Anaesthesia 2015, 70, 47–50
doi:10.1111/anae.12841
Original Article Radiation exposure to anaesthetists during endovascular procedures* T. Arii,1 S. Uchino,2 Y. Kubo,1 S. Kiyama3 and S. Uezono3 1 Instructor, 2 Associate Professor, 3 Professor, Department of Anaesthesiology, The Jikei University School of Medicine, Tokyo, Japan
Summary Medical radiation exposure increases the likelihood of cataract formation. A personal dosimeter was attached to the left temple of 77 anaesthetists during 45 endovascular aortic aneurysm repairs and 32 interventional neuroradiology procedures. Compared with interventional neuroradiology, the median (IQR [range]) total radiation dose emitted by fluoroscopic equipment was significantly lower during endovascular aortic aneurysm repair (4175 (3127–5091 [644– 9761]) mGy than interventional neuroradiology (1420 (613–2424 [165–10 840]) mGy, p < 0.001). However, radiation exposure to the anaesthetist’s temple was significantly greater during endovascular aortic aneurysm repair (15 (6–41 [1–109]) lSv) than interventional neuroradiology (4 (2–8 [0–67]) lSv, p < 0.001). These data suggest that anaesthetists at our institution would have to deliver anaesthesia for ~1300 endovascular aortic aneurysm repairs and ~5000 interventional neuroradiology cases annually to exceed the general occupational limits, and ~10 000 endovascular aortic aneurysm repairs and ~37 500 interventional neuroradiology cases to exceed the ocular exposure limits recommended by the International Commission on Radiological Protection. Nevertheless, anaesthetists should be aware of the risk of ocular radiation exposure, and reduce this by limiting the time of exposure, increasing the distance from the source of radiation, and shielding. .................................................................................................................................................................
Correspondence to: S. Uchino Email: [email protected] *Presented in part at Euroanaesthesia 2012, Paris, France; June 2012. Accepted: 29 July 2014
Introduction Anaesthetists are involved in increasingly more common fluoroscopic procedures, such as endovascular aortic aneurysm repair (EVAR) and interventional neuroradiology [1], potentially exposing them to greater occupational doses of radiation [2–4]. Although several previous studies have measured anaesthetists’ radiation exposure [5–10], little is known about occupational exposure during endovascular procedures. Eyes are sensitive to radiation [11], although radiation-induced cataracts may take many months to years © 2014 The Association of Anaesthetists of Great Britain and Ireland
to develop [12]. Radiation exposure during interventional fluoroscopy may exceed the threshold for eye injury [13]. Unlike standard practice for interventional radiologists and surgeons, who wear leaded glasses or using ceiling-mounted leaded shields to protect the face [12], there are no standards concerning eye care for anaesthetists involved in these procedures. The aims of this study were to measure radiation exposure to anaesthetists’ eyes during fluoroscopic endovascular procedures, and to determine if there were significant differences in exposure between aortic 47
Anaesthesia 2015, 70, 47–50
and intracranial procedures. We hypothesised that the anaesthetists’ eyes might be exposed to more radiation during EVAR than interventional neuroradiology.
