Optimal use of radiological investigations

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OPTIMAL USE OF RADIOLOGICAL DIAGNSOTIC PROCEDURES:

OPTIMAL USE OF RADIOLOGICAL DIAGNSOTIC PROCEDURES Dr. Sameer Verma Professor Radiodiagnosis , SMC

Definition:

Definition Use of minimum necessary imaging investigations to derive maximal diagnostic information thereby conserving patient and hospital resources and minimizing the inherent risks posed to the patient associated with the radiological investigations.

Slide3:

Need for optimisation of imaging Investigations As per various studies done in developed nations a s ignificant proportion of imaging investigations done are unnecessary and result in significant cost to the state and the public. There has been a phenomenal increase in exposure to medical radiation in the last three decades owing to increased diagnostic procedures (incl. DSA, CT, mammography and Digital x-rays) This increase in radiation exposure has put younger population at increased risk of future cancer and could be responsible for upto 0.3% of cancer related deaths per year

Slide4:

The UK government legislation, ‘Ionizing Radiation (Medical Exposure) Regulations (IRMER) 2000’,  states that when requesting a radiological investigation, the referrer (clinician) is required to provide sufficient and accurate clinical information for the IRMER practitioner (radiologist/radiographer) to be best able to determine whether the examination is appropriate and justified

Slide5:

There is paucity of data regarding unnecessary imaging in India and the consequential financial loss and patient morbidiy /mortality due to medical radiation exposure as there is no national registry /monitoring system Recently Cardiology dept at AIIMS New Delhi has started the Society for less investigative medicine (SLIM) that aims to tackle the menace of excessive/ unnecessary medical investigations .

Steps in Optimization of Imaging:

Steps in Optimization of Imaging Selection of most appropriate investigation/investigations as per clinical indication Proper patient preparation and informed consent Optimized technique/protocol Informed reporting and clinico -radiological correlation

Selection of appropriate radiologic investigation:

Selection of appropriate radiologic investigation Information required/ purpose of investigation to be clearly defined by referring clinician on requisition Mutual consultation with radiology department beneficial for both patients and healthcare setup avoiding unnecessary imaging Scheduling/ appointment of nonurgent procedures gives time for proper patient preparation and streamlining of work in busy radiology departments

All radiological procedures carry a risk to patient:

All radiological procedures carry a risk to patient due to radiation due to the contrast medium due to the technique . Respected organizations—such as the American College of Radiology (ACR), Royal College of Radiology (RCR) and the World Health Organization (WHO)—have developed " appropriateness criteria .” Evidence-based guidelines to assist referring physicians in making the most appropriate imaging or treatment decision for a specific clinical condition allowing most efficacious use of radiology and enhancing patient care.

Principles guiding the selection of diagnostic procedure::

Principles guiding the selection of diagnostic procedure: Justification that a proposed examination is of net benefit to the patient. 2. ALARP - doses should be kept As Low As Reasonably Practicable, economic and social factors being taken into account .

Radiological investigations:

Radiological investigations

Slide11:

EXAMINATION EFFECTIVE DOSE EQUIVALENT (mSv) EQUIVALENT PEROID OF NATURAL BACKGROUND RADIATION CHEST (PA) 0.02 3 days SKULL 0.1 2 weeks CERVICAL SPINE 0.1 2 weeks THORACIC SPINE 1.0 6 months LUMBAR SPINE 2.4 14 months HIP (1 only) 0.3 2 months PELVIS 1.0 6 months ABDOMEN 1.5 9 months EXTREMITY (hand, foot) <0.01 <1.5 days BARIUM MEAL 5.0 2.5 years B.M.F.T. 6.0 3 years BARIUM ENEMA 9.0 4.5 years I.V.P. 4.6 2.5 years CT HEAD 2.0 1 year CT CHEST 8.0 4 years CT ABDOMEN 8.0 4 years

INVESTIGATIONS IN PREFERRED ORDER IN VARIOUS CLINICAL INDICATIONS TRAUMA HEAD MSK CT Soft tissue- HRUSG MRI MRI X-RAYS CT Osseous CHEST XRAYS XRAYS CT SCAN CT USG ABDOMINAL USG XRAY CT:

INVESTIGATIONS IN PREFERRED ORDER IN VARIOUS CLINICAL INDICATIONS TRAUMA HEAD MSK CT Soft tissue- HRUSG MRI MRI X-RAYS CT Osseous CHEST XRAYS XRAYS CT SCAN CT USG ABDOMINAL USG XRAY CT

Slide13:

NON TRAUMA CNS IMAGING SPINE MRI XRAYS CT MRI USG (NEONATES) CT HEAD AND NECK PELVIS/GENITALSYSTEM X RAYS USG CT HSG (FEMALES) MRI MRI CHEST XRAYS CT USG

