You are on page 1of 14

C-ARM: ITS ESSENCE & THE CHANGES IT CREATES IN OPERATING ROOM

An output in partial fulfillment


in
Current Trends in Nursing

College of Nursing Graduate School


West Visayas State University

Submitted to
Prof. Sheila Beliran, R.N., M.A.N.

Submitted by
Melanie A. Bernardez, RN

February 18, 2017


INTRODUCTION

In the surgical treatment of emergent and traumatic orthopedic injuries, mobile


image intensifier systems (c arm) are used frequently to assess the complexity of
fractures, guide the surgical procedures and verify the results of surgical repair.
(e.g., the correct placement of instrumentation during open reduction and fixation).
C arm systems offer both a spot imaging m0de and a fluoroscopic image mode that
allows the generation of continuous real time moving images. The latter maybe
desirable to trace the progress of a surgical procedure to improve image quality by
correcting for errors and position and orientation of the c arm, or to visualize
changes in implant position with patient motion. However, the radiation levels to
which patients and operating room personnel are exposed during fluoroscopic
imaging are a potentially serious problem, even with resent technical advances,
such as pulsed-mode fluoroscopy, automated aperture optimization, digital imaging,
and laser localization.

One approach to controlling radiation exposure is to optimize the training of


operating room personnel who use c arm system so as to reduce the time and
radiation needed to obtain a specific radiograph or monitor a surgical procedure.
Training should not only impart knowledge about the physical properties and
biological effects of the radiation produced by the c arm, especially when it is used
in fluoroscopy mode, but also should develop the skills needed to obtain images of
sufficient quality for the surgical situation in a short time as possible and with a
minimal level of radiation exposure.

Because training with live volunteers is not feasible in training with cadavers is
costly, current training programs are based mainly on theoretical knowledge and
are lacking in practical application. Most practical training still takes place in the
operating room, were the risk to patients and personnel alike maybe high because
of poor understanding of the pattern of radiation distribution from the c arm.

Occupational radiation exposure from c arm fluoroscopy during continuous


orthopedic surgical procedures and its prevention.

Image intensifiers have become popular due to the concept of minimally invasive
surgeries leading to decreasing invasiveness, decreased operative time, and less
morbidity. The drawback, however, is an increased risk radiation exposure to
surgeon, patient and theater staff. These exposures have been of concern due to
their potential ability to produce biological effects. The present situation was
embarked analope the amount of radiation received by orthopedic surgeons using
standard precautionary measures and also the awareness about the use of image
intensifier safety in every days practice.

The use of fluoroscopy has increased time during in field of orthopedics. The image
intensifier have enable orthopedic surgeon to become technically more proficient
and decreased the morbidity of the patient by minimizing the area of operative field
and decreasing operating time.

Fluoroscopy has been used in abused. Some over views it forgetting the principles
of radiation protection while others have unfounded fears. In general, orthopedic
surgeons lack awareness about the radiation exposure they are getting and its
effects on health. And callous with protection, surgeons and assistants are at
maximum risk among all personnel due to proximity to exposure area. Some studies
concluded that whole body receive is well within recommended level but how
implied caution due to long term effects of even low dose radiation. It is pertinent
that any amount of exposure to ionizing radiation leading to secondary occupational
risk should be avoided or maximize caution exercise to minimize the exposure.

DISCUSSION

Orthopedic surgeon and assistants are the maximum radiation risk among all
personnel due to proximity to exposure area. There was a significantly positive
correlation between operating time and exposure time. In general, close reduction
and interlocking nailing procedure were associated with a higher exposure time in
comparison to open procedures and percutaneous procedure/ closed reduction and
others.

A. Personal protection
1. Shielding all personnel should wear protective gear. Lead apron keep in
reducing the exposure by a factor of 4 inches lateral view and a factor of 16
inches postero- anterior view. Thyroid guards decrease the exposure 2.5
times the normal. Eye protection is essential and is the first determined of
work load in all procedures. Lead apron should have at least 0.5mm
equivalent thickness of lead and the goggles should be at least 0.15mm lead
equivalent thick.
2. Distance the intensity of radiation at a point is inversely proportional to the
square of distance.

B. Personal related factors


1. Technical proficiency surgeon should be familiarize with the procedure,
the technique and the instrumentation. Effort should be to supplement
image to the clinical knowledge and not vice versa. Some studies have
reported that more the experience lessees are the exposure.
2. Adequately trained operation - will avoid unnecessary exposure.

3. Personnel monitor- routinely radiation dose meter should be worn by all


persons working in or near radiation fields.

