STUDY NAME: ASPIRATION IN INFANTS: Salivagram

ORDER NO: 4090, 4385

INDICATIONS: Suspected aspiration in infants

PATIENT

PREP: NPO for a minimum of one hour prior to the exam

RADIOPHARM

AND DOSE: ^99mTc sulfur colloid, in 0.1 ml (in TB syringe)

Physician prescribed dose or the dose from the standard Nuclear Medicine dose sheet.

INSTRUMENT

AND SET-UP: Gamma camera peaked on ^99mTc 140 kev with 20% window and LEAP / GP collimation. Positioned over the mouth, chest, and upper abdomen (in infant) (typically posterior under the imaging table).

Acquire 15 sec /frame for 1 hour.

PROCEDURE: Inject radiopharmaceutical under the tongue.

Image for 1 hour at 15 seconds perf frame.

IMAGING SUMMARY: Image posteriorly over the mouth, chest and upper abdomen at 15 sec/frame for one hour. Perform transmission flood spot at the end of the study for 3 minutes.

PROCESSING: Compress study into 5 minute frames and image as series. Send screen capture and raw data to PACS.

POST EXAM: No precautions or special instructions are necessary following the exam.

DYNAMIC ACQUISITION:

ACQUISTION
CAMERA	Acquisition type	Dynamic
	Collimator	LEUHR or LEHR
	Detectors	Detectors 1 and 2
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	15 sec/frame
	Number of images	240 frames
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

STATIC ACQUISITION

ACQUISTION
CAMERA	Acquisition type	STATIC
	Collimator	LEUHR or LEHR
	Detectors	Detector 1
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	180 seconds
	Number of images	1
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

STUDY NAME: Biliary scan

ORDER NO: IMG13003 (CPT 78227)

INDICATIONS: Evaluation of the hepatocyte and biliary tract function in adults and children for the diagnosis of hepatocellular disease, biliary tract obstruction, acute or chronic cholecystitis, or biliary atresia. The biliary scan is also useful for the determination of bile reflux gastritis, post surgical leaks, and sphincter of Odi disease.

PATIENT

PREPARATION: Patients with gallbladders should be NPO for a minimum of 4 hours, no hyper alimentation for 6 hours, and no pain medication i.e. opiates, morphine, Demerol for 12 hours. FASTING for greater than 24 hours is a limiting factor in accuracy, and requires delayed imaging.

PEDIATRIC patients with a diagnosis of Biliary Atresia must be premedicated with phenobarbital for five days prior to the scheduling of the exam. Consult the Radiologist for the dose of phenobarbital.

ISOTOPE

AND DOSE: ^99mTc MEBROFENIN

Physician prescribed dose or the dose from the standard Nuclear Medicine dose sheet.

INSTRUMENT: Gamma camera: LEHR resolution collimator peaked on 140 keV with a 20 % window. If portable, diverging collimator on Digirad Ergos.

Computer: Acquire a 120-minute dynamic in a 64x64 matrix at 60 sec/frame.

PROCEDURE: STANDARD ACUTE /CHRONIC CHOLECYSTITIS WORK-UP:

Immediately after injection position the patient supine under the camera with the liver in the upper right corner of the fields of view (FOV). The cardiac activity should be seen at the top of the FOV. The patient should remain in the same position for the duration of the exam.

Imaging should continue on patients with gallbladders until

(1) activity is seen in the gallbladder and the small bowel or

(2) 2 hr. have post injection have elapsed without visualization of the gallbladder.

Consult with a radiologist prior to and during the study for procedure direction.

If the gallbladder is visualized, a cholecyctokinin (CCK) augmented gallbladder ejection fraction should be performed when the gallbladder and small bowel are seen. In this case, a dynamic study of at least 25 minutes should be obtained. When at least 25 minutes is left in the original 120-minute dynamic study there is no need to set-up a separate dynamic acquisition. A CCK (Kenavac™) 5mg vial is reconstituted with 5 ml of sterile water and then diluted with saline to 10cc volume. Cholecystokinin is administered using a syringe pump set to deliver the 5mg/10cc over 20 minutes. When at new 25 minutes dynamic study must be set to evaluate gallbladder function the CCK is administered at 5 minutes into the dynamic acquisition.

Annotate the films and curves with the time CCK was given.

Patients with gallbladders that visualize and no activity is seen in the small bowel at one hour may be given CCK as described above when approved by the Radiologist. If there is no visualization of the gallbladder at the end of two hours the patient is discharged from the department and should be brought back for delay imaging at 4-6 hours. If the scan is suggestive of acute cholecystitis (no gallbladder within 2 hours) a delay image should be obtained at 4 hour post injection.

When gallbladder visualization is questionable due to activity in the common duct, duodenum, or small bowel, a left anterior oblique and right lateral are obtained. At the radiologist’s discretion, a rapid SPECT-CT can be obtained to determine if the gallbladder has filled.

Patients with activity in the duodenum that obscures the view of the gallbladder may be given water PO with the approval of the Radiologist to wash the activity from the duodenum. NOTE the time that the fluids are given.

500 uCi Sulfur Colloid can be given orally if it’s necessary to mark the stomach. Ask the radiologist for verification.

