Utfordringer ved høye huddoser. Novembermøtet 2017 Bente Konst

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1 Utfordringer ved høye huddoser Novembermøtet 2017 Bente Konst

2 Hvilke skader har vi i fokus? Poeng med diagnose? Hva er behandling?

3 Biological effects of ionizing radiation Deterministic e.g. Lens opacities, skin injuries, infertility, epilation, etc Stochastic Cancer, genetic effects. 3 tionalresources/training/1_trainingmaterial/r

4 Systemic effects Effects may be morphological and/or functional Factors: Which Organ How much Dose Effects Immediate (usually reversible): < 6 months e.g.: inflammation, bleeding. Delayed (usually irreversible): > 6 months e.g.: atrophy, sclerosis, fibrosis. Categorization of dose < 1 Gy: LOW DOSE 1-10 Gy: MODERATE DOSE > 10 Gy: HIGH DOSE Regeneration means replacement by the original tissue while Repair means replacement by connective tissue. urces/training/1_trainingmaterial/radiology.htm 4

5 Skin effects Histologic view of the skin From Atlas de Histologia.... J. Boya EPIDERMIS DERMIS Basal stratum cells, highly mitotic, some of them with melanin, responsible of pigmentation. Effects are: Erythema: 1 to 24 hours after irradiation of about 3-5 Gy Alopecia(*): 5 Gy is reversible; 20 Gy is irreversible. Pigmentation: Reversible, appears 8 days after irradiation. Dry or moist desquamation: traduces epidermal hypoplasia (dose 20 Gy). Delayed effects: teleangiectasia (**), fibrosis. (*):alopecia: loss or absence of hair (**): ectasia: swelling of part of the body sources/training/1_trainingmaterial/radiology.htm 5

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7 Ulike stadium for erythema Early phase: It is the phase when erythema can be seen within a few hours of irradiation (although it is extremely rare with radiological interventional procedures). This early phase of erythema is generally transient, subsiding after hours, but it may persist and evolve (see below), blending with the subsequent phases. Whether or not those early changes are of importance and influence the subsequent course of the skin reaction remains a matter of debate. However, it is generally considered that early erythema does not necessarily predict a particular severity of the later phases. Main erythematous phase: This corresponds clinically to a more The severe skin reddening becomes of the skin, and is usually associated with inflammatory reactions. It starts about 2 to 3 weeks after exposure. It may be painful (as a burn). Within a short time dry, it hairless, may become and associated with various degrees of skin desquamation, and possibly with pigmentation (See Figures 1& 2). Skin lesions that up to now were not very painful can become painful atrophied, this stage. losing These pains can be very severe when the irradiated volume was large. An important point here is that moist desquamation, which implies a total destruction of the its epidermis, colouring. is a clear predictor of late delayed injuries, particularly telangiectasias. Third erythema phase: Classically, a third phase of erythema can be observed later, between 8 to 20 weeks after irradiation. This phase is associated with dermal ischemia and may also evolve towards necrosis. Fourth stage: Evolution: If severe, skin reactions can be responsible for late radiodermatitis. Increased pigmentation is usual, but depigmentation can also be observed (usually at higher doses), with a combination of both being observed in some cases. The skin may also become hyperkeratotic. Fifth stage: Amplification and/or reactivation nformationfor/healthprofessionals/5_inter ventionalcardiology/phaseserythema.htm

8 Nasjonal faglig retningslinje for håndtering av CBRNE-hendelser med personskade

9 Meldekriterier til avvikssystemet

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16 DAP er ikke bare DAP Når får de hudskade hos oss?

17 Angio- og intervensjon EVAR Gjennomlysningstid (min) DAP(Gycm2) Median Min 14 9 Maks Nefrostomi Median Min Maks Gycm LAB LAB LAB LUNGELAB

18 Avviksmeldinger basert på DAP verdi Beregnet huddose basert på DAP verdi (feltstørrelse estimat) Beregnet hudose basert på air kerma (avstandsestimat) Beregnet effektiv dose basert på DAP (standard omregningsfaktor) Pasient 1 DAP: mgycm2. Beregnet huddoser: Basert på DAP 6.5 Gy Basert på air kerma 5.8 Gy Pasient 2 DAP: mgycm2. Beregnet huddoser: Basert på DAP 8.2Gy Basert ari kerma 8.7 Gy

19 Hud atrofi Telangiectas is Langtids erytem Hud nekrose Secondary ulcerasjon Appro x thresh old dose (Gy) 10 mgy/mi n 15 mgy/mi n 20 mgy/mi n 40 mgy/mi n 100 mgy/min 150 mgy/min 200 mgy/min Hud effekt Forbigående erytem Midlertidig epilation Kraftig erytem Permanent epilation

20 Huddose (mgy/min) cm PMMA Huddose sfa fokus-hud avstand (overbordsrør) Intervensjonslab, 18/ Fokus-hud avstand (cm) Abdomen 8 pps 50 % økning Abdomen 8 pps

21 Behandling: ringblomst hindre utvikling og lindre Takk for meg!