4. Staffing training Many of the surgeons and staff are callous towards
radiation protection. It has been personal experience that many persons do
not wear thyroid shields. Thyroid protector leads to a further 2.5 fold
decrease of ration dose than without thyroid protector. All staff should
undergo a regular orientation program towards radiation protection.

C. Procedure Related Factors


a. Duration of exposure the lesser the exposure time the lesser the
exposure dose and the radiation side effects.
a.1 Well planned procedure The procedure should be well planned
with job descriptions clearly marked out prior to surgery so as to
minimize the time of exposure.
a.2. intermittent fluoroscopy 3 seconds burst log off interval is
preferable. Continuous fluoroscopy should be avoided.
a.3. Pulse mode decreases radiation dose by 70%
a.4. Image capture and memory storage allows study of the image by
the surgeon without re- exposure to the patient.

b. Avoid direct handling of x-ray tables while in operation and placement of


the hand directly in the radiation beam.
c. Position of the c arm The intensity of scatter radiation is the maximum in
backward direction in orthopedic procedures. The amount of scatter
radiation to the surgeon is maximum in horizontal fluoroscopy and that is
why it was proposed that the beam should be directed from medial to
lateral direction.
d. Collimation Reduces the beam area and enhances thereby decreasing
the radiation dose to the surgery and other staff.
e. Exposure time alarm Would warn the surgeon and the operator of the
amount of radiation exposure received.
FEATURES

Centeno-Schulz Clinic (2012) emphasized that a C-arm machine is a device


used by a physician to guide surgical instruments while watching the instrument
being driven on a live x-ray machine. The C-arm is also referred to as an X-ray
image intensifier or XRII. Hospitals benefit from cost savings through fewer follow-
up operations and from minimized installation efforts.

Hospitals benefit from cost savings through fewer follow-up operations and
from minimized installation efforts. A C-arm comprises a generator (X-ray source)
and an image intensifier or flat-panel detector. The C-shaped connecting element
allows movement horizontally, vertically and around the swivel axes, so that X-ray
images of the patient can be produced from almost any angle. The generator emits
X-rays that penetrate the patient's body. The image intensifier or detector converts
the X-rays into a visible image that is displayed on the C-arm monitor. The doctor
can identify and check anatomical details on the image such as blood vessels,
bones, kidney stones and the position of implants and instruments at any time.

The C- arm can be moved and adjusted to different settings based on the
procedure. The C-Arm can also work in conjunction with a table that is designed for
C-Arms. This are used for the general surgery, pain management, aneurysm repair,
catheter placement, cardiac pacemaker implantation, hip replacement,
interventional neuroradiology, neurosurgery, trauma care, lap band surgery, and
needle biopsy.

When working with C-arm systems, enhancements accumulate over a long


timeline. In many cases, the changes are subtle, including image quality and
systems that are easier to use.
Now more than ever, healthcare reform, hospitals and clinics are having to find
innovative ways to be flexible with their imaging systems. Even without the threat
of reimbursement penalties hanging over their heads, it is not always practical to
have multiple dedicated systems scattered throughout the hospital. For orthopedic
clinics, surgical units and even some interventional applications, mobile C-armsare
providing a low-cost solution. The following are the few newest units/ models in the
C-arm Fluoroscopy.

Vision RFD 3-D mobile C-arm (Ziehm Imaging)


This unit was one of the first on the market along with Ziehms Vision RFD
Hybrid. It offers four motorized axes, allowing the surgeon to have total control over
movement through a dual-joystick system., the Vision RFD 3-D offers other
ergonomic improvements, including a three-position memory feature and color
coding on the axes to help the surgeon guide the technologist through manual
movements.
Ziehm Vision RFD 3D is the only 3D C-arm worldwide with flat-panel
technology that provides a 16 cm edge length per scan volume. It combines 2D and
3D functionality to offer maximum ease-of-use. Available with a 30 cm x 30 cm flat-
panel, the C-arm offers game-changing 3D imaging and is ideally suited
for orthopedics,traumatology and spinal surgery, but also for demanding cardio-
vascular hybrid applications.