Methods With Institutional Review Board approval, a prospective cohort study was carried out among consenting anaesthesia residents and fellows participating in EVAR and interventional neuroradiology procedures under general anaesthesia at Jikei University hospital, Japan, between 1st June, 2011 and 30th September, 2011. There are three adult radiology procedure rooms (ORs) at our institution (OR1 Philips Integris V C-arm biplane system, Philips Medical Systems, Amsterdam, the Netherlands; OR4 and OR5 Artis zeego, Siemens Medical Solutions, Erlangen, Germany). A personal dosimeter (ALOKA MYDOSE Mini x PDM-127, Hitachi Aloka Medical, Tokyo, Japan, measurement range 1 lSv to 1 Sv, error 10%) was taped to the left temple (patient-facing) of each anaesthetist. Dosimeter absorbtion was assumed to represent ocular radiation exposure. Anaesthesia was administered at the discretion of each anaesthetist, who was instructed to maintain their routine safety measures (lead apron (lead equivalent 0.35 mmPb), thyroid shield (lead equivalent 0.35 mmPb) and portable leaded acrylic shield). For each procedure, we measured overall procedural duration, total fluoroscopic radiation emission and the number of interruptions of mechanical ventilation during angiography. The only previous study reported for interventional neuroradiology [10] included 31 patients, and contained no information about radiation exposure during EVAR. Unable to calculate an informed sample size, we selected a convenience sample in excess of 30 patients per group. Radiation exposure and procedural duration were compared using the Mann–Whitney U-test. Pearson correlation analysis was used to detect correlations between radiation exposure and potentially causative variables (overall procedural duration, total fluoroscopic radiation emission and the number of interruptions of mechanical ventilation during angiography). Multivariate linear regression analysis was conducted to detect independent variables (procedural duration, total radiation dose, number of mechanical ventilation 48
Arii et al. | Radiation exposure during endovascular procedures
interruptions, the inverse square of the distance between the anaesthesia machine and the radiation source, and type of procedure) correlated with radiation exposure. Values of p < 0.05 were considered statistically significant. A commercially available statistical package (SPSS 19.0; IBM, Tokyo, Japan) was used for all statistical analyses.
Results A total of 27 anaesthetists were involved in 77 procedures (Table 1). Mechanical ventilation was interrupted during EVAR only, a median (IQR [range]) of 17 (11–22 [0– 41]) times every procedure. Dosimeter absorption correlated significantly with duration of procedure (Fig. 1a,d) and total radiation emission (Fig. 1b,e), but not mechanical ventilation interruptions during angiography (Fig. 1c). After multivariate analysis, dosimeter absorption was found to correlate significantly with total radiation emission (p = 0.006) but not with type of procedure (p = 0.842).
Discussion Although the median total dose of radiation emitted during fluoroscopy was three times higher during interventional neuroradiology compared with EVAR, median dosimeter absorption – a surrogate for ocular radiation exposure in anaesthetists in this study – was four times higher during EVAR procedures. Radiation absorption varies according to the square of the distance from the source, but median absorption remained of the order of three times greater during EVAR, even once the smaller size of OR1 had been accounted for. As the total dose emitted was higher during interventional neuroradiology, then it is plausible to suggest that greater dosimeter absorption, and therefore ocular radiation exposure, during EVAR is accounted for by closer proximity of the anaesthetist during the interruptions to mechanical ventilation that are an intrinsic part of the EVAR procedure (enabling fluoroscopic view by radiologists/surgeons). A previous study reported that anaesthetists are exposed to 6.5 5.4 lSv per procedure, more than three times greater than radiologists, during neuroradiological procedures [10]. Several studies have © 2014 The Association of Anaesthetists of Great Britain and Ireland
Arii et al. | Radiation exposure during endovascular procedures
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Anaesthesia 2015, 70, 47–50
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100
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Figure 1 Anaesthetists’ radiation exposure during endovascular aortic aneurysm repair (top; a–c) and interventional neuroradiology (bottom; d–e), plotted against the duration of the procedure (a, d), the total radiation emission (b, e), and the number of interruptions to mechanical ventilation (c). p values indicate the significance of Pearson correlation. Table 1 Type and duration of procedure, operating room characteristics, and radiation doses emitted during fluoroscopy and absorbed by dosimeters. Values are number or median (IQR [range]). Endovascular aortic repair Operating room number Distance of radiation source to anaesthesia machine; cm Procedure Abdominal endovascular aortic repair Thoracic endovascular aortic repair Coiling of cerebral artery aneurysm Embolisation of arteriovenous malformation Procedural duration; min Total fluoroscopic radiation emission; mGy Dosimeter radiation absorption; lSv
1 200
5 230
29 9
5 2
– –
– –
160 (125–219 [73–471]) 1324 (606–1806 [165–10 840]) 16 (6–46 [2–109])
139 (131–248.5 [117–335]) 2090 (1700–2774 [351–3842]) 6 (4–16 [1–41])
Interventional neuroradiology
1+5
4 240
– – 26 6 151 (125–221 [73–471]) 1420 (613–2424 [165–10 840]) 15 (6–41 [1–109])
163 (120–212 [85–427])* 4175 (3127–5091 [644–9761])† 4 (2–8 [0–67])†
*p = NS. †p < 0.0001.