IF the patient has had prolonged fasting (> 24 hours) and the gallbladder is not visualized at 4 hours, the patient is to remain NPO and a 24 hours delayed sport image is to be obtained. If gallium is available at the 4 hour time point, a dose of 6 mCi of ⁶⁷gallium citrate (dose per weight) is to be administered, with a dual energy spot of both ⁶⁷gallium citrate and ^99mTc-Mebrofenin at 24 hours.

BILIARY ATRESIA WORK-UP:

Imaging should continue until

(1) activity is seen in the small bowel or

(2) 2 hr. post injection have elapsed without visualization of the gut.

Consult with a radiologist prior to and during the study for procedure direction.

NOTE: The patient does not need to be NPO after the 1^st hour of imaging.

If the gallbladder, but not gut is seen, CCK (dose per weight by standard dose chart) can be given to visualize the gut.

If the gut is not visualized at 2 hours, delayed imaging at 4 hours (with and without lead shielding of hepatic activity) is performed, and if still negative for gut activity, 24 hour imaging is obtained with both planar spot and with SPECT to look for gut activity.

BILIARY LEAK WORK-UP: (THESE PATIENTS DO NOT NEED TO BE NPO)

Imaging should be continued through one hour or until a leak is visualized. If the gut has not visualized, delayed imaging should be performed at the guidance of the monitoring radiologist. Use of gravity to shift abdominal activity and / or SPECT-CT may be performed at the request of the monitoring radiologist.

IMAGING SUMMARY: ACUTE OR CHRONIC CHOLECYSTITIS: 1 minute /frame for 2 hours (or until gallbladder / gut visualized, and GB Ejection fraction obtained).

IF gallbladder does not visualize, image until 4 hours in outpatients.

IF gallbladder does not visualize and patient is inpatient with prolonged fasting, image until 24 hours (and if possible use gallium as well at 4 hour time point, with 24 hour dual energy spot image of gallium and Mebrofenin).

At the discretion of the monitoring radiologist, use LAO and Right lateral imaging to identify the Gallbladder. Consider SPECT-CT if needed. Water can be used to clear the duodenum and if needed, Sulfur colloid can be used to mark the stomach.

BILIARY ATRESIA: Image at 1 minute/frame for 2 hours, with delayed imaging at 4 hours and 24 hours (SPECT at 24 hours) UNTIL the gut is visualized. Consider shielding the liver activity on delayed images to see gut. Patient does not need to be NPO after the first hour.

BILE LEAK: Image at 1 minute per frame for 1 hour. If drain present, clamp drain, then image after 1 hour with drain unclamped (including the drain bulb). Use gravity or SPECT-CT at the discretion of the monitoring physician.

DATA

PROCESSING &

FILMING: A scan without the gallbladder ejection fraction is compressed to 5-minute frames on the computer and warp to largest display size. Display all compressed planar images on one page. Annotate for type of exam, orientation, view, name, medical record number, and date of exam, make a snapshot and send snapshot to PACS. If the exam includes a gallbladder ejection fraction, a curve of the numeric data must be generated. Draw Areas of Interest over the gallbladder, the liver parenchyma (20x20 square), and the common duct if visible. Generate the curve by applying the areas to the 60-sec dynamic data. The curve must be scaled from 0 to maximum counts. Annotate the curve at the point where CCK is given. Annotate for type of exam, orientation, view, name, medical record number, and date of exam, make a snapshot and send snapshot to PACS.

DYNAMIC ACQUISITION:

ACQUISTION
CAMERA	Acquisition type	Dynamic
	Collimator	LEUHR or LEHR
	Detectors	Detector 1*
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	1 MIN/frame
	Number of images	120 frames
	Magnification	0-2.0 (Pending patient size)
	Patient Orientation	Feet First Supine

DELAY STATIC ACQUISITION:

ACQUISTION
CAMERA	Acquisition type	STATIC
	Collimator	LEUHR or LEHR
	Detectors	Detector 1
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	5 MIN
	Number of images	ANT, RT LAT, LAO
	Magnification	0-2.0 (or more based on patient size)
	Patient Orientation	Feet First Supine

DELAY STATIC ACQUISITION WITH GALLIUM:

ACQUISTION
CAMERA	Acquisition type	STATIC
	Collimator	MEGP
	Detectors	Detector 1
	Isotope	GA-67
	Peak	93, 180, 300 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	5 MIN
	Number of images	ANT, RT LAT, LAO
	Magnification	0-2.0 (or more based on patient size)
	Patient Orientation	Feet First Supine

PROCEDURE: Bone Scan Whole Body (IMG13065)(Performable)

ORDER NO. IMG13005 Bone Scan 3 Phase (orderable) IMG13066 Bone Scan w/Blood Pool (performable CPT 78315), Both Whole body and SPECT codes are used when both type scans are performed.

FOR patients receiving SPECT-CT a separate order must be placed:

BONE SPECT (IMG13067)(Performable)

INDICATIONS: Bone pain, trauma, primary or metastatic bone cancer, and osteomyelitis or bone infarction. Many other less common indications.

Osteonecrosis or infarct - consult the Nuclear Medicine physician about performing a marrow scan.