It was introduced at the Radiological Society of North America (RSNA) Annual


Meeting (2014) and approved by the U.S. Food and Drug Administration (April 2016)

Ziehm Vision FD (Ziehm Imaging)

The first mobile C-arm in the world that uses flat-panel detector technology.
The Ziehm Vision FD features a flat-panel detector based on amorphous silicon (a-
Si) photodiode technology with a field size of 20 cm x 20 cm. The flat-panel detector
provides an unmatched dynamic range with an image quality suitable for a wide
variety of different interventional radiology procedures. The compact design enables
better patient access and increased mobility, so that the unit can easily be brought
to the patient instead of the patient to the unit. The system runs with a pulsing
generator featuring Vision Pulse technology running at a frame rate of up to 30
frames/sec in fluoroscopy mode as well as in DSA or cine loop modes. The user
interface offers an intuitive workflow and logical guidance using two synchronized
TFT touchscreen control panels, one conveniently mounted on a swivel arm of the C-
arm, the other one mounted on the monitor cart.

MultiScan G-arm system (Whale Imaging)

The MultiScan provides simultaneous live AP/LT fluoroscopy images in the


operating room without having to rotate the machine; it can rotate up to 270
degrees if needed. Motorized mechanics control orbital rotation, height and SID
distance for smooth motion and reduced disruption of the sterile field. A console
touchscreen and touchpad allow easy image manipulation, patient retrieval and
function selection, with numerous anatomic pre-sets included to simplify workflow
and improve productivity. Bright HD 19-inch monitors allow easy viewing even in OR
lighting. It was introduced at the Radiological Society of North America (RSNA) in
2015.

Cios Select Mobile C-arm and Cios Connect Mobile C-arm (Siemens Healthcare)

Both models are designed for high-quality imaging in surgical applications but
offer slightly different advantages. The Cios Select is geared toward novice
operators with an intuitive button-based user interface and positioning system that
are designed to minimize necessary training. The Cios Connect focuses on
multifunctional usage with an extended free space of 79 cm and immersion depth of
73 cm. Both systems utilize IDEAL (Intelligent Dose Efficiency Algorithm) to provide
a clear view of anatomical details at low dose, with a laser-light localizer on the
image intensifier and tube allowing radiation-free positioning of the C-arm. The
surgeon can fully control the system from one of three touchscreens, one on the C-
arm itself, one on the mobile workstation and one on the tableside control. A sports
vessel overlay software that provides the surgeon with better navigation during
vascular procedures.It was approved by the U.S. Food and Drug Administration
(2014) and was introduced at the Radiological Society of North America (RSNA) in
2015.

OEC Brivo Prime mobile C-arms (GE Healthcare)

The OEC Brivo Prime brings top-notch image quality to mobile C-arms. It has
a Smart AutoTrak that locates and adjusts the image when the anatomy is not
properly centered. It also have an Auto SmartMetal for metal compensation and an
Auto Window feature that increases brightness and illustrates sharp bone
edge. Received U.S. Food and Drug Administration clearance in 2013.

OEC 9900 Elite (GE Healthcare)

This C-arm system include dynamic range management (DRM) and motion-
tolerant subtraction, which help deliver superior images in various mobile C-arm
imaging situations such as small and dense anatomy. The advanced processing
algorithms provided by DRM and MTS technologies enable real-time elimination of
background information without using a mask image and stepper table. This
patented imaging technique delvers digitally subtracted angiographic runs even
while the patient is moving. This flexibility helps technologists obtain the correct
image quickly with fewer exposures, improving workflow and reducing patients
radiation exposure. The 9900 Elite also offers a motorized option that provides
surgeons and technologists the flexibility to control the C-arm remotely or at the
tableside with a remote user interface and foot pedal. The surgeon has the control
to give direction to the C-arm operator to position the device to the exact, correct
angle in order to have an image that is needed for the procedure. Thus it decreases
the radiation exposure and contract media, saves time because of improved
workflow.

Veradius Unity (Philips Healthcare)

This system marked the switch from image intensifiers to digital detectors.
Several navigational aids were incorporated into the system, including the
ClearGuide function that correlates directions in the image (up/down/left/right) with
physical markers on the detector (3/6/9/12). Operators can use a marker pen with
the outline tool to create free format drawings on live fluoroscopy images, including
vessel outlines and other anatomical references.

It was introduced at the Radiological Society of North America (RSNA) in


2014.

Flouroscan Insight-FD (Hologic)


This C-arm uses a rotating flat-panel cesium iodide (CsI) digital detector. The
new detector offers distortion-free imaging at a lower radiation dose, with
touchscreen controls for image adjustment and system rotation. Productivity is
further enhanced by the thin profile and improved workspace access, allowing easy
positioning in rooms of any size.It was introduced at the Radiological Society of
North America (RSNA) in 2014
Flouroscan Insight Mini C-Arm (Hologic)

This device is more versatile, efficient and cost-effective for completing


precision extremity surgery. Flouroscan Insight is used by orthopedic surgeons in
operating rooms so that surgeons can do their own imaging, easy to use and
automated as much as possible. The improved software give the system even
greater imaging flexibility and allow the user to set and store physician preferences
for all imaging parameters. This includes deeper C-arm that accommodates virtually
any hand table. The redesign flex arm increases articulation range and improves
maneuverability.

