnancy but proves harmful during the first trimester [87].  

Despite increased resistance in the later stages, high doses of radiation (above 0.5 Gy or 50 rad) can lead to serious adverse outcomes, such as miscarriage, stunted growth, decreased IQ, and significant mental disability [87]. Healthcare professionals, including clinicians and radiologists, should provide guidance to pregnant patients, regardless of gestational age [87]. 

Fetal Effects 

Significant negative impacts of radiation exposure on the fetus can include miscarriage, birth defects, developmental or cognitive impairments, restricted fetal growth, and cancer induction [42]. Standard diagnostic procedures do not reach the radiation levels necessary to cause malformations, fetal death, or damage to the central nervous system.  

Central nervous system anomalies could develop if radiation exceeds a dose threshold of 100 mSv. Fetal exposure to doses of 100 mSv or more between 8 and 16 weeks of gestation may lead to reduced intelligence and microcephaly [42] [88].  

High doses of prenatal radiation cause deterministic effects. In the first two weeks post-conception, radiation can either terminate the pregnancy or have no effect, due to the small number of cells (an all-or-none outcome). At this stage, there’s reduced susceptibility to birth defects but an increased risk of pregnancy loss due to radiation [42].  

The sensitivity to birth defects increases during organogenesis (3rd to 8th week post-conception), raising the likelihood of organ malformations [42]. Between the 8th and 15th week of gestation, the risk for cognitive or developmental impairments emerges, estimated at about 0.4% per gray [42]. Post the 16th week, the fetus’s central nervous system becomes more resistant to radiation. In the final trimester, significant organ deformities and functional issues are rare [43].  

The threshold dose for observable deterministic effects ranges between 100–200 mGy (10–20 rad) for acute whole-body exposure [43]. Most extra-abdominal diagnostic x-rays result in fetal doses under 1 mGy (100 mrad), though abdominal or pelvic examinations may expose the fetus or embryo to higher doses.  

Accidental irradiation might exceed 50 mGy (5 rad) if fluoroscopy lasts over seven minutes but surpassing 100 mGy (10 rad) in diagnostic x-rays is unusual, making deterministic effects improbable from such studies [89]. The carcinogenesis risk from radiation below 100 mGy (10 rad) to the conceptus is low. For doses above 100 mGy, professionals must consider both deterministic and stochastic radiation effects [89]. 

Considerations for Pregnant Staff 

Under federal law, pregnant women may continue working in environments with occupational radiation exposure at levels deemed safe for adult workers. The Nuclear Regulatory Commission (NRC) guidelines for Radiation Protection (10 CFR 20) mandate that licensees restrict radiation exposure to the embryo/fetus of a worker exposed to occupational radiation to no more than 500 mrem (5 mSv) throughout the pregnancy, provided the worker has declared her pregnancy and radiation exposure is from licensed radioactive materials [90].  

Pregnant radiation workers are subject to monitoring as per radiation safety regulations. The dose limits for the unborn set by the International Commission on Radiological Protection (ICRP) and U.S. regulations differ [87]. The ICRP recommends that the work conditions post-pregnancy declaration should limit additional embryo/fetus exposure to approximately 1 mSv for the rest of the pregnancy [91]. 

U.S. federal regulations require that the total dose to an embryo/fetus from a pregnant worker’s occupational exposure not exceed 5 mGy (500 mrad) throughout the pregnancy [87]. 

Evidence suggests that maintaining a fetal dose limit of 1 mGy is achievable for full-time interventional fluoroscopy physicians [92]. A study involving 30 interventional radiologists showed dosimeter readings under lead aprons ranging from 0.02 mSv to 0.39 mSv over two months, projecting an annual dose of 0.22–4.11 mSv for a 10.6-month work year [92] [93].  

The data indicated that workers using thicker lead aprons received lower radiation doses, suggesting that additional protective measures may be beneficial in interventional radiology settings [92] [93]. 

Radiation Safety in Children  

Children are more vulnerable to radiation than adults, with sensitivity up to 15 times higher depending on their age and gender [94]. Nonetheless, the link between low-level radiation and the onset of fatal cancer remains uncertain, necessitating a cautious approach when assessing risks associated with medical imaging when communicating with patients, their families, and caregivers.  

Experts consider radiation exposure under 100–150 mSv to be low level [95] [96]. 

While the risks of higher doses are well-acknowledged, the potential hazards of lower doses are subject to debate, influenced by factors such as gender, age, exposure area, genetic predisposition, and whether the exposure is acute or prolonged [95][96]. 

