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ORIGINAL ARTICLE
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Radiation exposure among anesthetist, orthopedic surgeon, and scrub nurse in orthopedic operation theater complex


1 Department of Anaesthesia, BJMC and SGH, Pune, Maharashtra, India
2 Department of Orthopaedics, BJMC and SGH, Pune, Maharashtra, India

Date of Submission26-Dec-2020
Date of Decision25-Aug-2021
Date of Acceptance20-Sep-2021

Correspondence Address:
Yogesh Gavali,
Department of Anaesthesia, BJMC and SGH, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_721_20

  Abstract 


Background and Aims: Orthopedic operation theater staff is exposed to primary and scattered radiation during various fluoroscopy-assisted operative procedures during their routine working hours. This exposure is associated with significant health hazard. This prospective study is designed primarily to determine the level of radiation exposure among them and to compare it with the current safety guidelines and secondarily to measure the cumulative scattered radiation exposure inside operation theater complex. Subjects and Methods: Total 15 thermoluminescent dosimeters (TLDs) were used during the study. Seven TLDs were used per team and per procedure at designated position. Participating staff were instructed to use personal protective equipment and to wear the TLDs at all times during their study period. TLDs were analyzed at the end of 6 months. Results: The mean value of radiation exposure of anesthesia machine, orthopedic surgeon, anesthetist with TLD above lead apron, anesthetist with TLD below lead apron, and scrub nurse was 0.05, 1.85, 0.1, 0, and 0.625 mSv units, respectively. The highest individual values for orthopedic surgeon, anesthetist with TLD above the lead apron, and scrub nurse were 2.75, 0.1, and 0.7 mSv units, respectively. All these readings were within permissible limit. Conclusions: If standard safety precautions were followed, cumulative ionizing radiation exposure to participating staff as well as scattered radiation exposure within operation theater complex is minimal and within permissible limit. Routine personal dosimetric monitoring is desirable in staff working with fluoroscopy-guided procedure along with the use of personal protective equipment. Periodic training on radiation risk and protection should be conducted for them to heighten the awareness.

Keywords: Orthopedic operation theater staff, personal protective equipment, radiation exposure, scattered radiation, thermoluminescent dosimeter monitoring



How to cite this URL:
Tandale SR, Gavali Y, Naik S, Chandanwale A, Kelkar KV, Kelkar VS, Pandit S. Radiation exposure among anesthetist, orthopedic surgeon, and scrub nurse in orthopedic operation theater complex. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2022 Dec 1]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=337618




  Introduction Top


The use of intraoperative fluoroscopy is a valuable diagnostic and therapeutic tool in orthopedic procedures. It is commonly used for closed reductions, intramedullary nails, open reduction, and internal fixations of fractures. Fluoroscopy-guided procedures pose a constant risk of ionizing radiation to anesthetist, orthopedic surgeon, and scrub nurse as they are routinely involved in managing these procedures inside operation theater complex.[1] This can significantly increase the cumulative radiation exposure to all of them particularly for those working for long periods of time. Medical literature search revealed that the exposure to even low-dose radiation may be a cause for concern because such exposure can result in leukemia, thyroid malignancies, and other cancers.[2] Other effects of radiation include genetic mutation, HIV type I replication activation, lens damage, and developmental malformation in children whose mothers were exposed to radiation during pregnancy.[2],[3] A number of studies have looked at radiation exposure among orthopedicians during orthopedic surgery, however, it is difficult to directly extrapolate the conclusions of these studies to anesthetist and scrub nurse.[4],[5] The available literature on the extent of radiation exposure to anesthetist, orthopedic surgeon, and scrub nurse during orthopedic procedure and extent of scattered radiation in operation theater complex is limited.[6],[7] This prospective study is designed to determine the level of radiation exposure of anesthetist, orthopedic surgeon, and scrub nurse working in operation theater complex with fluoroscopy-assisted orthopedic procedures and to compare it with the current safety guidelines. The secondary objective is to measure the cumulative scattered radiation exposure operation theater complex.