reported radiation exposure among vascular surgeons involved in fluoroscopy-assisted surgery [14–16], and found exposure to be within safe recommended limits. Safe radiation exposure limits are recommended by the International Commission on Radiological Protection (IRCP). The IRCP recommends that occupational © 2014 The Association of Anaesthetists of Great Britain and Ireland
‘planned exposure situations’, including fluoroscopy in EVAR and interventional neuroradiology, should not exceed 20 mSv.year 1, averaged over 5 years, with no more than 50 mSv in any one year, and should not exceed 150 mSv.year 1 to the eye [13]. Encouragingly, our absorption data suggest that anaesthetists at our 49
Anaesthesia 2015, 70, 47–50
institution would have to deliver anaesthesia to ~1300 EVAR and ~5000 interventional neuroradiology cases annually to exceed general occupational limits, and ~10 000 EVAR and ~37 500 interventional neuroradiology cases to exceed ocular exposure limits. Our data could be extrapolated by readers to their own institutions, by adjusting for procedure time and distance. Nevertheless, it is important that anaesthetists understand the basic concepts of radiation safety to keep occupational exposure to a minimum. Radiation exposure is reduced by limiting the time of exposure, increasing distance from the source of radiation and by shielding [4, 17–19]. Interruptions to mechanical ventilation should be kept to a minimum through communication with radiologists and surgeons. The layout of radiology intervention suites should maximise anaesthetists’ distance from the radiation source, and allow space for the interposition of acrylic shields. Anaesthetists should request and wear intact lead gowns, thyroid shields and eye protection. Personal dosimeters should be worn by anaesthetists who routinely undertake interventional neuroradiology and EVAR lists. In summary, we found radiation exposure to the temple of anaesthetists during EVAR and interventional neuroradiology to be within safe recommended limits. Nevertheless, anaesthetists who regularly administer for EVAR and interventional neuroradiology need to remain aware of the risk of occupational and ocular radiation exposure, and take appropriate steps to minimise this, by limiting dose exposure, increasing distance from the source, wearing suitably protective clothing and using shields.
Competing interests No external funding and no competing interests declared.
References 1. Chuter TA, Parodi JC, Lawrence-Brown M. Management of abdominal aortic aneurysm: a decade of progress. Journal of Endovascular Therapy 2004; 11: II82–95.
50
Arii et al. | Radiation exposure during endovascular procedures 2. Berrington A, Darby SC, Weiss HA, Doll R. 100 years of observation on British radiologists: mortality from cancer and other causes 1897–1997. British Journal of Radiology 2001; 74: 507–19. 3. Vano E, Gonzalez L, Fernandez JM, Haskal ZJ. Eye lens exposure to radiation in interventional suites: caution is warranted. Radiology 2008; 248: 945–53. 4. Dagal A. Radiation safety for anesthesiologists. Current Opinion in Anesthesiology 2011; 24: 445–50. 5. Kincaid OW. The problem of repeated exposure to radiation by anesthesiologists. Anesthesia and Analgesia 1958; 37: 361–70. 6. Katz JD. Radiation exposure to anesthesia personnel: the impact of an electrophysiology laboratory. Anesthesia and Analgesia 2005; 101: 1725–6. 7. Ismail S, Khan FA, Sultan N, Naqvi M. Radiation exposure of trainee anaesthetists. Anaesthesia 2006; 61: 9–14. 8. McGowan C, Heaton B, Stephenson RN. Occupational X-ray exposure of anesthesiologists. British Journal of Anaesthesia 1996; 76: 868–9. 9. Roh JH, Kim DW, Lee SJ, et al. Intensity of extremely low-frequency electromagnetic fields produced in operating rooms during surgery at the standing position of anesthesiologists. Anesthesiology 2009; 111: 275–8. 