Fluoroscopic systems have two main configurations. One class commonly


utilizes a radiolucent patient examination table with an under-table mounted tube
and an imaging system mounted over the table, while the other is commonly
referred to as a C-arm system used where greater flexibility in the examination
process is needed such as neuro or cardiac imaging. The non-C-arm based systems
are used in most X-ray departments as ascreening rooms. The types of
investigations for which this machine can be used for is vast, including, Barium
studies, Endoscopy studies. The C-arm systems are commonly used for studies
requiring the maximum positional flexibility such as: Angiography studies,
Therapeutic studies Cardiac studies, Orthopaedic procedures. Generally using a
portable / mobile C-arm gives a maximum flexibility in positional use.

The use of mobile fluoroscopic devices during procedures is associated with


substantial concern with regard to the radiation exposure to surgeons and support
staff. The perceived increased risks associated with large c-arm devices have been
well documented. Here I believe that for every advantage that technology brings us,
it also brings us a disadvantage at the same time. Skin can be damaged by
excessive radiation and may develop cancer later on. Irradiated bone marrow can
cause anemia (low red blood cell count) and therefore fatigue and muscle
weakness. Poor digestion and absorption of nutrients can stem from an irradiated
gastrointestinal tract. Large doses of radiation cause hair loss and dryness of skin.
Over time, large doses of radiation can cause Cancer and the formation of cataracts
on the lenses of the eyes. The risk of developing these types of damage is usually
consistent with the level of exposure to radiation beyond a certain threshold
amount.

Radiation may also cause genetic problem that can directly damages the
reproductive organs, and therefore affects any offspring that individual may have
after the damage has occurred. Damage is done to genes and chromosomes, which
can be passed on to future generations. Studies of survivors of the Hiroshima and
Nagasaki bombings and of the Chernobyl survivors in Ukraine have shown that
there are increased rates of stillbirths, miscarriages, and infant deaths. If the
children survive past the first few years of life, they tend to develop leukemia or
microcephaly (slower cranial development), have birth defects (limbs missing, large
growths), or mental impairments. If exposure to radiation was not acute, then
genetic effects may be minor or may not appear at all. However, Health Canada
acknowledges that exposure to even minute doses of radiation from medical
procedures such as x-rays, fluoroscopy or CT scans can have repercussions on the
unborn fetus and therefore it is recommended that no procedures involving ionizing
radiation be performed during pregnancy.

RATIONALE

A C-arm is an imaging scanner intensifier. The name derives from the C-


shaped arm used to connect the x ray sources and x-ray detector to one another. C-
Arms have radiographic capabilities, though they are used primarily for fluoroscopic
intra operative imaging during surgical, orthopedic and emergency care procedures.
The devices provide high resolution x-ray images in real time, thus allowing the
physician to monitor progress and immediately makes any correction. Through its
intensifying effect, the viewer can more easily see the structure of the image object
than fluorescent screens alone. The C arm systems are commonly used for studies
requiring the maximum positioned, flexibility, Physician can checks anatomical
details such as bone and the position of implants and instruments at any time and
almost in any angle.

This technology is considered to be one of the widely equipment used in diagnosing


and treatment of patients in modern era, to become more advance in leading to
minimally invasive procedure in dealing to be more accomplished perform
procedures with less morbidity, decrease operative time thus heading to early
patients recoupment or recovery.

As a health team member in the operating room theater, be knowledgeable and


skillful enough in upgrading of technology in this modern time of treating patients. I
must be updated and well equipped in the recent trends in my nursing profession
especially in the area where I belong. This equipment, I considered as latest in the
institution where Im connected and to share and discuss this topic in order to be
currently uphold and aware of this trend in the operative set up. Its benefits and
pitfalls to the patients and to the health team as well. They consider this equipment
as for minimally invasive procedure, so as nurses will be able to assist the surgeons
in performing and be part of giving more advance treatment with less invasive and
shorter time exposure to the procedure performed.

