Cardiovascular Journal of Africa: Vol 32 No 5 (SEPTEMBER/OCTOBER 2021)

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 32, No 5, September/October 2021 236 AFRICA procedures, will keep all involved vigilant to protect themselves and the patients. Other active processes include radiation dose monitoring, real-time dose monitoring, limiting fluoroscopy time and low frame-rate options. Passive processes include shielding, whether it is fixed or movable. The use of protective apparel includes suspended shielding or wearing lead protective attire, which includes caps, eyewear, gloves and other shields. 1 As newer technologies further develop and are incorporated in X-ray equipment, risks of radiation exposure may be reduced. These management tools and functions are available on most modern radiation equipment, while image quality is maintained. Practical and simple techniques are important and should be part of the radiation suite culture to protect patients and staff. Checklists will constantly remind staff and may include duration, distance and shielding techniques. It is important to involve all role-players in the catheterisation laboratory design and discuss the work flow and storage of consumables to reduce potential exposure. The involvement of a medical physicist may improve the design and identify possible areas where staff may be at higher risk of exposure. Monitoring Institutions should have a radiation safety culture and follow quality assurance programmes and targets to meet the International Commission on Radiological Protection (ICRP) objectives. 6 These guidelines aim to limit the effects of ionising radiation exposure and ensure appropriate protection, without the loss of benefits associated with radiation. National monitoring guidelines should be followed, and each unit should have stringent monitoring and standard operating protocols. The wearing of dosimeters should be obligatory and controlled during pre-procedure checklists. Exposure doses, including cumulative doses, should be available to all personnel with regular feedback. Staff with high radiation exposure should be notified and interventions applied to prevent possible exposure-related complications. Real-time radiation-exposure monitoring is available in newer radiation equipment. This function allows the operator to monitor specific patient areas in real time. Operators will be warned once a specific dose is reached, and this may prevent possible overexposure. 7 Duration Ensuring adequate staffing numbers and working on a rotational basis can lessen exposure. Fluoroscopy time can be reduced by using review image hold, adjusting and lowering frame rates. Distance Distance from the radiation source is crucial and exposure may be decreased if personnel take two steps back. All staff that can move away from the table should be warned and allowed to move if possible. 3 As discussed in the article in this issue, the operator’s hands are at high risk for exposure and operators should use all measures to protect their hands. Shielding of the operator’s hands remains problematic and operators should actively avoid exposure. Patients should be positioned optimally to minimise angulation, and the X-ray source should be placed under the patient and as close as possible to limit exposure. 1,2 Closure of theatre doors prevents staff from entering during procedures, and indicator lights warn when active screening is taking place. The installation of automatic doors with foot activation can ensure that doors remain closed and are easily operated. Tubing extensions on contrast injectors will increase the distance away from the source to protect the radiographer. Moving the foot pedal from the cardiologist to the radiographer may increase the source distance for the cardiologist, and increase the possibility of proper shielding, especially of the legs. Shielding A variety of shielding is available and these should be used. Examples include eyewear with side protection, caps, aprons and anti-X-ray hand cream. Table and ceiling suspension screens should be used during every case. Lead aprons of sufficient thickness should be used and the integrity monitored. Staff that work with their backs to the radiation source should not neglect to wear protective lead clothing. 1,4,5,8 Radiation safety will always be important, and small, simple measures play a significant role in protecting patients and staff. References 1. Biso SMR, Vidovich MI. Radiation protection in the cardiac catheteri- zation laboratory. J Thorac Dis 2020; 12 (4): 1648–1655. 2. Mohsen M, Leili D, Effat A. Reduction of radiation risk to interven- tional cardiologists and patients during angiography and coronary angioplasty. J Tehran Heart Centr 2017; 12 (3): 101–106. 3. Smilowitz NR, Balter S, Weisz G. Occupational hazards of interven- tional cardiology. Cardiovasc Revasc Med 2013; 14 (4): 223–228. 4. Madder RD, La Combe A, Van Oosterhout S, et al. Radiation expo- sure among scrub technologist and nurse circulators during cardiac catheterization: the impact of accessory lead shields. J Am Coll Cardiol Cardiovasc Interv 2018; 11 : 206–210. 5. Padmanabhan D, Shankar S, Chandrasharaiah A, et al . Strategies to reduce radiation exposure in electrophysiology and interventional cardi- ology. US Cardiol Rev 2019; 13 (2): 117–122. 6. IRCP 2007. 2007 Recommendations of the International Commission on Radiological Protection (user edn). ICRP Publication 103 (user edn). Ann ICRP 2007; 37 (2–4). 7. Christopoulos G, Papayannis AC, Alomar M, et al. Effect of a real-time radiation monitoring device on operator radiation exposure during cardiac catheterization. Circ Cardiovasc Interv 2014; 7 : 744–750. 8. Panetta CJ, Galbraith EM, Yanavitski M , et al . Reduced radiation exposure in the cardiac catheterization laboratory with a novel vertical radiation shield. Catheter Cardiovasc Interv 2020; 95 : 7–12.