Why Health Care Facilities Do Not Apply Radiation Protective Garments to Patients Undergoing an X-Ray in the OR

Lead-free Alternatives in the OR

Radiological imaging devices (eg, portable x-ray machine, C-arm) are commonly used in the OR. The C-arm is highly convenient in the OR because of its ability to provide real-time imaging, flexibility in positioning, minimal invasiveness, reduced radiation exposure, improved workflow efficiency, and enhanced surgical planning. It is widely used during orthopedic and trauma surgery. A radiation protective garment is worn by doctors and nurses when performing imaging to protect them from any radiation that may be emitted. Lead, which is a dense material that can effectively absorb x-rays and block their penetration, is one type of material used in radiation protective garments. However, there are lead-free garments made of combined materials such as tin, rubber, polyvinyl chloride, and proprietary attenuating metals. Other materials that may block or absorb radiation include antimony, tungsten, bismuth, or other elements.¹ Lead-free garments are made from these lighter metals and offer non-toxic alternatives to the traditional lead garment.² Both lead and lead-free garments are designed to shield the body from x-rays, particularly the vital organs and reproductive areas, which are more sensitive to radiation.

For decades, patients and health care workers abided to shielding patients from radiation by applying a radiation protective garment onto the patient. Gonadal shielding was recommended in the 1950s to introduce a safer way of preventing heritable genetic effects from radiation exposure.³ It was believed that radiation protective garments would protect the patient from radiation, which would decrease their risks of fetal developmental issues, birth defects, reproductive organ harm, or cancer. However, this practice might be more nuanced than once believed. In some circumstances (eg, when automatic exposure control [AEC] is used), shielding patients can sometimes cause more harm than benefit. Because there are so many unique considerations when it comes to patient shielding in the OR, the AORN “Guideline for radiation safety”⁴ recommends that the perioperative team consult with either the radiation safety officer or the radiology professional in the room regarding the use and placement of protective shielding between the patient and the source of radiation. Modern imaging machines use approximately 96% less radiation than what the machines used when lead shielding was first recommended.⁵ At Boston Children’s Hospital, we ensure that our pediatric-specific x-ray equipment is calibrated to minimize patient exposure to radiation.

There are many problems that could occur with shielding. Incorrect placement of radiation protective garments on small children could cover areas of the body that need to be seen by medical professionals, thus requiring a repeat exam and increasing radiation exposure.⁶ Garments made from metals can also create a barrier that can trick the imaging machines to increase the beam intensity in order to capture an image and thus expose unprotected tissue to higher amounts of radiation.⁷ Such possible scenarios validate the reason why the radiation safety officer or a radiology professional should be involved in the placement of radiation protective garments.  

Although patient shielding has been recommended for many years, the National Council on Radiation Protection and Measurements issued a statement in 2021 that advised against the use of in-field shielding during radiographic imaging of the abdomen and pelvis. According to their scientific evidence, gonadal shielding has shown to increase radiation exposure with the use of AEC.³ The National Council on Radiation Protection and Measurements recommends not shielding during abdominal and pelvic radiography to prevent an increased dose of radiation to the pelvic and abdominal radiosensitive organs. Shielding can sometimes be displaced during patient movement or positioning. When this occurs, it is important that the AEC detector is not partially or completely blocked. In instances where it is blocked, radiation dosage to all abdominal organs increases by up to 25%.⁸ This reduces the effects of shielding protection and increases radiation to the rest of the imaged area of the abdomen and pelvis.³

Other ways of reducing radiation exposure that we practice include limiting time and distance during x-ray procedures. By practicing the “as low as reasonably achievable” principle, we ensure our equipment is regulated to limit the amount of radiation exposure to the patient and personnel during procedures. Although some imaging studies require the use of radiation, Boston Children’s Hospital personnel tailor their equipment and protocols specifically to children to carry out the “as low as reasonably achievable” principle while still producing high-quality images. By using ultrasound or magnetic resonance imaging, radiation can be avoided in some cases.

To conclude, the use of shielding can do more harm than good when considering the dosage levels of radiation through radiographs or fluoroscopy. Staying up to date and knowledgeable about current shielding practices and working in partnership with the radiation safety officer and radiology professionals for the care of perioperative patients will not only reduce the amount of radiation exposure but also provide a safer practice for health care workers and their patients.

Figure caption: A perioperative staff member stands next to a patient on a bed with protective shielding under them.

References

1. Jaquith K. 3 different types of radiation shielding materials (part 1). Universal Medical Inc. Accessed December 31, 2024. https://blog.universalmedicalinc.com/3-different-types-radiation-shielding-materials/
2. Lead vs. lead-free radiation protection products: what’s the difference? Burlington Medical. Accessed December 31, 2024. https://burmed.com/lead-vs-lead-free-radiation-protection-products-whats-the-difference/
3. NCRP Recommendations for Ending Routine Gonadal Shielding During Abdominal and Pelvic Radiography. National Council on Radiation Protection and Measurements. Accessed November 21, 2024. https://ncrponline.org/wp-content/themes/ncrp/PDFs/Statement13.pdf
4. Guideline for radiation safety. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2024:765-794.
5. X-ray shielding FAQ. Nationwide Children’s. Accessed November 21, 2024. https://www.nationwidechildrens.org/specialties/radiology/xray-faq
6. Biggers L. Lead-based shields no longer recommended for routine x-rays. Duke Health. Accessed November 21, 2024. https://www.dukehealth.org/blog/lead-based-shields-no-longer-recommended-routine-x-rays
7. Wait — now I don’t need a pelvic shield during x-rays? Yale Medicine. Accessed November 21, 2024. https://www.yalemedicine.org/news/dont-need-pelvic-shield-during-x-rays
8. Kaplan SL, Strauss KJ, Magill D, et al. Quantification of increased patient radiation dose when gonadal shielding is used with automatic exposure control. J Am Coll Radiol. 2020;17(12):1698-1704.

 Sidebar 1. Radiation Safety Recommendations¹

• Establish a radiation safety program when potential for occupational radiation exposure exists and appoint a radiation safety officer and a radiation safety committee to lead and direct the radiation safety program.
• The radiation safety program must include measures, including shielding, for protecting both patients and perioperative personnel from unnecessary exposure to ionizing radiation.
• Consult with the radiation safety officer or radiology professional regarding the use and placement of protective shielding or garments between the patient and the source of radiation.
• Perform a radiation safety time out before starting the procedure.

Please reference the AORN “Guideline for radiation safety” for the full set of radiation safety recommendations.

Reference

1. Guideline for radiation safety. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2024:765-794.