MERITS
Fluoroscopy can use in a wide variety of examinations and procedures. These can
be a non-invasive and painlessly which can help to diagnose disease and a support
for medical and surgical treatment planning.
Easily portable, image accessible at multiple locations at the same time, images can
be transmitted over long distances without being distorted and better image quality.
It enabled surgeons to become technically more proficient leading to decreasing
invasiveness, decreased operative time and less morbidity.
In the operating room it guides the surgical team as they insert catheters, stents, or
other devices inside the body.
DEMERITS

The C arm fluoroscopy emits radiation which can cause illness such as skin damage
and the underlying tissues, leukemia, poor digestion and absorption of nutrients
which may occur later in life because of bone marrow irritation and radiation
induce cancer.

C arm manipulation is not open to anyone. There should be an authorized person to


operate the machines that have undergone proper training of C arm system.

The machine is very much expense that cost millions of pesos.

APPLICATION TO NURSING EDUCATION

Having the knowledge about the motion of c- arm will prepare the nurses in
facing the newly trends in nursing profession in how this equipment / devices being
used by the health team professionals. Recognizing the importance and danger or
treat of one of the latest trends in medical fields can warrant the health team and
can avoid the risk factors. Each one of us, nurses, can have the opportunity to be
educated and know how to handle this type of machines to become more efficient
with the skills we have been doing. Knowledge, skills and attitude are the keys
towards a more effective health team practitioner.

APPLICATION TO NURSING PRACTICE

Being skillful in the field we are doing is an asset to become a good health care
provider. To be trained to handle a more advance equipment is an edge and can be
a one step higher. So, we must not stop learning as we go on everyday in our
practice since learning can lead us to a brighter future not only in our profession but
as well as for our self improvement.

APPLICATION TO NURSING RESEARCH


Continuing education and exposure to nursing research can enhance our
knowledge in uplifting our ideas and knowing more trends for the welfare of our
patient safety and health team safety as well. This can widen and broaden our
horizon in taking good care of our patients health care situation. Nursing research
with this type of equipment can help our health team to become more efficient and
to discover preventive measures to lessen the risk factors and to consider safety
measures in this widely used technologist/ devices.
Safety is the first line of defense we are considering. In any situation safety
precautions are being held up.
Bibliography

Radiology, A. C. (2012, March 20). ACR Practice guideline for imaging pregnant or
potentially pregnant adolescents and women with ionizing radiation.
Retrieved from ACR:
http://www.arc.org/SecondaryMainCategories/quality_safety/guidelines/dxPreg
nancy.aspx
He, J., & al, e. (2016, March 1). Comparison of Isocentric C-Arm 3-D Navigation and
Conventional Fluoroscopy for Percutaneous Retrograde Screwing for Anterior
Column Fracture of Acetabulum: An Observatory Study. Retrieved from
Science Direct:
http://www.sciencedirect.com/science/article/pii/S1529943004009076
Administration, F. a. (2012, March 8). Performance Standard for ionizing Radiation
Emitting Products, Diagnostic X-Ray Systems and their Major Components.
Retrieved from FDA: http://www.accessdata.fda.gov/scripts/cdrh/ cfdocs/ cfcfr/
CFRSearch. cfm
Hsu, R., Lareau, C., & al., e. (2014, August 6). The Effect of C-Arm Position on
Radiation Exposure During FIxation of Pediatric Supracondylar Fractures of
the Humerus. Retrieved from DOI Org: http://dx.doi.org/10.2106/JBJS.M.01076
Ruan, Z., Lou, C., Zeng, B., & et.al. (2013, November 11). Percutaneous Screw
Fixation for the Acetabular Fracture with Quadrilateral Plate involved by
Three DImensional Flouroscopy Navigation: Surgical Technique. Retrieved
from The Journal of Bone and Joint Surgery: http://jbjs.org/content/97/9/721?
trendmd-shared=0
Machita, F., & et.al. (2014, February 4). CT Angiographyafter 20 Years: A
Transformation in Cardiovascular Disease Characterization Continues to
Advance. Retrieved from Blue Sky Ex: http://www.blueskyex.com/index.php?
action=searchsell&cattype=imaging&desc=C-Arm&type=1#
Sean, B., Raymond, T., & et.al. (2013, July 17). Bone Joint Surgery AM. Retrieved
from DOI Org: http://dx.doi.org/10.2016/JBJS.L.00893
Appendices

Appendix A. A case report of successful removal of multiples sewing needles in


thegastrointestinal tract and pancreas using intraoperative C-
armfluoroscopy.

Appendix B. Comparison of intraoperative O-arm- and conventional fluoroscopy


(C-arm)-assisted insertion of pedicle screws in the treatment of fracture
Of thoracic vertebrae.

Appendix C. The Mini C-arm Adds Quality and Efficiency to the Pediatric Orthopedic
Outpatient Clinic.

You might also like