SMALL BOWEL BARIUM CT/MR ENTEROCLYSIS USG GUT IMAGING UPPER USG IVU MRU/CTU LOWER USG MCU/RGU:

SMALL BOWEL BARIUM CT/MR ENTEROCLYSIS USG GUT IMAGING UPPER USG IVU MRU/CTU LOWER USG MCU/RGU HEPATO-BILIARY USG MRCP/CEMRI CECT ERCP/PTC GIT IMAGING UPPER- ENDOSCOPY BARIUM/GASTROGRAFFIN LOWER COLONOSCOPY BARIUM

Most commonly prescribed radiological investigations:

Most commonly prescribed radiological investigations Chest X-ray USG abdomen/pelvis Obstetric USG CT head MRI LS spine MRI Head CT CHEST/ABDOMEN

Chest X-ray :

Chest X-ray Chest pain Dyspnoea/pedal edema/ NVE Cough > 3 weeks Hemoptysis Abnormal RFT Trauma Chest swelling Routine exam/ pre op/employment workup/ malignancy workup

Abdominal Ultrasound:

Abdominal Ultrasound Indications: Abdominal pain/mass/distension/suspected ascites Recurrent Nausea/vomiting Chronic Dyspepsia/ indigestion/ malabsorption Suspected gallstones and/or Bile Duct Stones Jaundice Abnormal lab values (CBC, LFT,RFT, CRP etc ) Suspected pancreatic disease Unexplained weight loss Portal hypertension/ Cirrhosis K/c/o malignancy/ secondaries F/U of documented abnormality/ guided biopsy /intervention

KUB Ultrasound:

KUB Ultrasound Kidney stone suspected clinically/on Xray Hematuria Flank or lower back pain/ palpable mass Signs of renal failure / infection Urinary tract infection (UTI) Dysuria Clinically documented prostatic enlargement

Pelvic Ultrasound:

Pelvic Ultrasound Palpable mass Irregular menstrual cycle Dysmenorrhea Menorrhagia/ post menopausal bleeding Infertility/PCOD/Recurrent abortions Recurrent Urinary tract infection (UTI) Excessive vaginal discharge/Pelvic Inflammatory Disease IUD detection and location Urinary incontinence/dysuria/ prolapse Follow up of documented abnormality

Obstetric Ultrasound :

Obstetric Ultrasound Confirmation of intra/ extrauterine pregnancy Fetal number, viability, maturity,presentation Liquor assessment Detection of Fetal abnormalities Biophysical profile Obstetric doppler for fetal distress/ uteroplacental insufficiency USG guided intervention (CVS, Polyhramnios Mx , Fetal interventions)  

Neck ultrasound:

Neck ultrasound Neck/submandibular/ preauricular mass Hypocalcaemia Abnormal thyroid function test Scrotal Ultrasound Suspected Epididymitis / orchitis / torsion Testicular mass Scrotal pain/ trauma Scrotal enlargement/hydrocele

Chest USG:

Chest USG Confirmation of pleural effusion/thickening/mass Localisation of loculated/encysted effusion USG guided biposy/ therapeutic procedures

Carotid doppler:

Carotid doppler Carotid artery stenosis/Cervical or carotid bruit Memory Loss/Fluctuating confusion Cluster type headache Loss of balance/ Vertigo/ Syncope Loss of vision/ Amaurosis Fugax (transient monocular blindness) Neurologic deficit Previous/recurrent stroke/ Motor or sensory deficit Unilateral paresthesias

Extremity doppler:

Extremity doppler Suspected Deep venous thrombosis (DVT)/ F/u Pulmonary embolism Anti-coagulant therapy evaluation Pain/tenderness/ Varicose veins/Ulcers Pigment discoloration Poor/absent pulses/ discoloration/ gangrene Increased limb tenderness Increased warmth/ cold extremity

Indications for CT (Computed Tomography):

Indications for CT (Computed Tomography) Head injury Headache Seizures/ stroke Suspected ICSOL/ raised ICT Lung mass/nodule/non resolving consolidation Mediastinal disease Diffuse airspace / interstitial lung disease Evaluation of chest X-ray abnormality Unexplained pleural effusions Idiopathic pneumothorax

CT indications:

CT indications Further evaluation of osseous trauma Bone tumors Further evaluation of abdominal trauma/ masses/ inflammatory/ infectious pathology Documented renal,ureter,UB mass/ anomaly Mass lesions of the neck Nasal/paranasal sinosal disease/epistaxis Misc. HRCT temporal bone, CT angiograhy, Coronary Ca scoring

Indications for MRI (Magnetic Resonance Imaging):

