docTeaching DR/CR with Best Dose Practices WCEC 2013
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Teaching DR/CR with Best Dose Practices WCEC 2013
Sunday 10 Feb Teaching DR/CR with Best Dose Practices WCEC 2013 Dennis Bowman RT(R) Clinical Instructor/Staff Radiographer Community Hospital of the Monterey Peninsula (CHOMP) Cabrillo – Clinical Instructor Speaker/Consultant – Digital Radiography Solutions (DRS) & MTMI Discussion Topics 1. 2. 3. 4. 5. 6. What is the new Optimum kV? CR and DR Universal Technique Charts DI ranges for different vendors Old and new EI systems How EI numbers are corrupted Image Critique/ Automatic rescaling Stewart Bushong and the penguin 1 Sunday 10 Feb Low Flier I have 14 Low Flier’s. Barry Burns –the CR guru Barry Burns ‐ MS, RT(R), DABR – Retired adjunct Professor of Radiologic Science, University of North Carolina School of Medicine in Chapel Hill, North Carolina, stipulates that when using CR everyone can increase 15‐20 kV from film/screen techniques (except Konica which is 5‐10 kV). 2 Sunday 10 Feb The following slides show a hand phantom exposed from 50 to 100 kV to demonstrate the minute differences visualized on an image using higher kV’s with both CR and DR. CR 50 kV CR 60 kV 3 Sunday 10 Feb CR 70 kV CR 80 kV CR 90 kV 4 Sunday 10 Feb CR 100 kV DR 50 kV DR 60 kV 5 Sunday 10 Feb DR 70 kV DR 80 kV DR 90 kV 6 Sunday 10 Feb DR 100 kV These are the “new” digital Optimum kVs as developed by Barry Burns So what does kVp and mAs do? Not what it did in the film world, that’s for sure!! There is still an optimum kVp, but it now controls only subject contrast. To a huge extent, mAs does not really control density/brightness any more. Density and brightness are now mainly controlled by processing algorithms. You just need enough mAs or your image will have quantum noise (pixel starvation, mottle). 7 Sunday 10 Feb What does optimum kV mean? Optimum means the best!! Even though it’s digital, you still have to stay in the optimum range, you can’t start using 120 kV on everything. If you do use too much kV it will penetrate right through your patient and hit the IR because of incorrect attenuation. This will cause the image to be over penetrated, (saturated) causing a permanent loss in contrast. Or if too little mAs is used it may cause mottle. Film/Screen Technique Chart Size of the Patient – The techniques are of a small, medium and large male Small = 120‐160 lbs. Medium = 160‐200 lbs. Large = 200‐240 lbs. Females would be approximately 10 lbs. lighter. 8 Sunday 10 Feb Film/Screen Technique Chart How can there be a Universal CR/DR technique chart? As we all well know, this would have been impossible in the film/screen processor days. All modern generators (25 years or newer) are high frequency, so if the tubes are in calibration they should all be shooting the same. Since the CR/DR manufacturers set their systems up to have the perfect Dose Exposure Indicator # appear when 1 mR hits the plate, then any given technique will work with all the vendors if the x‐ray tubes are all shooting the same. Universal CR Technique Chart & The Konica Chart (both) using the Most mAs 9 Sunday 10 Feb Page 2 Universal CR Technique Chart & The Konica Chart (both) using the Most mAs Universal CR Technique Chart Lowest mAs Universal CR Technique Chart Lowest mAs (Page 2) 10 Sunday 10 Feb Differences between the Lowest Dose, 33% More, 66% More and Most Dose technique charts For example: the 33% More chart uses 33% more mAs than the Lowest Dose chart. This means that the Most Dose chart uses twice the mAs (so twice the dose) of the Lowest Dose chart. So start with the Most Dose chart and then if possible go down to the 66% More chart. Speaking of How Low We Can Go…Here is the CESIUM DR UNIVERSAL TECHNIQUE CHART. Page 2 of the CESIUM DR UNIVERSAL TECHNIQUE CHART. 11 Sunday 10 Feb Here is the GADOLINIUM DR UNIVERSAL TECHNIQUE CHART. Page 2 of the GADOLINIUM DR UNIVERSAL TECHNIQUE CHART. CR versus DR We discovered that most CR techniques used twice the mAs of Cesium detectors. Gadolinium detectors need 25‐50% more radiation over Cesium detectors to make a similar exposure. 12 Sunday 10 Feb This is the proof of how much dose you save your patient when you increase the kV and decrease the mAs and/or decrease the EI #. How Low Can You Go? This is how I now teach ALARA. With the new optimum kVp’s already in place, it’s figuring out how low can you take the mAs and get an image with no, or acceptable, mottle. I’m hoping that everyone will make it a competition or goal to see what is the minimum dose they can use for any given view. Differences Between Digital And Film The concept of Agfa’s 2.0‐2.3 LgM range, Fuji’s 400‐100 S range, GE’s (DR) .2‐.6 (or .8‐2.4) range and Siemens‘ 200‐900 range. Even with the range you should always be shooting for the “best” number in that range (which means the lowest dose). Lead shields and metal in the body will dramatically affect the EI number. If you are not able to use at least 33% of the IR you will probably have a corrupted EI number. 