Plan to Pause and Pulse

The new phase of the Image Gently™ campaign concentrates on pediatric fluoroscopy.pause and pulse

Continuing its mission to increase awareness of optimizing radiation dose in pediatric imaging, the Alliance for Radiation Safety in Pediatric Imaging is launching the Image Gently™ campaign's fourth phase — "Pause and Pulse," which focuses on diagnostic fluoroscopic procedures.

"There is no doubt that medical imaging saves lives, but children are particularly susceptible to the potential adverse effects of radiation, so fluoroscopic procedures should be used wisely with dose optimization in accordance with the ALARA principle [as low as reasonably achievable]," says Marta H. Hernanz-Schulman, M.D., FACR, FAAP, professor of radiology and pediatrics at Vanderbilt University Medical Center in Nashville, Tenn., and chair of the campaign.

Although the availability of endoscopy and CT has reduced the number of fluoroscopic procedures, fluoroscopy sometimes provides the only noninvasive method of diagnosing or monitoring treatment. In fact, the international push to lower radiation dose has spurred tremendous innovation in fluoroscopic equipment. The latest equipment, Hernanz-Schulman notes, often achieves "significant reductions in dose while maintaining, and sometimes significantly improving, image quality."

"Pulsing the X-ray is one of the greatest dose-saving measures in fluoroscopy and is especially important to children with [their] smaller bodies and greater vulnerability to radiation," she continues. "Radiologists need to pause and make sure the study is indicated for the clinical problem. As with any test, there should be clear reasons to request the study. In some situations, ultrasound or, occasionally, magnetic resonance imaging could provide similar information without exposing a child to radiation," she says.

Radiologists can use numerous techniques to significantly decrease the amount of radiation children are exposed to while still producing diagnostic-quality images. These include:

• Having a clear initial understanding of the patient's problems and goals of the study
• Limiting fluoroscopic time in general and limiting the use of magnification mode in particular
• Carefully collimating to the area of interest and appropriate shielding
• Matching tube output (kVp and mAs) to the child's size
• Utilizing pulsed digital fluoroscopic equipment with adjustable frame speeds, as well as last image hold and capture capability

To ensure that a qualified, experienced, and credentialed medical team is performing the fluoroscopic examination with fluoroscopic equipment suitable to children, referring physicians and parents are encouraged to ask:

• If the technologists are certified
• How frequently the facility performs the requested fluoroscopic study in children
• If a board-certified radiologist with pediatric experience or a pediatric radiologist will be performing and interpreting the study

Ishtiaq Hussain Bercha, M.Sc., lead medical physicist on the fluoroscopy phase of Image Gently and a medical physicist at The Children's Hospital in Aurora, Colo., notes, "The medical physicist, having a background in physical sciences as applied to medicine, is uniquely positioned to help optimize the whole procedure, including radiation safety. The physicist should work very closely with all of the professionals involved." He also highlights the need to recognize potential radiation exposure to the fluoroscopist and assisting personnel when the medical team is trying to immobilize and position the child during a procedure.

As always, the radiologic technologist plays a key role in radiation dose safety. "Reducing dose is a team effort," says Greg Morrison, M.A., RT(R), C.N.M.T., CAE, chief operating officer of the American Society of Radiologic Technologists and member of the alliance's steering committee. "Acquiring an optimal pediatric fluoroscopic exam with minimal radiation dose to the patient must be a coordinated effort among the radiologist, physicist, and radiologic technologist," he adds.

"We really need to image our kids with care," says Hernanz-Schulman. "The 'Pause and Pulse' campaign reminds medical professionals to pause and properly plan and prepare for study; to activate dose-saving features of equipment; to take no exposures unless necessary; to depress last image hold instead; and to pulse at the lowest possible frame rate." For more information, visit

By Matthew Robb

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