10. Anastasian ZH, Strozyk D, Meyers PM, Wang S, Berman MF. Radiation exposure of the anesthesiologist in the neurointerventional suite. Anesthesiology 2011; 114: 512–20. 11. International Commission on Radiological Protection. The 1990 Recommendations of the International Commission on Radiological Protection. The system of protection for proposed and continuing practices. ICRP Publication 60. Annals of the ICRP 1991; 21: 32–49. €rr W, et al. Radiation cataracto12. Ainsbury EA, Bouffler SD, Do genesis: a review of recent studies. Radiation Research 2009; 172: 1–9. 13. International Commission on Radiological Protection. The 2007 Recommendations of the International Commission on Radiological Protection. Biological and epidemiological information on health risks attributable to ionising radiation. ICRP Publication 103. Annals of the ICRP 2007; 37: 137–246. 14. Ho P, Cheng SW, Wu PM, et al. Ionizing radiation absorption of vascular surgeons during endovascular procedures. Journal of Vascular Surgery 2007; 46: 455–9. 15. Lipsitz EC, Veith FJ, Ohki T, et al. Does the endovascular repair of aortoiliac aneurysms pose a radiation safety hazard to vascular surgeons? Journal of Vascular Surgery 2000; 32: 704–10. 16. Ketteler ER, Brown KR. Radiation exposure in endovascular procedures. Journal of Vascular Surgery 2011; 53: 35S–8S. 17. Phillips G, Monaghan WP. Radiation safety for anesthesia providers. American Association of Nurse Anesthetists Journal 2011; 79: 257–67. 18. Taylor J, Chandramohan M, Simpson KH. Radiation safety for anaesthetists. Continuing Education in Anaesthesia, Critical Care and Pain 2012; 13: 59–62. 19. International Commission on Radiological Protection. Radiological protection in fluoroscopically guided procedures outside the imaging department. ICRP Publication 117. Annals of the ICRP 2010; 40: 1–102.
© 2014 The Association of Anaesthetists of Great Britain and Ireland
doi:10.1111/anae.12841
Original Article Radiation exposure to anaesthetists during endovascular procedures* T. Arii,1 S. Uchino,2 Y. Kubo,1 S. Kiyama3 and S. Uezono3 1 Instructor, 2 Associate Professor, 3 Professor, Department of Anaesthesiology, The Jikei University School of Medicine, Tokyo, Japan
Summary Medical radiation exposure increases the likelihood of cataract formation. A personal dosimeter was attached to the left temple of 77 anaesthetists during 45 endovascular aortic aneurysm repairs and 32 interventional neuroradiology procedures. Compared with interventional neuroradiology, the median (IQR [range]) total radiation dose emitted by fluoroscopic equipment was significantly lower during endovascular aortic aneurysm repair (4175 (3127–5091 [644– 9761]) mGy than interventional neuroradiology (1420 (613–2424 [165–10 840]) mGy, p < 0.001). However, radiation exposure to the anaesthetist’s temple was significantly greater during endovascular aortic aneurysm repair (15 (6–41 [1–109]) lSv) than interventional neuroradiology (4 (2–8 [0–67]) lSv, p < 0.001). These data suggest that anaesthetists at our institution would have to deliver anaesthesia for ~1300 endovascular aortic aneurysm repairs and ~5000 interventional neuroradiology cases annually to exceed the general occupational limits, and ~10 000 endovascular aortic aneurysm repairs and ~37 500 interventional neuroradiology cases to exceed the ocular exposure limits recommended by the International Commission on Radiological Protection. Nevertheless, anaesthetists should be aware of the risk of ocular radiation exposure, and reduce this by limiting the time of exposure, increasing the distance from the source of radiation, and shielding. .................................................................................................................................................................