Osteomyelitis- Abscess Localization Whole Body 24hr and Abscess Localization SPECT need to be ordered and scheduled as well.

PATIENT

PREP: Hydration post injection.

RADIOPHARM

AND DOSE: ^99mTc MDP. Physician prescribed dose or the dose from the standard Nuclear Medicine dose sheet.

INSTRUMENT

AND SET-UP: LEUR collimators with MCA preset for ^99mTc energy with 15-20% window. Preset Blood Pool, Whole Body Bone, or Bone SPECT acquisition protocol.

Choose the preset protocol from the 'protocol' cycle field in the acquisition window. Type any necessary demographics into the acquisition window.

PROCEDURE: All bone scans are performed with a whole body blood pool scan. Patients with arthropathy / bone pain / arthritis workups, include blood pool and delayed spots of the hands and feet. A physician reviews all bone scans prior to dismissing the patient

Planar and SPECT-CT imaging of the bones are performed 2-5 hours post injection of the prescribed radiopharmaceutical dose.

630/Forte/Symbia/670 SPECT/CT

WHOLE BODY scan blood pool & bone delay; the patient is positioned with their head away from the gantry and the feet as close to the end of the table as possible. The table and camera heads are positioned so that the distance from the heads to the patient is at a minimum. Scan the patient for 5 minutes for blood pool, 20 minutes for bone delay, from head to toe to accommodate the entire body. Instruct the patient to remain motionless for the scan.

SPOT planar images are acquired for one minute blood pool and three minutes for bone delay. Position the camera heads over the area to spot, set the camera head as close to patient as possible. Tell the patient to remain still.

SPECT scan; The ECT palate is inserted on the table supports. The patient in most instances will be positioned with their head away from the gantry, the exception may be for head imaging. Position the gantry and camera heads over the area to be scanned by translating the camera. Raise the table to center the patient in the camera heads. When mapping keep the heads as close to the patient as possible (1-2 inches). Remind the patient to remain still for the entire scan.

670 SPECT/CT

The patient in most instances will be positioned with their head away from the gantry, the exception may be for head imaging. When possible keep the arms over the head and out of the area of the scan. Position the gantry and camera heads over the area to be scanned by translating the table. Raise the table to a position that places the central long axis of the patient in the center of the gantry. Key in the gantry button sequence to initiate the 360' mapping function. Index head one in to within an inch of the bottom of palate and begin mapping. When mapping keep the heads as close to the patient as possible (1-2 inches). On completion of the map the camera will disable, re-enabling the gantry will start a test of the created map. The scan is initiated by clicking the set create and acquire buttons in the acquisition window.

CT: Factory set Low Dose for attenuation correction. Pediatric reduce mAs and kVp both to value of 80.

IMAGING SUMMARY: 5 minute whole body scan at 90 seconds after injection.

20 minute whole body scan at 2 hours after injection.

Tail on detector (TOD) on all prostate cancer, bladder cancer, and GYN cancer cases.

Additional spot images as requested by monitoring radiologist

SPECT-CT as ordered by monitoring radiologist.

All “arthritis/arthropathy/joint pain patients” require spot images of hands and feet on both blood pool and delay

PROCESSING: Whole body and spot images require no post processing. Screen capture and sent to PACS

SPECT: The SPECT images are reconstructed in a 128x128 matrix and saved in all planes. A reprojection image is reconstructed using MIPS. Transverse reconstructions (AC and NON-AC) and screen captures sent to PACS

POST EXAM: No special instruction or precautions are necessary following this scan

WHOLEBODY IMAGING:

ACQUISTION
CAMERA	Acquisition type	WHOLEBODY
	Collimator	LEHR OR LEUHR
	Detectors	DetectorS 1 AND 2
	Isotope	99M-TC
	Peak	140 KeV
	Energy Window	20%
	Matrix	256X1024
	Acquisition time	40 CM/MIN B POOL 15 CM/MIN DELAY
	Number of images	1
	Magnification	NONE
	Patient Orientation	Feet First Supine

STATIC ACQUISITION

ACQUISTION
CAMERA	Acquisition type	STATIC
	Collimator	LEUHR or LEHR
	Detectors	Detector 2*
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	256X256
	Acquisition time	60 seconds
	Number of images	ANT, POST, LATS, OBLIQUES
	Magnification	2.0 (or more based on patient size)
	Patient Orientation	Feet First Supine

TOMOGRAPHIC:

ACQUISTION
CAMERA	Acquisition type	TOMOGRAPHIC
	Collimator	LEUHR or LEHR
	Detectors	DETECTORS 1 AND 2
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	20 SEC/STEP
	Number of images	30 STEPS
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

PROCEDURE: Bone Marrow Scan(IMG13004)(Performable)

ORDER NO.

INDICATIONS: Bone infarction (especially in sickle cell disease) , Osteonecrosis or suspected cancer involvement in bone marrow (to differentiate marrow expansion from tumor involvement, particular in using labeled WBCs for prosthetic infection.)

PATIENT

PREP: None

RADIOPHARM

AND DOSE: Filtered (< 0.1-micron particle size) ^99mTc Sulfur Colloid.