  Subjects and Methods Top


We conducted a prospective observational study in the orthopedic operation theater of tertiary care referral center in Pune, India, from October 2018 to March 2019. The study was approved by the hospital's institutional ethics committee. The study was registered in the Clinical Trials Registry of India (CTRI/2018/05/013883;www.ctri.in). Orthopedic and anesthesia departmental permission was obtained. All orthopedic surgeons (trainee and qualified), anesthetists (trainee and qualified), and scrub nurses (qualified) who gave voluntary written consent to participate in the study were included. The study was carried out in accordance with the principles of good clinical research practice. The study was performed in the morning working hours (8–9 duty h) on working days. Surgeries during emergency duty hours and holidays were excluded. Thermoluminescent dosimeters (TLDs), a type of radiation detector was used by participating staff for measurement of radiation exposure. These TLDs use CaSO4: Dy phosphor whose effective atomic number as 15.3. They are small in size, convenient to use, and inexpensive.[8] The TLD measures the cumulative dose of ionizing radiation exposure by measuring the amount of visible light emitted from a crystal in the detector when the crystal is heated. The amount of light emitted is dependent upon the amount of radiation exposure. TLDs can measure a wide dosimetric range (from 10 μGray to 10 Grays) of radiation exposure.[9]

Each TLD was numbered for easy identification and analysis during the study. Principal investigator was given the charge of appropriate placement and the use of TLDs. During the study, anesthetist used two TLDs throughout procedure during the study period: one underneath lead apron at chest level and one above the lead apron at right shoulder level. Operating orthopedic surgeons used one TLD per person above lead apron at chest level. The surgeon's number varied between 2 and 3 per procedure: one TLD was used by scrub nurse above lead apron at chest level. In addition, two TLDs were placed in operation theater complex: the first one was kept on anesthesia machine front side to know any scattered radiation and the second one was kept in postanesthesia care unit as a control which is remote from experimental orthopedic theater, and no fluoroscopic-guided procedures were performed at that place. Thus, a total of 15 TLDs were used during the study period and seven TLDs were used per procedure. At the end of the day, TLDs were kept at the anesthesia department. At a time, two fluoroscopy-guided procedures were allowed to perform inside theater. Participating staff were instructed to wear the TLDs at all times during their study period. OT personnel not required to present during fluoroscopy were made to wait outside operation theater. Personal protective equipment in the form of lead apron (of 0.5-mm equivalent lead thickness) was used by all participating staff during the study procedure. Fluoroscopic procedures were performed by model Allengers HF-49 and Siemens.

At the end of the study, TLDs were submitted to the department of nuclear medicine for analysis. Datasheets were maintained which included number of cases, types of surgical procedure, and patient's registration details. The distance between the C-arm fluoroscope and participating staff could not be standardized due to frequent change in position. The primary outcome of this study was to quantify cumulative radiation exposure to anesthetist, orthopedic staff, and scrub nurse working in operation theater complex over a period of 6 months in the course of their routine working hours and to compare it with safety guidelines. The secondary outcome was measurement of cumulative scattered radiation exposure in operation theater complex.


  Results Top


The study was conducted over 146 working days from October 2018 to March 2019. Total 1086 patients underwent fluoroscopy-guided surgical procedures, of which 32,456 and 598 patients were operated for spine, upper extremity, and lower extremity surgeries, respectively. 172, 423, 38, and 54 procedures were performed under general anesthesia, spinal anesthesia, epidural anesthesia, and combined spinal–epidural anesthesia, respectively. The mean age of the patient was 32.36 years and 57% and 43% of the patients were male and female. The mean duration of surgical procedure was 137 min [Table 1] and [Table 2].
Table 1: Demographic data of patients who underwent fluoroscopy-guided procedure during the study period

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Table 2: Total number of orthopedic procedures under different types of anesthesia

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Control TLD placed in postoperative care unit has served a measure of baseline atmospheric ionizing radiation, and all other measurements of TLDs are reported above this baseline. The results of dosimetric analysis of participating staff TLDs are shown in [Table 3]. The mean value of radiation exposure of anesthesia machine, orthopedic surgeon, anesthetist with TLD above lead apron, anesthetist with TLD below lead apron, and scrub nurse is 0.05, 1.85, 0.1,0, and 0.625 mSv units, respectively. The highest individual values for orthopedic surgeon, anesthetist with TLD above the lead apron, and scrub nurse were 2.75, 0.1, and 0.7 mSv units, respectively.
Table 3: Thermoluminescent dosimeter dose report of participating staff