13 Sunday 10 Feb The new standards have 3 important definitions Exposure Index (EI) – measure of the radiation in the region of interest (ROI) which may vary depending on manufacturer. Target Exposure Index (TEI) – is the exposure index number when an image is optimally exposed. This will be determined by each facility depending on body part, view, procedure, image receptor and radiologist. Deviation Index (DI) – quantifies how much the EI varies from the TEI. Standardized Exposure Index and Deviation Index International Electrotechnical Commission (IEC) 62494‐1 published standards in 2008. American Association of Physicists in Medicine Task Group (AAPM TG) 116 issued report in 2009. 41 Repeat Deviation Index (DI) Underexposed Overexposed Excessive ‐3 ‐2 ‐1 0 +1 +2 +3 ‐20% ‐20% ‐20% Deviation Index (DI) +25% +25% +25% Perfect Exposure Toshiba Leading Innovation>>>> Here is what this system would look like with mAs ‐3 ‐2 ‐1 0 +1 +2 +3 ‐20% ‐20% ‐20% Perfect +25% +25% +25% repeat underexposed Perfect Overexposed Excessive ‐3 ‐2 ‐1 15 mAs 18.5 mAs 24 mAs 0 30 mAs +1 38 mAs +2 48 mAs +3 60 mAs 14 Sunday 10 Feb Here is the 4 color system I want to set up and what it looks like with mAs. “How to Fix an Incorrect mAs” – for repeats Centering and the Dose Exposure Numbers These EI numbers are easily corrupted (but only up to 75% in most cases). The following slides show the elbow, chest and shoulder phantoms and how a change in centering and or collimation can affect (corrupt) the dose exposure number. 15 Sunday 10 Feb Perfect centering – 4 sided collimation LgM 1.81 Kitty Corner – touching at both corners LgM 1.81 0% change Long side touching edge LgM 1.85 13.3% change 16 Sunday 10 Feb Centered – top side touching LgM 1.85 13.3% change Seimens portable detector in bucky Perfectly centered and collimated to 14”x14” 125 kVp @ 2.7 mAs EXI 356 Perfectly centered, no collimation 125 kVp @ 2.7 mAs EXI 351 2.8% change 17 Sunday 10 Feb Centered 1” high ‐ 125 kVp @ 2.7 mAs EXI 399 12.1% change Centered 2” Low ‐ 125 kVp @ 2.7 mAs EXI 442 24.2% change Centered 1” low ‐ 125 kVp @ 2.7 mAs EXI 313 ‐24.2% change 18 Sunday 10 Feb Shoulder phantom with 3 sheets of Polyethylene to make it the thickness of a large adult male. These experiments will show the difference in EXI numbers when the collimation is left more and more open. GE built in detector (DEI range .42 ‐1.27) 8”x8” DEI .60 0.0% change GE built in detector 9”x9” DEI .66 10.0% change 19 Sunday 10 Feb GE built in detector 10”x10” DEI .71 18.3% change GE built in detector 11”x11” DEI .80 33.3% change GE built in detector 12”x12” DEI .89 48.3 % change 20 Sunday 10 Feb GE built in detector 13”x13” DEI .96 60.0 % change To summarize the previous 16 corrupted dose exposure number slides. With all the examples, the technique always stayed the same. It was just the centering or collimation changes that corrupted the EI number. Even though the dose exposure number (EXI, S, LgM, DEI) has been corrupted up to 75%, the image is still perfectly passable in any facility. If your EI number is above 75% over what is considered perfect, this means you over exposed. Ways to Critique a Digital (DR or CR) Image You must use the EI numbers. You definitely need to use the magnification mode to check for noise and burn. You should always be able to Level and Window and make your image look well penetrated and contrasty. 21 Sunday 10 Feb Problems with critiquing digital images It is impossible to prove you used the ideal technique if all you are using is the finished image contrast and density as a gauge. Witness the awesome power of Automatic Rescaling Fuji 85 kVp @ 4 mAs ‐ S# 357 22 Sunday 10 Feb 85 kVp @ 8 mAs ‐ S# 171 85 kVp @ 32 mAs ‐ S# 38 85 kVp @ 200 mAs ‐ S# 6 23 Sunday 10 Feb 85 kVp @ 400 mAs ‐ S# 3 85 kVp @ 500 mAs ‐ S# 4 GE built in detector (.36 – 1.07) 85 kv @ 2 mAs DEI .96 24 Sunday 10 Feb 85 kv @ 4 mAs DEI 1.97 85 kv @ 8 mAs DEI 4.0 85 kv @ 16 mAs DEI 7.72 25 Sunday 10 Feb 85 kv @ 32 mAs DEI 14.67 85 kv @ 64 mAs DEI 27.41 Grid cut‐off with grid suppression software. Is usually very difficult to see. 26 Sunday 10 Feb 40” 99 kV @ 63 mAs No Angle Angled up Angled up 5 degrees 10 degrees Horizontal and short axis grids with a 10 degree caudad angle. The horizontal grid had a smaller LgM number, is brighter (lighter) and has less contrast . LgM 2.03 LgM 2.10 Siemens equipment with Canon detector. Grid landscape, tube parallel with floor. 117 kV @2.8 mAs EXI 334 27 Sunday 10 Feb Grid landscape, tube angled 10 degrees to floor. 117 kV @2.8 mAs EXI 205 Grid portrait, tube angled 10 degrees to floor. 117 kV @2.8 mAs EXI 331 GE portable. Grid with handle up, tube parallel with floor. 120 kV @2 mAs DEI .65 28 Sunday 10 Feb Grid with handle up, tube angled 10 degrees to floor. 120 kV @2 mAs DEI .54 Grid with handle to the side, tube angled 10 degrees to floor. 120 kV @2 mAs DEI .66 Post processing collimation (shuttering) for CR. Courtesy of Becky Daley, TCC 29 Sunday 10 Feb Agfa/Fuji/Carestream EI Comparisons Konica/Shimadsu/SwissRay EI Comparisons Radiographic Image Analysis by Kathy McQuillen Martensen Third Edition 30 Sunday 10 Feb Digital Radiography Solutions Specializing in Educational Conferences and Seminars Dennis Bowman Website: digitalradiographysolutions.com Email: [email protected] Phone: 831‐601‐9860 31