Correspondence to: S. Uchino Email: [email protected] *Presented in part at Euroanaesthesia 2012, Paris, France; June 2012. Accepted: 29 July 2014
Introduction Anaesthetists are involved in increasingly more common fluoroscopic procedures, such as endovascular aortic aneurysm repair (EVAR) and interventional neuroradiology [1], potentially exposing them to greater occupational doses of radiation [2–4]. Although several previous studies have measured anaesthetists’ radiation exposure [5–10], little is known about occupational exposure during endovascular procedures. Eyes are sensitive to radiation [11], although radiation-induced cataracts may take many months to years © 2014 The Association of Anaesthetists of Great Britain and Ireland
to develop [12]. Radiation exposure during interventional fluoroscopy may exceed the threshold for eye injury [13]. Unlike standard practice for interventional radiologists and surgeons, who wear leaded glasses or using ceiling-mounted leaded shields to protect the face [12], there are no standards concerning eye care for anaesthetists involved in these procedures. The aims of this study were to measure radiation exposure to anaesthetists’ eyes during fluoroscopic endovascular procedures, and to determine if there were significant differences in exposure between aortic 47
Anaesthesia 2015, 70, 47–50
and intracranial procedures. We hypothesised that the anaesthetists’ eyes might be exposed to more radiation during EVAR than interventional neuroradiology.
Methods With Institutional Review Board approval, a prospective cohort study was carried out among consenting anaesthesia residents and fellows participating in EVAR and interventional neuroradiology procedures under general anaesthesia at Jikei University hospital, Japan, between 1st June, 2011 and 30th September, 2011. There are three adult radiology procedure rooms (ORs) at our institution (OR1 Philips Integris V C-arm biplane system, Philips Medical Systems, Amsterdam, the Netherlands; OR4 and OR5 Artis zeego, Siemens Medical Solutions, Erlangen, Germany). A personal dosimeter (ALOKA MYDOSE Mini x PDM-127, Hitachi Aloka Medical, Tokyo, Japan, measurement range 1 lSv to 1 Sv, error 10%) was taped to the left temple (patient-facing) of each anaesthetist. Dosimeter absorbtion was assumed to represent ocular radiation exposure. Anaesthesia was administered at the discretion of each anaesthetist, who was instructed to maintain their routine safety measures (lead apron (lead equivalent 0.35 mmPb), thyroid shield (lead equivalent 0.35 mmPb) and portable leaded acrylic shield). For each procedure, we measured overall procedural duration, total fluoroscopic radiation emission and the number of interruptions of mechanical ventilation during angiography. The only previous study reported for interventional neuroradiology [10] included 31 patients, and contained no information about radiation exposure during EVAR. Unable to calculate an informed sample size, we selected a convenience sample in excess of 30 patients per group. Radiation exposure and procedural duration were compared using the Mann–Whitney U-test. Pearson correlation analysis was used to detect correlations between radiation exposure and potentially causative variables (overall procedural duration, total fluoroscopic radiation emission and the number of interruptions of mechanical ventilation during angiography). Multivariate linear regression analysis was conducted to detect independent variables (procedural duration, total radiation dose, number of mechanical ventilation 48
Arii et al. | Radiation exposure during endovascular procedures
interruptions, the inverse square of the distance between the anaesthesia machine and the radiation source, and type of procedure) correlated with radiation exposure. Values of p < 0.05 were considered statistically significant. A commercially available statistical package (SPSS 19.0; IBM, Tokyo, Japan) was used for all statistical analyses.
Results A total of 27 anaesthetists were involved in 77 procedures (Table 1). Mechanical ventilation was interrupted during EVAR only, a median (IQR [range]) of 17 (11–22 [0– 41]) times every procedure. Dosimeter absorption correlated significantly with duration of procedure (Fig. 1a,d) and total radiation emission (Fig. 1b,e), but not mechanical ventilation interruptions during angiography (Fig. 1c). After multivariate analysis, dosimeter absorption was found to correlate significantly with total radiation emission (p = 0.006) but not with type of procedure (p = 0.842).