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Since these highest individual readings were obtained during routine working hours (i.e., 8–9 h in 24 h) within 6 months, the projected readings for similar exposure throughout the year, assuming a 24-h duty period, would be 16.5, 0.6, and 4.2 mSv for orthopedic surgeon, anesthetist, and scrub nurse, respectively, which is below the safety limit of 20 mSv/year.[10]


  Discussion Top


Widespread use of fluoroscopy exposes not just the surgeon but also the anesthesia team, nurses, auxiliary staff, and patient to the harmful effects of ionizing radiation. This is a cause of concern in the orthopedic operation theater staff working for long period of time. Negative effects of ionizing radiation due to cumulative doses are more likely to be experienced by anesthesia team, scrub nurse, and auxiliary staff than orthopedic surgeon because of their fixed working pattern as against rotating working pattern of orthopedic surgeons. There is a paucity of literature on radiation exposure among three of them during their normal working pattern. The result of our study confirms as well as reassures that the extent of radiation exposure to participating staff during the course of routine working hours is well within the acceptable limits. We also tried to measure the amount of scattered radiation within operation theater and postoperative care unit, which contributes to overall radiation exposure. Moreover, we found that the cumulative radiation exposure was almost immeasurable with both of them.

The radiation absorption dose (rad) is defined as 1 rem = 1 rad in mammals, 100 rad = 100,000 mrem, and 100 mrem = 1 mSv. According to the International Commission on Radiological Protection, all radiation doses should be as low as reasonably achievable and maximum dose limit for exposure is 20 mSv per year over a period of 5 years for the whole body.[11]

Anesthetist and scrub nurses, as their mobility is not restricted, can protect themselves against radiation from fluoroscopy than orthopedic surgeon by maintaining a safe distance from C –ARM Machine should be used instead of scopy tube. A study performed in orthopedic operation theater by Radhi et al. has noticed that the highest radiation exposure was received by orthopedic surgeon than other theater personnel; however, estimated cumulative dose was much below permissible annual dose limit.[6] Similarly, another study looked into radiation exposure inside operation theater by placing dosimeter at various locations and found to have a higher amount of radiation exposure from location consistent with orthopedicians' position.[12] The findings of our study are comparable with the results of these previous studies.

The strength of our study is the adequate representative data which are obtained from 1086 patients undergoing various fluoroscopic procedures over a period of 6 months. We also measured the scattered radiation within operation theater complex and postoperative care unit other than measuring radiation exposure of participating staff and found it to be negligible. The efficiency and quality of available lead apron were also assessed by comparing the radiation exposure between TLD placed above lead apron and below lead apron of anesthetist. TLD placed below apron had nil exposure and placed above lead apron had 0.1-mSv exposure. Lead of 0.5-mm thickness has been reported to reduce radiation exposure by 97%–99%.[13]

There are many limitations to our study. First, we were not able to standardize the distance between the scopy tube and participating staff due to frequent change in position. We did not analyze the relationship between the quantity of radiation exposure and numerous variables such as fluoroscopic-guided procedure of upper extremity, lower extremity and spine, fluoroscopy time, surgical procedure time, and experience of orthopedic surgeon. Finally, as the number and type of procedures can vary on a day-to-day basis which affects the overall radiation exposure, this makes it difficult to extrapolate the results for rest of the years.

The purpose of the present study was not only to determine the radiation dose among orthopedic operation theater staff but also to serve as a reminder of the precautions that should be taken. The radiation doses measured in our study are within safe limits according to international standard, but it should not be the reason for personnel to feel safe as various studies have shown that exposure to even small doses of radiation creates the risk of solid organ cancers and leukemia.[2]

To protect against detrimental effects of ionized radiation, one must take maximum protective precautions such as use of lead aprons, neck guard to protect the thyroid, and protective eyeglasses. The use of a scopy technician, an experienced surgical team, and maintenance of an adequate distance from scopy tube helps in minimizing the exposure.[1] Mehlman and DiPasquale demonstrated that a distance of 1.5 m was sufficient to reduce the exposure dose to 0.[7]

Khan et al. reported the lack of awareness regarding negative effects of ionizing radiation and protection from the same in new orthopedic staff. They may take radiation safety norms lightly,[14] hence specialized periodic training sessions should be conducted for orthopedic operation theater staff on the subject of radiation risk and protection. It is also recommended that radiation safety should form a part of the formal education for anesthetic, surgical, and nursing students.