Physician prescribed dose or the dose from the standard Nuclear Medicine dose sheet.

INSTRUMENT

AND SET-UP: Any of our whole body scanners: LEUR collimators, preset ^99mTc energy control, Bone protocol lengthened to 30 minutes for whole body pass.

SPECT-CT: LE collimators, preset ^99mTc energy control, 30 minute SPECT-CT acquisition.

PROCEDURE: Bone scans are typically performed in conjunction with marrow scans. The Nuclear Medicine physician should protocol marrow scans or any bone scan consults with a diagnosis of Osteonecrosis or neuroblastoma.

Wholebody or SPECT Imaging of the marrow is performed at 30 minutes post injection of the prescribed dose of ^99mTc Sulfur Colloid

IMAGING SUMMARY: 30 minute whole body scans at 20 minutes.

SPECT-CT as ordered by monitoring radiologist.

PROCESSING: Whole body and spot images require no post-processing. Screen capture and sent to PACS

SPECT-CT: The SPECT images are reconstructed in a 128x128 matrix and saved in all planes. A reprojection image is reconstructed using MIPS. Transverse, sagittal, coronal, and reprojection images sets are transferred to PACS. Transverse reconstructions (AC and NON-AC) sent to PACS

CT: Factory set Low Dose for attenuation correction. Pediatric reduce mAs and kVp both to value of 80.

POST EXAM: No special instruction or precautions are necessary following this scan

WHOLEBODY IMAGING:

ACQUISTION
CAMERA	Acquisition type	WHOLEBODY
	Collimator	LEHR OR LEUHR
	Detectors	DetectorS 1 AND 2
	Isotope	99M-TC
	Peak	140 KeV
	Energy Window	20%
	Matrix	256X1024
	Acquisition time	15 CM/MIN
	Number of images	1
	Magnification	NONE
	Patient Orientation	Feet First Supine

STATIC ACQUISITION

ACQUISTION
CAMERA	Acquisition type	STATIC
	Collimator	LEUHR or LEHR
	Detectors	Detector 2*
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	256X256
	Acquisition time	60 seconds
	Number of images	ANT, POST, LATS, OBLIQUES
	Magnification	2.0 (or more based on patient size)
	Patient Orientation	Feet First Supine

TOMOGRAPHIC:

ACQUISTION
CAMERA	Acquisition type	TOMOGRAPHIC
	Collimator	LEUHR or LEHR
	Detectors	DETECTORS 1 AND 2
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	20 SEC/STEP
	Number of images	30 STEPS
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

STUDY NAME: Brain Thallium (or Sestamibi) SPECT-CT

ORDER NO. Brain Function SPECT(IMG13070)(Performable)

Other protocols to see; Brain scan,

Brain Embolization and Brain occlusion

INDICATION: Suspected primary tumors primarily in pediatric patients as baseline and follow-up to therapy. To differentiate residual /recurrent tumor from radionecrosis.

PATIENT

PREP: 400 mg Potassium perchlorate or Sodium perchlorate 30 minutes prior to injection of ^99mTc labeled product.

RADIOPHARM

AND DOSE: ^99mTc-sestamibi or ²⁰¹Tl Thallous chloride.

Physician prescribed dose or the dose from the standard Nuclear Medicine dose sheet.

INSTRUMENT: SPECT-CT

PROCEDURE

AND SET-UP: The patient, when possible, is prepped with Sodium perchlorate 30 minutes prior to the procedure.

PATIENT POSITION

Position the patient in the head holder and make them as comfortable as possible so to reduce their movement during the scans. The head should be taped across the forehead to the head holder to

ACQUISITION

Inject and wait 10 minutes (with either agent), then perform standard high-resolution SPECT-CT (Continuous step and shoot mode); 20 minute acquisition.

CT: Factory set Low Dose for attenuation correction. Pediatric reduce mAs and kVp both to value of 80.

IMAGING SUMMARY: Inject, wait 10 minutes, perform SPECT-CT (20 minute).

PROCESSING: Transverse image sets for both ^99mTc sestamibi or Tl-201 are reconstructed using the standard ^99mTc reconstruction filter. Transverse (AC and Non-AC) reconstructions and all screen captures sent to PACS

POST EXAM: No special instruction or patient care is required following this procedure. If sedation was administered to the patient, contact the radiology nursing staff for patient after care.

STUDY NAME: Brain ECD (or HMPAO)

ORDER NO. Brain Perfusion/Function SPECT(IMG13008)(Performable)

INDICATION: Patients with cerebral vascular accident, TIA, sickle cell disease, or carotid artery disease. To evaluate stroke, dementia, focal seizure disorder.

PATIENT

PREP: Thirty minutes prior to injection of ^99mTc ECD give an oral dose of 400mg of either Potassium perchlorate or Sodium perchlorate

RADIOPHARM

AND DOSE: ^99mTc ECD.

Physician prescribed dose or dose from the standard Nuclear Medicine dose sheet.

INSTRUMENT: SPECT-CT

No sooner than 10 minutes after injection, and no later than 3 hours.

Protocol summary: Standard high resolution SPECT-CT (20 minute acquisition using continuous step and shoot)

PROCEDURE

AND SET-UP: The patient, when possible, is prepped with Sodium perchlorate 30 minutes prior to the procedure.