Maximum Permissible Doses to Tissue  

The National Council on Radiation Protection and Measurements provides guidelines on the highest acceptable annual radiation doses to different organs and tissues [75]. Exposures beneath these thresholds have shown not to result in substantial harmful effects [75]. However, the International Commission on Radiological Protection (ICRP) advises that individuals should limit their exposure to no more than 10% of these maximum permissible levels [97] [98].  

The annual limit set for the thyroid, extremities, and reproductive organs is 500 mSv (50 rem), while the limit for the lens of the eye is set at 150 mSv (15 rem). For pregnant women, the maximum dose allowed to reach the fetus is 5 mSv (0.5 rem) [97][98].  

The threshold dose for immediate skin reddening (acute erythema) is around 2 Gy, whereas delayed deep skin ulcers appear after exposure to doses between 12 and 15 Gy [99]. The likelihood of deterministic harm increases with repeated procedures on the same body part (for instance, several Y-90 embolization treatments in the liver or TIPS placements with subsequent adjustments) [100]. Radiation-induced skin injuries manifest after a delay, emerging days or even weeks post-procedure after surpassing the threshold for skin exposure [99]. Several factors elevate the risk of skin damage from radiation, such as connective tissue disorders, obesity, and diabetes. Reducing the likelihood of deterministic radiation effects should be a primary goal of radiation protection efforts [101].  

Radiation-induced skin effects follow a spectrum of reactions with varying thresholds and onset times. Early transient erythema can occur with a dose of approximately 2 Gy, appearing within 2 to 24 hours [101][102]. The main erythema reaction has a threshold of about 6 Gy and manifests around 1.5 weeks after exposure [101][102]. Temporary hair loss occurs with doses around 3 Gy at about 3 weeks, while permanent hair loss requires a 7 Gy dose, also occurring around 3 weeks post-exposure [101][102]. 

Skin begins to show dry peeling at a dose of 14 Gy after 4 weeks, and moist peeling at 18 Gy around the same time frame [101][102]. Secondary ulceration, requiring a 24 Gy dose, appears after 6 weeks. Late erythema, observed with a 15 Gy dose, and ischemic dermal necrosis at 18 Gy, become evident after 8 to 10 weeks and more than 10 weeks [101][102]. 

Long-term effects such as dermal atrophy and telangiectasia, both occurring after doses of 10 Gy, as well as delayed dermal necrosis at doses greater than 12 Gy, emerge after more than 52 weeks [101][102]. These timelines and dose thresholds highlight the varied nature of skin responses to radiation, ranging from immediate reactions to long-term damage. 

Deterministic Effects of Radiation  

Deterministic effects stemming from radiation exposure encompass a range of conditions such as hair loss, cataract formation, suppression of bone marrow, spontaneous miscarriages, birth defects, and restrictions in fetal growth. The likelihood of experiencing deterministic injuries from radiological procedures ranges from 1 in 10,000 to 1 in 100,000 [42]. 

With the exception of cataracts, radiation-induced deterministic effects are associated with apoptosis, or cell death [42]. The susceptibility of cells to radiation-induced damage varies, with dividing cells being most vulnerable [42]. In contrast, cells that have completed the division process exhibit less sensitivity [42]. 

The occurrence and severity of deterministic effects following radiation exposure depend on several factors: the magnitude of the dose, the amount of exposed tissue, the nature of the radiation, and the duration of the administered dose [89]. Cell types exhibit varying levels of radiation tolerance and timelines for effect manifestation.  

Early radiological signs often result from impacts on parenchymal cells, whereas later symptoms may stem from damage to vascular cells [89]. Factors such as the patient’s body mass, procedural complexity, prior radiation exposure, existing health conditions, including cancer, and other comorbidities can heighten the risk of injuries related to deterministic effects [79].  

The Joint Commission classifies extended fluoroscopy, resulting in a peak skin dose exceeding 15 Gy to a single area within six months, as a sentinel event. The American Association of Physicists in Medicine has proposed revising this definition, contesting the Joint Commission’s suggestion that such radiation doses are unforeseen and avoidable. In certain situations, life-saving interventions may necessitate surpassing the 15-Gy limit [104]. If a patient undergoes multiple procedures involving radiation directed at the same region the risk of breaching the threshold can occur [103].  

Radiation overdose sentinel events also lists cases such as neonatal serum bilirubin levels exceeding 30 mg/dl, prolonged fluoroscopy leading to a cumulative dose greater than 1500 rads [15 Gy] to a single area, or any instance of radiotherapy administered to an incorrect region or exceeding the planned dose by more than 25% [103].  

Regulations mandate hospitals to perform a thorough investigation into the root causes of such events and report them, regardless of whether the adverse outcomes have manifested [105].  