Discussion Although the median total dose of radiation emitted during fluoroscopy was three times higher during interventional neuroradiology compared with EVAR, median dosimeter absorption – a surrogate for ocular radiation exposure in anaesthetists in this study – was four times higher during EVAR procedures. Radiation absorption varies according to the square of the distance from the source, but median absorption remained of the order of three times greater during EVAR, even once the smaller size of OR1 had been accounted for. As the total dose emitted was higher during interventional neuroradiology, then it is plausible to suggest that greater dosimeter absorption, and therefore ocular radiation exposure, during EVAR is accounted for by closer proximity of the anaesthetist during the interruptions to mechanical ventilation that are an intrinsic part of the EVAR procedure (enabling fluoroscopic view by radiologists/surgeons). A previous study reported that anaesthetists are exposed to 6.5 5.4 lSv per procedure, more than three times greater than radiologists, during neuroradiological procedures [10]. Several studies have © 2014 The Association of Anaesthetists of Great Britain and Ireland
Arii et al. | Radiation exposure during endovascular procedures
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Anaesthesia 2015, 70, 47–50
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Figure 1 Anaesthetists’ radiation exposure during endovascular aortic aneurysm repair (top; a–c) and interventional neuroradiology (bottom; d–e), plotted against the duration of the procedure (a, d), the total radiation emission (b, e), and the number of interruptions to mechanical ventilation (c). p values indicate the significance of Pearson correlation. Table 1 Type and duration of procedure, operating room characteristics, and radiation doses emitted during fluoroscopy and absorbed by dosimeters. Values are number or median (IQR [range]). Endovascular aortic repair Operating room number Distance of radiation source to anaesthesia machine; cm Procedure Abdominal endovascular aortic repair Thoracic endovascular aortic repair Coiling of cerebral artery aneurysm Embolisation of arteriovenous malformation Procedural duration; min Total fluoroscopic radiation emission; mGy Dosimeter radiation absorption; lSv
1 200
5 230
29 9
5 2
– –
– –
160 (125–219 [73–471]) 1324 (606–1806 [165–10 840]) 16 (6–46 [2–109])
139 (131–248.5 [117–335]) 2090 (1700–2774 [351–3842]) 6 (4–16 [1–41])
Interventional neuroradiology
1+5
4 240
– – 26 6 151 (125–221 [73–471]) 1420 (613–2424 [165–10 840]) 15 (6–41 [1–109])
163 (120–212 [85–427])* 4175 (3127–5091 [644–9761])† 4 (2–8 [0–67])†
*p = NS. †p < 0.0001.
reported radiation exposure among vascular surgeons involved in fluoroscopy-assisted surgery [14–16], and found exposure to be within safe recommended limits. Safe radiation exposure limits are recommended by the International Commission on Radiological Protection (IRCP). The IRCP recommends that occupational © 2014 The Association of Anaesthetists of Great Britain and Ireland
‘planned exposure situations’, including fluoroscopy in EVAR and interventional neuroradiology, should not exceed 20 mSv.year 1, averaged over 5 years, with no more than 50 mSv in any one year, and should not exceed 150 mSv.year 1 to the eye [13]. Encouragingly, our absorption data suggest that anaesthetists at our 49
Anaesthesia 2015, 70, 47–50
institution would have to deliver anaesthesia to ~1300 EVAR and ~5000 interventional neuroradiology cases annually to exceed general occupational limits, and ~10 000 EVAR and ~37 500 interventional neuroradiology cases to exceed ocular exposure limits. Our data could be extrapolated by readers to their own institutions, by adjusting for procedure time and distance. Nevertheless, it is important that anaesthetists understand the basic concepts of radiation safety to keep occupational exposure to a minimum. Radiation exposure is reduced by limiting the time of exposure, increasing distance from the source of radiation and by shielding [4, 17–19]. Interruptions to mechanical ventilation should be kept to a minimum through communication with radiologists and surgeons. The layout of radiology intervention suites should maximise anaesthetists’ distance from the radiation source, and allow space for the interposition of acrylic shields. Anaesthetists should request and wear intact lead gowns, thyroid shields and eye protection. Personal dosimeters should be worn by anaesthetists who routinely undertake interventional neuroradiology and EVAR lists. In summary, we found radiation exposure to the temple of anaesthetists during EVAR and interventional neuroradiology to be within safe recommended limits. Nevertheless, anaesthetists who regularly administer for EVAR and interventional neuroradiology need to remain aware of the risk of occupational and ocular radiation exposure, and take appropriate steps to minimise this, by limiting dose exposure, increasing distance from the source, wearing suitably protective clothing and using shields.