^99mTc -ECD – SPECT-CT images are acquired at 10 minutes- 3 hours post injection, the preference is 10- minutes post injection followed immediately by a 10-minute acquisition wholebody survey on whole body dual headed camera. 20 minute SPECT using continuous step and shoot technique.

CT: Factory set Low Dose for attenuation correction. Pediatric reduce mAs and kVp both to value of 80.

IMAGING SUMMARY: 10 minutes after injection: SPECT-CT of the head (20 minute scan)

PROCESSING: SPECT Image sets are reconstructed in transverse, coronal , and sagittal planes.

FILMING

THE STUDY: SPECT images – standard imaging. Send transverse (AC and Non-AC) and screen captures to PACS.

POST EXAM: No special instruction or patient care is required following this procedure.

TOMOGRAPHIC:

ACQUISTION
CAMERA	Acquisition type	TOMOGRAPHIC
	Collimator	LEUHR or LEHR
	Detectors	DETECTORS 1 AND 2
	Isotope	Tc99m OR 201-Tl
	Peak	140 KeV OR 81 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	30 SEC/STEP
	Number of images	30 STEPS
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

WHOLEBODY IMAGING:

ACQUISTION
CAMERA	Acquisition type	WHOLEBODY
	Collimator	LEHR OR LEUHR
	Detectors	DetectorS 1 AND 2
	Isotope	99M-TC OR 201-Tl
	Peak	140 KeV OR 81KeV
	Energy Window	20%
	Matrix	256X1024
	Acquisition time	20 CM/MIN
	Number of images	1
	Magnification	NONE
	Patient Orientation	Feet First Supine

STUDY NAME: Brain ECD with Diamox

ORDER NO. Brain Perfusion/Function SPECT(IMG13008)(Performable)

INDICATION: Patients with cerebral vascular accident, TIA, sickle cell diseae, or carotid artery disease to determine the regions of the brain that are a risk of infarct due to compromised blood flow. Determination of cerebrovascular reserve.

The patient must be scheduled for or already have had a baseline ECD brain scan, and whole body image

PATIENT

PREP: Thirty minutes prior to injection of ^99mTc ECD give an oral dose of 400mg of either Potassium perchlorate or Sodium perchlorate

RADIOPHARM

AND DOSE: ^99mTc ECD.

Physician prescribed dose or dose from the standard Nuclear Medicine dose sheet.

Diamox - 1 gram of Diamox is given IV slowly over 3 minutes, ^99mTc ECD is injected IV at 20 minutes after the beginning of the Diamox infusion.

INSTRUMENT: SPECT-CT

No sooner than 10 minutes after injection, and no later than 3 hours.

Protocol summary: Standard high resolution SPECT-CT

Whole body: post void 10 minute wholebody scan immediately after the SPECT-CT acquisition. This is used to obtain a total body count for calculation of percent uptake in the brain.

PROCEDURE

AND SET-UP: The patient, when possible, is prepped with Sodium perchlorate 30 minutes prior to the procedure.

^99mTc -ECD – SPECT-CT images are acquired at 10 minutes- 3 hours post injection, the preference is 10- minutes post injection (20 minute SPECT using continuous step and shoot technique) followed immediately by a 10-minute acquisition whole body survey on whole body dual headed camera.

CT: Factory set Low Dose for attenuation correction. Pediatric reduce mAs and kVp both to value of 80.

IMAGING SUMMARY: 10 minutes after injection: 20 minute SPECT-CT of the head, immediately followed by 10 minute whole body scan on dual headed system.

PROCESSING: SPECT Image sets are reconstructed in transverse, coronal, and sagittal planes. Transverse (AC and NON-AC) and screen captures sent to PACS.

POST EXAM: No special instruction or patient care is required following this procedure.

STUDY NAME: Brain scan (^99mTc-pertechnetate)

ORDER NO: Brain Death Scan(IMG13007)(Performable)

INDICATION: Brain death.

PATIENT

PREP: Must use verified “good venous line”.

RADIOPHARM

AND DOSE: Adult ^99mTc DTPA. Physician prescribed dose or the dose from the standard Nuclear Medicine dose sheet.

INSTRUMENT: NON-SPECT (Classically now performed portably with a Digirad Ergos Camera)

Gamma camera with leap collimation, peaked on ^99mTc 140 keV with 20% window.

Computer set to acquire dynamic with post-static images;

Dynamic 64x64x8 matrix 90 seconds at 1 sec/frame;

Static images in 256x256x16 for 3-5 minutes.

PROCEDURE

AND SET-UP: Flow study - camera and computer are set to obtain serial images for a minimum of 90 seconds. If possible, use tourniquet over upper calvarium to limit external circulation. Position the patient for an anterior study. The injection technique is a fast bolus injection with a 15-20 cc rapid flush behind the dose. Start camera and computer, then administer the dose: this assures that the initial flow will be captured.

Static images for BRAIN DEATH are obtained at 2 post injection in an anterior view. Static anterior image of the kidneys is also obtained to assess the kidneys for possible harvest if the patient is a donor.