For accreditation, the Joint Commission mandates that healthcare facilities implement a thorough approach to analyze sentinel events through a systematic approach [105]. Root Cause Analysis (RCA) involves utilization. By employing the RCA process, healthcare organizations are able to enhance patient care and implement strategies to reduce incidents that jeopardize patient safety.  

The Joint Commission has created a framework and series of 24 questions to aid in organizing an RCA [105]. This framework should serve as a general template when preparing the RCA report that healthcare professionals will submit to the Joint Commission after thorough evaluation. The 24-question framework recommended by the Joint Commission considers various situational factors that may have contributed to a sentinel event.  

This includes examining the systematic process, human factors, equipment malfunctions, environmental factors, uncontrollable external factors, organizational factors, staffing and qualifications, contingency plans, performance expectations, informational disruptions, communication, environmental risks, training, and technology [104].  

Stochastic Effect of Radiation  

Stochastic effects refer to radiation effects where there is no direct correlation between the dose’s magnitude and the injury’s severity, with genetic mutations and cancer induction being prime examples [106].  

There is no specific threshold dose below which stochastic effects of do not to occur, indicating that no amount of radiation exposure can be considered to be without harm [89]. Therefore, it is essential to ensure that providers conduct fluoroscopic procedures in the safest manner possible to minimize risk and harm. Although the likelihood of stochastic effects does not correlate with the dose received, the risk increases with the total radiation exposure accumulated by the patient [89].  

The induction of cancer is a significant concern regarding stochastic effects of radiation, yet the likelihood of cancer from invasive radiologic procedures is lower than the natural incidence of the disease [75]. For adults, the estimated risk of fatal cancer from an effective dose of 100 mSv over an average lifetime is about 0.5%, compared to a 16.5% chance of developing a non-radiation-related cancer within the next decade for a 60-year-old man [75]. 

In pediatric cases, the procedures often involve lower radiation doses. Nonetheless, due to their smaller body size, children are more susceptible to receiving higher radiation doses if precise collimation techniques are not employed [75]. It is crucial to account for the stochastic effects of radiation in pediatric and young adult patients when exposure involves radiosensitive areas such as the thyroid, gonads, and breast tissue [107].  

The longer life expectancy and heightened vulnerability to radiation-related damage in these groups necessitate careful consideration. Newborns are at a threefold greater risk of experiencing radiation-related damage than adults. Moreover, even though adolescents may have the physical stature of adults, their susceptibility to radiation toxicity is still higher [79]. 

Radiation Dose Measurement and Documentation  

The ability to predict the occurrence of deterministic and stochastic effects in patients hinges on knowledge of their radiation history, underscoring the importance of documenting patient radiation doses [89]. Tracking and documenting dose information ensures quality assurance and enhances patient safety, with feedback aiding in the optimization of radiation usage [104].  

For example, the diverse range of complexities in conditions treated with fluoroscopy-assisted endovascular procedures often necessitates extended operation times, thereby elevating radiation exposure for both patients and healthcare providers [109]. By pinpointing the procedures that entail high doses of radiation, it becomes possible to implement more strategic dose management approaches [108]. Such strategies have the potential to diminish the risk of radiation-induced harm to patients and curtail the overall radiation exposure experienced by physicians. 

The Society of Interventional Radiology (SIR) advocates for the recording of both general radiation doses and all specific dose data for fluoroscopic procedures [108]. The ICRP suggests dose measurement when exceeding 3 Gy, or 1 Gy for repeated procedures, recommending recording the peak skin dose and skin dose map [108]. The FDA places the onus on healthcare facilities to determine which procedures necessitate dose recording. 

Measuring Patient Radiation Doses in Interventional Fluoroscopy  

There are four primary techniques utilized for dose measurement during interventional fluoroscopic procedures (CT fluoroscopy excluded) [110][111]: 

• Peak skin dose 
• Reference air kerma 
• Kerma-area product 
• Duration of fluoroscopy 

The accuracy of reported patient doses is subject to variability due to differences in dose measurement and estimation methods. The kerma-area product serves as a valuable marker of stochastic risk to patients and is associated with the radiation exposure of operators and staff [111]. Recommendations are to monitor patient doses in fluoroscopic procedures.  

Peak skin dose aims to identify the maximum radiation received by any skin area, crucial for assessing the potential and severity of radiation skin injuries [111]. Recommendations are to measure peak skin dose for interventional radiology, practical implementation presents challenge [99]. Dosimeters placed on the skin are employed for this purpose yet point measurements can undervalue the actual peak skin dose if not positioned at the precise irradiation site [99][111]. 