Indications for MRI (Magnetic Resonance Imaging) Neurologic deficit/delayed milestones/ epilepsy Dementia/ neurodegenerative diseases Suspected brain tumor/further characterisation of CT abn Suspected encephalitis/ leptomeningitis / secondaries Intervertebral disc disease Vertebral bone tumors ( In addition to CT if req ) Spinal cord abnormalities (Cong/Trauma/tumor/ myelomalacia ) Unexplained weakness of limbs

MRI:

MRI Soft tissue injury of joints (knee/hip/shoulder/ankle/wrist etc ) Non-osseous bone disease Soft tissue masses or swelling Further characterization of CT/USG abdomen findings Evaluation of Hepatobiliary-pancraetic system (MRCP) Further documentation of pelvic/ fetal anomalies

PATIENT PREPARATION:

PATIENT PREPARATION

IVU:

IVU NBM 8-12 HRS WITH MAINTAINED HYDRATION (CLEAR FLUIDS ALLOWED) BOWEL PREPARATION IN ELDERLY PATIENTS OR THOSE WITH H/O CONSTIPATION BLOOD UREA (<50mg%) AND SERUM CREATININE (<1.5mg%) INJ PREDNISOLONE 32g ORALLY 12 AND 2 HRS PRIOR TO CONTRAST INJECTION WITH USE OF NONIONIC CONTRAST IN C/O PREVIOUS H/O CONTRAST REACTION

BARIUM STUDIES:

BARIUM STUDIES Ba swallow- usually none Ba meal- NBM 6 hrs , avoidance of smoking Ba MFT- same as above, preferably low residue diet for 2 days prior to exam Ba enema- low residue diet for 2-3 days prior, dulcolax in morning/evening previous day, soap/plain water enema previous night

Gastrograffin studies:

Gastrograffin studies Indications Suspected perforation. Meconium ileus. To distinguish bowel from other structures on CT . Gastrografin should NOT be used for the investigation of a tracheo -oesophageal fistula or when aspiration is a possibility. Barium should NOT be used if perforation is suspected.

ULTRASOUND:

ULTRASOUND Fasting for 6-8 hrs for upper abdominal exam Full bladder for pelvis Clear fluid intake advisable for whole abdomen No preparation required for USG small parts, MSK, vascular and cardiac.

Slide41:

Ultrasound examination in children can, in most cases, be performed with no preparation apart from explanation and reassurance to both child and parent. In cases where the child is excessively frightened or where immobility is required then sedation may be necessary.

CT scan:

CT scan NCCT head/Chest/KUB/MSK - none Min 3hrs NBM for CECT head, chest, extremities, Se Creat and Bl Urea for all IV contrast studies, IV line preferably CECT abdomen/pelvis with oral contrast- 8-12 hrs NBM with hydration maintained. Dulcolax previous day and low residue diet for prior 2 days. Oral diluted contrast 1-2 hrs prior for small bowel and 3-4 hrs prior for large bowel opacification . Rectal conrast if required

MRI :

MRI Usually none Sedation/short aneasthesia for uncooperative pts / children Oral clear fluids/ methycellulose with buscopan if bowel study planned Gadolinium contrast to be avoided in pts with compromised renal function to avoid possibility of nephrogenic systemic fibrosis

CLINICORADIOLOGIC CORRELATION AND INFORMED REPORTING:

CLINICORADIOLOGIC CORRELATION AND INFORMED REPORTING Requires support of referring clinician and patients Availability of previous records and investigations expedites the process of reporting and prognostication Helps in narrowing the differential diagnosis in difficult cases with increased diagnostic confidence Avoids unnecessary or repeat imaging saving time and money Generates clinical and imaging database for future imaging and diagnosis

References:

References Levin CD, J Am Coll Radiol 2004;1:169-172. "Do you need that scan?". Canadian Association of Radiologists. 2009. Retrieved June 27, 2011. Miglioretti DL, The Use of Computed Tomography in Pediatrics and the Associated Radiation Exposure and Estimated Cancer Risk. JAMA Pediatr . 2013;(): 1-8. Field, S. (1992) Just how harmful are diagnostic X-rays? - the college response. Clin . Radiol . 46, 295

Suggested reading:

Suggested reading A guide to radiological procedures. Stephan Chapman, Richard Nakielny ( ed ), 4 th edition, Saunders. ACR Appropriateness Criteria®, The American College of Radiology. Available at:http ://www.acr.org/secondarymainmenucategories/quality_safety/app_criteria.apx Initiative to Reduce Unnecessary Radiation Exposure From Medical Imaging, Center for Devices and Radiological Health, U.S. Food and Drug Administration, February 2010. Available at:http ://www.fda.gov/downloads/RadiationEmittingProducts/RadiationSafety/RadiationDoseReduction/UCM200087.pdf .

THANK YOU:

THANK YOU

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