^99mTc –ECD SPECT-CT images (alternative technique) are acquired at 5-60 minutes post injection, the preference is 10 minutes post injection. (20 minute SPECT using continuous step and shoot technique)

CT: Factory set Low Dose for attenuation correction. Pediatric reduce mAs and kVp both to value of 80.

IMAGING SUMMARY: Flow study: 2 sec/frame for 30 frames (anterior), followed by immediate 3 minute anterior spot image and then anterior spot image of the kidneys.

PROCESSING/FILMING

CASE: The flow study is compressed to 6-second frames and screen captured to PACS.

SPECT Image sets (if performed) are reconstructed in transverse, coronal, and sagittal planes. Transverse (AC and Non-AC) sent to PACS

POST EXAM: No special instruction or patient care is required following this procedure.

DYNAMIC FLOW:

ACQUISTION
CAMERA	Acquisition type	Dynamic
	Collimator	LEUHR or LEHR
	Detectors	Detector 1
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	2 sec/frame
	Number of images	30 frames
	Magnification	0-2.0 (Pending patient size)
	Patient Orientation	Feet First Supine

STATIC ACQUISITION

ACQUISTION
CAMERA	Acquisition type	STATIC
	Collimator	LEUHR or LEHR
	Detectors	Detector 1
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	256X256
	Acquisition time	60 seconds
	Number of images	2 (ANT HEAD, ANT ABDOMEN)
	Magnification	0-2.0 (Pending patient size)
	Patient Orientation	Feet First Supine

STUDY NAME: Cisternogram - CSF Scan (non-leak)

ORDER NO: Cisternogram(IMG13010)(Performable)

INDICATION: Suspected NPH, types of hydrocephalus. (rarely performed; must be approved by Nuclear Medicine physician)

PATIENT

PREP: Consent signed for lumbar puncture.

RADIOPHARM

AND DOSE: ¹¹¹INDIUM - DTPA.

Physician prescribed dose or the dose from the standard Nuclear Medicine dose sheet.

INSTRUMENT

AND SET-UP: SPECT-CT Camera fitted with medium energy collimator is peak for 247 and 172 keV photo peaks (247 primary peak) with a 20 percent window.

Lumbar puncture performed by Neuroradiology in Fluoroscopy suite.

PROCEDURE: Lumbar puncture in neuroradiology: The radiologist will perform the lumbar puncture and inject the ¹¹¹In- DTPA and usually follow with a flush of bacteriostatic free saline. The technologist will assist the radiologist in the lumbar puncture if needed. Samples of CSF may be obtained, they should be sent to the lab with the appropriate lab form for analysis.

Following the lumbar puncture, an image of the injection site is obtained to determine the location of the tracer within the spinal column. If possible the patient should remain supine to improve circulation of the tracer and CSFFor non-leak CSF studies, The patient should return at 1, 4, and 24 hours post injection for images of the tracer, with option of 48 and 72 hours scans. Spot images at 1 and 4 hours, with SPECT-CT at 24, 48, and 72 hours, at the monitoring radiologist’s discretion.

SPECT-CT imaging: Can be utilized as the discretion of the supervising radiologist. Medium energy collimation, peaked over 173 keV and 247 keV. 20 minute SPECT using continuous step and shoot acquisition.

CT: Factory set Low Dose for attenuation correction. Pediatric reduce mAs and kVp both to value of 80.

Images should be checked by the radiologist prior to patient departure from the department.

IMAGING SUMMARY: 3 minute spot after initial injection to insure adequate placement.

3 minute spot at 1 hour to insure normal passage to the basal cisterns.

3 minute spots (anterior, posterior, both laterals) at 4 hours to confirm movement

SPECT-CT at 24, 48, and 72 hours (at the monitoring radiologist’s discretion)

PROCESSING/FILMING

CASE: Planar imaging sent as screen capture to PACS. SPECT Image sets are reconstructed in transverse, coronal, and sagittal planes. Transverse (AC and Non-AC) reconstructions and screen captures sent to PACS

POST EXAM: No special instruction or patient care is required following this procedure.

STATIC ACQUISITION

ACQUISTION
CAMERA	Acquisition type	STATIC
	Collimator	MEGP
	Detectors	Detector 1
	Isotope	111-IN
	Peak	174 & 247
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	180
	Number of images	1
	Magnification	0-2.0 (Depending on patient size)
	Patient Orientation	Feet First Supine

TOMOGRAPHIC:

ACQUISTION
CAMERA	Acquisition type	TOMOGRAPHIC
	Collimator	MEGP
	Detectors	DETECTORS 1 AND 2
	Isotope	111-IN
	Peak	174 & 247 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	30 SEC/STEP
	Number of images	30 STEPS
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

STUDY NAME: Cisternogram - CSF Scan with leak

ORDER NO. : Cisternogram CSF Leak(IMG13009)(Performable)

INDICATION: CSF leaks.

PATIENT

PREP: Consent signed for lumbar puncture; contact ENT clinic to make them aware the patient will need placement of pleglettes for a CSF leak exam..

RADIOPHARM

AND DOSE: ¹¹¹INDIUM - DTPA, alternately ^99mTc DTPA.

Physician prescribed dose or the dose from the standard Nuclear Medicine dose sheet.