Competing interests No external funding and no competing interests declared.
References 1. Chuter TA, Parodi JC, Lawrence-Brown M. Management of abdominal aortic aneurysm: a decade of progress. Journal of Endovascular Therapy 2004; 11: II82–95.
50
Arii et al. | Radiation exposure during endovascular procedures 2. Berrington A, Darby SC, Weiss HA, Doll R. 100 years of observation on British radiologists: mortality from cancer and other causes 1897–1997. British Journal of Radiology 2001; 74: 507–19. 3. Vano E, Gonzalez L, Fernandez JM, Haskal ZJ. Eye lens exposure to radiation in interventional suites: caution is warranted. Radiology 2008; 248: 945–53. 4. Dagal A. Radiation safety for anesthesiologists. Current Opinion in Anesthesiology 2011; 24: 445–50. 5. Kincaid OW. The problem of repeated exposure to radiation by anesthesiologists. Anesthesia and Analgesia 1958; 37: 361–70. 6. Katz JD. Radiation exposure to anesthesia personnel: the impact of an electrophysiology laboratory. Anesthesia and Analgesia 2005; 101: 1725–6. 7. Ismail S, Khan FA, Sultan N, Naqvi M. Radiation exposure of trainee anaesthetists. Anaesthesia 2006; 61: 9–14. 8. McGowan C, Heaton B, Stephenson RN. Occupational X-ray exposure of anesthesiologists. British Journal of Anaesthesia 1996; 76: 868–9. 9. Roh JH, Kim DW, Lee SJ, et al. Intensity of extremely low-frequency electromagnetic fields produced in operating rooms during surgery at the standing position of anesthesiologists. Anesthesiology 2009; 111: 275–8. 10. Anastasian ZH, Strozyk D, Meyers PM, Wang S, Berman MF. Radiation exposure of the anesthesiologist in the neurointerventional suite. Anesthesiology 2011; 114: 512–20. 11. International Commission on Radiological Protection. The 1990 Recommendations of the International Commission on Radiological Protection. The system of protection for proposed and continuing practices. ICRP Publication 60. Annals of the ICRP 1991; 21: 32–49. €rr W, et al. Radiation cataracto12. Ainsbury EA, Bouffler SD, Do genesis: a review of recent studies. Radiation Research 2009; 172: 1–9. 13. International Commission on Radiological Protection. The 2007 Recommendations of the International Commission on Radiological Protection. Biological and epidemiological information on health risks attributable to ionising radiation. ICRP Publication 103. Annals of the ICRP 2007; 37: 137–246. 14. Ho P, Cheng SW, Wu PM, et al. Ionizing radiation absorption of vascular surgeons during endovascular procedures. Journal of Vascular Surgery 2007; 46: 455–9. 15. Lipsitz EC, Veith FJ, Ohki T, et al. Does the endovascular repair of aortoiliac aneurysms pose a radiation safety hazard to vascular surgeons? Journal of Vascular Surgery 2000; 32: 704–10. 16. Ketteler ER, Brown KR. Radiation exposure in endovascular procedures. Journal of Vascular Surgery 2011; 53: 35S–8S. 17. Phillips G, Monaghan WP. Radiation safety for anesthesia providers. American Association of Nurse Anesthetists Journal 2011; 79: 257–67. 18. Taylor J, Chandramohan M, Simpson KH. Radiation safety for anaesthetists. Continuing Education in Anaesthesia, Critical Care and Pain 2012; 13: 59–62. 19. International Commission on Radiological Protection. Radiological protection in fluoroscopically guided procedures outside the imaging department. ICRP Publication 117. Annals of the ICRP 2010; 40: 1–102.
© 2014 The Association of Anaesthetists of Great Britain and Ireland