  Conclusions Top


Literature on ionizing radiation exposure among orthopedic operation theater staff altogether is scarce. We found that if standard safety precautions were followed, cumulative ionizing radiation exposure to participating staff as well as scattered radiation exposure within operation theater complex is minimal and within permissible limit. Routine personal dosimetric monitoring is desirable in staff working with fluoroscopy-guided procedure to monitor ionizing radiation exposure.

Acknowledgment

Funding for purchase of TLD was provided by the Research Society of BJMC and SGH Pune.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kesavachandran CN, Haamann F, Nienhaus A. Radiation exposure of eyes, thyroid gland and hands in orthopaedic staff: A systematic review. Eur J Med Res 2012;17:28.  Back to cited text no. 1
    
2.
AI-Lamki L. Radiation exposure from medical imaging: A wake-up call for Oman! Sultan Qaboos Univ Med J 2011;11:1-4.  Back to cited text no. 2
    
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Faure E. X-rays-induced secretion of cellular factor(s) that enhance(s) HIV-1 promoter transcription in various non-irradiated transfected cell lines. Cell Mol Biol (Noisy-le-grand) 1998;44:1275-92.  Back to cited text no. 3
    
4.
Bahari S, Morris S, Broe D, Taylor C, Lenehan B, McElwain J. Radiation exposure of the hands and thyroid gland during percutaneous wiring of wrist and hand procedures. Acta Orthop Belg 2006;72:194-8.  Back to cited text no. 4
    
5.
Goldstone KE, Wright IH, Cohen B. Radiation exposure to the hands of orthopaedic surgeons during procedures under fluoroscopic X-ray control. Br J Radiol 1993;66:899-901.  Back to cited text no. 5
    
6.
Radhi AM, Masbah O, Shukur MH, Shahril Y, Taiman K. Radiation exposure to operating theatre personnel during fluoroscopic-assisted orthopaedic surgery. Med J Malaysia 2006;61 Suppl A: 50-2.  Back to cited text no. 6
    
7.
Mehlman CT, DiPasquale TG. Radiation exposure to the orthopaedic surgical team during fluoroscopy: “How far away is far enough?” J Orthop Trauma 1997;11:392-8.  Back to cited text no. 7
    
8.
Izewska J, Rajan G. Radiation dosimeters. In: Podgorsak EB, editor. Radiation Oncology Physics: A Handbook for Teachers and Students. Vienna: IAEA; 2005. p. 71-99.  Back to cited text no. 8
    
9.
Khan FM, Doppke KP, Hogstrom KR, Kutcher GJ, Nath R, Prasad SC, et al. Clinical electron-beam dosimetry: Report of AAPM Radiation Therapy Committee Task Group No. 25. Med Phys 1991;18:73-109.  Back to cited text no. 9
    
10.
Bajaj SS. Atomic Energy Regulatory Board, Government of India. AERB Directive No. 01/2011 [Under Rule 15 of the Atomic Energy (Radiation Protection) Rules 2004]; April 27, 2011. Available from: http://www.aerb.gov.in/AERBPortal/pages/English/Constitution/directives_jsp.action. [Last accessed on 2013 Dec 09].  Back to cited text no. 10
    
11.
International Commission on Radiological Protection: ICRP Publication 60. 1990 recommendations of the international commission on radiological protection. Ann ICRP 1991;2:1-3.  Back to cited text no. 11
    
12.
Çeçen GS, Gülabi D, Pehlivanoğlu G, Bulut G, Bekler H, Asil K. Radiation in the orthopedic operating theatre. Acta Orthop Traumatol Turc 2015;49:297-301.  Back to cited text no. 12
    
13.
Schueler BA, Balter S, Miller DL. Radiation protection tools in interventional radiology. J Am Coll Radiol 2012;9:844-5.  Back to cited text no. 13
    
14.
Khan F, Ul-Abadin Z, Rauf S, Javed A. Awareness and attitudes amongst basic surgical trainees regarding radiation in orthopaedic trauma surgery. Biomed Imaging Interv J 2010;6:e25.  Back to cited text no. 14
    



 
 
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