INSTRUMENT

AND SET-UP: Gamma camera and computer for enhancement of images.

A well counter or other means of assaying pleglettes is required.

Camera with medium energy collimation, peak on 247 and 173 keV photo peaks (247 primary peak); 20 percent window.

Computer set to acquire static images in a high resolution matrix, 256x256x8 for 5-10 minutes or rollover.

Lumbar puncture performed by Neuroradiology in fluoroscopy.

For CSF leak study: See attached protocol for preparation of pleglettes, sampling, analysis and calculations

PROCEDURE: NO FRIDAYS

Explain the complete procedure to the patient and obtain compliance.

The radiologist must obtain informed consent for the lumbar puncture.

The patient should be gowned for the lumbar puncture. LP performed by neuroradiology in fluoroscopy. The radiologist will perform the lumbar puncture and inject the ¹¹¹In DTPA and usually follow with a 2.0 cc flush of 10% dextrose (if normal saline is used for flushing it must be bacteriostatic free). The technologist will assist the radiologist in the lumbar puncture, if needed. Samples of CSF may be obtained, they should be sent to the lab with the appropriate lab form for analysis.

Following the lumbar puncture an image of the injection site is obtained to determine the location of the tracer within the spinal column. If possible the patient should remain supine to improve circulation of the tracer and CSF. Once the tracer is circulated to the base of the brain, the patient is sent to ENT clinic for placement of pleglettes. A blood sample is drawn at the time of pleglette placement. The patient should then return to Nuclear Medicine and be instructed to assume a position that induces leaking. The patient is imaged with the pleglettes in place at 2-4 hours after they are installation.

SPECT-CT imaging is performed on patients with leaks, typically at the 4 hour point, just after removal of the pleglettes.

Patient can be placed in the head holder for this scan. Medium energy collimation, peaked over 173 keV and 247 keV

CT: Factory set Low Dose for attenuation correction. Pediatric reduce mAs and kVp both to value of 80.

Pleglettes are removed just before SPECT-CT. A second blood sample is taken at the time of pleglette removal. Pleglettes are returned to the corresponding weighed counting tube for analysis.

Images should be checked by the radiologist prior to patient departure from the department.

IMAGING SUMMARY: 3 minute spot after initial injection to insure adequate placement.

3 minute spot at 1 hour to insure normal passage to the basal cisterns.

SPECT-CT at 4-6 hours (just after pledgett removal)

PROCESSING/FILMING

POST EXAM: No special instruction or patient care is required following this procedure.

STATIC ACQUISITION

ACQUISTION
CAMERA	Acquisition type	STATIC
	Collimator	MEGP OR LEUHR/LEHR
	Detectors	Detector 1
	Isotope	11-IN OR TC99m
	Peak	174 & 247 OR 140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	180
	Number of images	1
	Magnification	0-2.0 (Depending on patient size)
	Patient Orientation	Feet First Supine

TOMOGRAPHIC:

ACQUISTION
CAMERA	Acquisition type	TOMOGRAPHIC
	Collimator	MEGP OR LEUHR/LEHR
	Detectors	DETECTORS 1 AND 2
	Isotope	111-IN OR TC99m
	Peak	174 & 247 KeV OR 140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	30 SEC/STEP
	Number of images	30 STEPS
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

CISTERNOGRAM WITH PLEDGETS

NO FRIDAYS. This study is performed on patients who are suspect for CSF leaks into the region of the nasal sinuses (or into the ear canal). This may occur from trauma, after surgery, or spontaneously, for no clear antecedent reason. Since the ¹¹¹In DTPA will diffuse out of the CSF compartment, small amounts will appear in the secretions of normal people. The object of this study is to compare the counts of tracer in nasal secretions with those of plasma. If the ratio of counts per fluid gram in the nasal secretions exceeds that of plasma by 1.5, a CSF leak is indicated and further invasive procedures are necessary.

Equipment Required:

1. Eight surgical patties (pledget)

2. Counting tubes with caps

3. Green top vaccutainer tubes

4. Adhesive labels in the following colors: blue, yellow, red, brown, and black

5. Cisternogram/pledget worksheet

6. Analytical balance

7. Automated multi-sample counter

Procedure:

1. Prior to patient arrival, label both counting tubes and their caps with numbers 1 through 8. (Use a permanent marker).

2. Attach colored labels to the end of the strings on the surgical patties and number as follows:

1-blue, upper right

2 -yellow, mid right

3-red, lower right

4-brown, right buccal

5-blue, upper left

6-yellow, mid left

7- red, lower left

8-black, left buccal

3. Insert patties into the correspondingly numbered tubes. Leave the labels hanging outside of the tube. Cap the tubes

4. Weigh all tubes (with labels) and record as "pre-weight" on worksheet.

5. Two hours post injection of the ¹¹¹In DTPA, the pledgets will be inserted into the patient by ENT staff and a blood sample must be drawn (green top tube). After the pledgets are inserted, check to make sure that they are all in the correct locations per worksheet.

6. Four hours post insertion, the pledgets will be removed by ENT staff. Pledgets must be returned to their appropriate original tubes. Put the labels inside the tubes at this point before capping. Draw a post removal blood sample (green top tube).

