in the industry
it was determined that the fluoroscopic
dose area product (DAP) was required
to estimate effective dose in millisieverts
(mSv) for various procedures. The DAP
was documented for four types of fluoroscopy examinations performed on
the main campus of ACH between December 1, 2011 and May 30, 2012. The
exam types included in this work were:
upper gastrointestinal (UGI) without
scout abdominal radiograph; UGI with
small bowel follow through; voiding
cystourethrograms (VCUG); and swallowing function. DAP from overhead
radiographs was also determined. The
DAPs were used to calculate the energy
imparted, which also depends on tube
kilovoltage (kV), beam half value layer
(HVL) and patient thickness. Effective
doses were estimated from energy imparted by using region specific conversion factors. The median and maximum
effective doses were binned by age and
plotted for each of the four exam types.
The measured DAPs were up to 90%
less than published reference levels;
however, the DAPs and effective doses
were up to 10 times higher than other
published data. Although diligently following radiation safety practices ensured
patient doses were well below published
reference levels, it is apparent that much
lower doses are achievable.
Investigation is underway to further
reduce dose through physical and software modifications to existing equipment, such as additional tube filtration
and pediatric specific automatic brightness control algorithms.
Based on these findings, the following
changes were made to the fluoroscopy
• Removal of the grid for the smaller
• Decrease the pulse fluoro to 2 fps
• Improve the DR technique for over-
head small bowel abdomen films
• Duplicated low dose on new fluoro
equipment at second hospital campus
The end result improved the staff
consciousness of radiation dose and we
were able to reduce the overall radiation
to our patients.
A brochure was created with the results
of the average effective doses received
from the aforementioned fluoroscopic
exams. These have been distributed to
referring physicians and are available for
patients and families. A video briefly explaining concern for acquiring the lowest
doses possible at ACH, and the results of
our data, is being produced. This will be
on the hospital Intranet for employees
and physicians and on the hospital website for the public. Effective doses (mSv)
will be available on the Intranet and
ACH website in a format that the general public can understand. Quarterly dose
spreadsheets are maintained for the main
campus and one of our outlying facilities.
Practicing best radiation safety practices
is not sufficient to ensure pediatric fluoroscopy doses are ALARA. Institutions
that examine pediatric patients under
fluoroscopy should work with their
medical physicists and equipment manufacturers to ensure the hardware and
software on their fluoroscopy equipment
is optimized for pediatric examinations.
ACH has implemented similar improvements for other fluoroscopy procedures.
The hospital and the radiology department are grateful to AHRA and Toshiba
for providing grant money for such viable studies to improve the quality of
radiology and keep the children that we
serve as safe and healthy as possible.
1Brice J. Dangerous exposure: radiology
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Accessed January 23, 2014.
2. Fabricant PD, Berkes MB, Dy CJ, Bogner
EA. Diagnostic medical imaging radiation
exposure and risk of development of solid
and hematologic malignancy. Orthopedics .
May 2012; 35( 5):415-420. Available at:
Accessed January 23, 2014.
3. Phillips AJ. Radiation safety: a growing
concern. ERADIMAGING. November 26,
2010. Available at: http://eradimaging.
com/site/ article.cfm?ID=756. Accessed
January 23, 2014.
Ronald V. Bucci is the administrative director of
radiology, Dr. Godfrey Gaisie is a CAQ pediatric
radiologist and past chairman of radiology, Cheryl
Miller is a radiologic technologist, and Dr. Michael
Rubin is a CAQ pediatric radiologist and the chairman
of radiology at Akron Children’s Hospital in Akron, Oh.
Adam Springer is a medical physicist with National
Physics, Inc. in Cleveland, OH.