Recording Patient Radiation Doses  

The American College of Radiology advises documenting all accessible radiation dose information in the patient’s health records [75].  

If the air kerma or air kerma-area-product data are unavailable, recommendations are to log the duration of fluoroscopic exposure and the count of images captured (be it radiography, cine, or digital subtraction angiography) in the patient’s medical file [111].  

Adhering to the practice of recording radiation doses is a crucial aspect of conducting fluoroscopic procedures. While managing radiation dose is essential, the primary aim remains to deliver optimal patient care. The ACR-SIR Practice Guideline for Reporting and Archiving Interventional Radiology Procedures mandates including radiation dose information in the concluding report of all fluoroscopy-guided interventions [110].  

Furthermore, whenever feasible, the fluoroscopy device should store all dose data captured alongside the procedure’s images. Post – procedure, professionals can record dose information on the procedure worksheet. Each healthcare facility must define the precise documentation methods to align with its own quality improvement initiatives and medical recording standards [112].  

Experts also recommend logging radiation dose data for fluoroscopy-guided procedures involving lower patient radiation doses, such as venous access operations. This practice ensures comprehensive documentation, reducing the risk of overlooking dose recording in procedures with higher radiation exposure levels [112]. 

Measuring Patient Radiation Exposure  

Radiology divides radiation dose monitoring methods into direct and indirect approaches. Direct approaches involve placing a dosimeter directly on the patient’s skin, whereas indirect methods estimate the dose based on variables from the radiology equipment to gauge the air kerma [111]. 

Direct radiation dose readings are achievable with a dosimeter. These devices come in two types: real-time, including ionization chambers, diodes, and optical fibers, and non-real time, such as thermoluminescent dosimeters and optically stimulated luminescence (OSL) dosimeters [113]. Thermoluminescence (TL) is the phenomenon in which a crystalline material emits light previously absorbed from ionizing radiation upon being heat [113]. 

Tenets of Radiation Safety in Clinical Practice 

The Society of Interventional Radiology (SIR) has developed guidelines to support healthcare professionals in delivering safe, high-quality care using interventional radiology technologies [114].  

These guidelines aim to establish a set of practice principles rather than strict rules, encouraging a flexible approach to patient care. The SIR emphasizes that the final decision on patient treatment should rest with the physician, considering the specific needs of the patient and the resources at hand [114]. 

The SIR promotes a comprehensive care approach that spans from preprocedural planning through to post procedure management. A crucial element of preprocedural planning is obtaining informed consent, which includes a discussion about the radiation dose and its associated risks [114]. 

Conclusion 

The State of Oregon mandates specific training and certification requirements for Advanced Practice Registered Nurses (APRNs) to operate fluoroscopy, ensuring they are well-versed in radiation safety, procedural methodologies, and emergency management [2]. These requirements aim to safeguard patient and healthcare personnel health while sustaining high-quality care standards.  

Fluoroscopy, a technique that provides real-time X-ray imaging, finds use across various medical fields for its benefits in reducing procedure invasiveness, infection risks, and recovery time [55]. With the advancement from traditional to digital fluoroscopy, there is a heightened emphasis on minimizing radiation exposure by adhering to the ALARA principle and employing the minimal acceptable dose for the shortest necessary duration [2].  

In Oregon, APRNs seeking to perform or supervise fluoroscopic procedures must fulfill comprehensive didactic and clinical training, including a mandated 40 hours of supervised clinical practice in a fluoroscopic suite [2]. The oversight of fluoroscopy by APRNs falls outside the purview of the Nursing Practice Act. The Oregon Board of Medical Imaging requires APRNs to pass the ARRT fluoroscopy examination and obtain a limited fluoroscopy permit for supervisory role [2]. 

The regulations underscore the importance of reducing radiation exposure through adherence to safety principles such as justification, optimization, and dose limitation. Protective measures, including the use of lead aprons, thyroid shields, and lead glasses, play a crucial role in a comprehensive radiation safety program. The American College of Radiology and the Society of Interventional Radiology advocate for the meticulous documentation of radiation dose data for all fluoroscopic procedures to enhance patient safety and quality assurance [75][110]. 

Radiation safety training encompasses understanding the biological effects of radiation, including both deterministic and stochastic effects, with specific guidelines to protect vulnerable populations such as pregnant patients and children [42]. The legislation also emphasizes continuous education and adherence to safety protocols to mitigate the risks associated with radiation exposure, ensuring that healthcare providers maintain a high standard of patient care while minimizing potential harm from fluoroscopic procedures. [43]. 

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