7. Re-weigh all tubes and record "post" weights on worksheet.

8. Ensure that all pledges are located on the bottom of the counting tubes.

9. Centrifuge the blood samples and pipette duplicate 1ml samples of each into appropriately labeled counting tubes.

Preparation for Counting:

1. Using the automated multi-sample well counter set for dual window ¹¹¹Indium counting 174 keV, 247 keV.

2. Count a "pre insertion" plasma sample for 10 minutes. If the counts are less than 80K, count the remaining tubes for 10 minutes each. Be sure to include tubes for machine background. If the pre-insertion plasma counts are greater than 80K, adjust the counting time appropriately to obtain counts less than 80K. Count all tubes for this amount of time.

3. Record gross counts on the worksheet.

Calculation:

1. Calculate net weights (post - pre weights).

2. Calculate net corrected counts (gross counts - machine background).

3. Divide the corrected counts by the corresponding net weights and record (counts per ml).

4. Average the net plasma counts from the four plasma samples.

5. Divide each pledget counts/ml by the average plasma counts to obtain a pledget to plasma ratio.

6. Notify a Nuclear Medicine physician of any ratio greater than 1.5.

STUDY NAME: Cystogram, Nuclear - Voiding

ORDER NO: Radionuclide Cystogram(IMG13048)(Performable)

PURPOSE: Follow-up for uretheral reflux on patients with previously documented reflux on a contrast VCUG.

PATIENT

PREP: None.

RADIOPHARM

AND DOSE: ^99mTc sulfur colloid instilled with sterile water to bladder capacity.

Physician prescribed dose or the dose from the standard Nuclear Medicine dose sheet.

INSTRUMENT

AND SETTING: Single headed camera (Digirad or Siemans) peaked for ^99mTc 140 keV with 20% window. Computer set to acquire dynamic frames for 900 sec at 10 sec/frame in a 64x64 matrix with post static images for 60 second in a 128x16 matrix.

PROCEDURE: The materials required for this exam are: universal catheter tray without catheter (obtain from central sterile supply), catheters of various sizes (8-12fr), IV administration set, one liter sterile water with IV adopter cap, sterile gloves, fracture pan, and several chux (plastic backed absorbent pads).

The patient is gowned for this exam.

The table should be prepared by placing several chux on top of the other where the patient’s pelvis will be positioned. The pad can then be pulled from under the patient as they are contaminated.

Radiology Nurses will insert a urinary catheter into the patient's bladder under aseptic technique and obtain a clean catch urine specimen. The catheter should be large enough to keep the patient from urinating round the catheter.

Connect the sterile water IV to the catheter and begin instilling sterile water into the bladder. The initial rate of instillation can be rather quick. Inject the ^99mTc sulfur colloid into the IV port at a slow rate to allow dilution of the trace in the sterile water.

Begin imaging as the bladder fills. The bladder and later bedpans or urinals containing high-count activity at time of voiding should remain barely visible at the edge of the field of view. This necessitates moving the camera, patient, or table as the study progresses, this is extremely important for obtaining diagnostic images of low count activity reflux up the ureters.

When the patient begins to complain about pressure from a full bladder, the infusion should be slowed or stopped for a moment to let the patient relax and become accustomed to the pressure and then begin infusing again at a slow rate. Filling should continue as long as the patient will tolerate or until they start to urinate around the catheter or the IV will no longer infuse.

At any of these points the catheter is pulled; the pan placed under the patient, who is then instructed to urinate. After the patient has emptied their bladder as completely as possible the dynamic imaging is stopped.

The volume infused and the time (frame number of the dynamic is recorded) voiding began.

The pan is removed along with the top chux and a static image is obtained over the bladder and kidneys. The pan can be emptied into the toilet.

If residual activity remains in the bladder the patient is asked to go the restroom and attempt to urinate. Another static image is obtained following this attempt to void.

The examination is complete and the patient can dress and leave.

IMAGING SUMMARY: Dynamic series at 10 sec/frame during filling and voiding.

Delayed posterior 3 minute spots of kidneys and bladder after voiding.

Further delayed imaging per monitoring radiologist.

PROCESSING: The dynamic frames are compressed to 60-second frames.

FILMING: If reflux is not observed prior to voiding then the frames from the start of voiding to the last frame are transferred to PACS. If reflux occurs during filling then the frames from the first reflux to the last frame are transferred to PACS. Transfer the static images of the bladder and kidneys to PACS and annotate to describe when they were taken, i.e. immediate post void, post ambulating and urination.

Annotate images with volume infused, volume voided and frame voiding began.

POST EXAM: No precautions or special instructions are required following this exam.

DYNAMIC:

ACQUISTION
CAMERA	Acquisition type	Dynamic
	Collimator	LEUHR or LEHR
	Detectors	Detector 2
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	10 sec/frame
	Number of images	60 frames (FILL AND EMPTY BLADDER)
	Magnification	0-2.0 (Depending on patient size)
	Patient Orientation	Feet First Supine

STATIC ACQUISITION

ACQUISTION
CAMERA	Acquisition type	STATIC
	Collimator	LEUHR or LEHR
	Detectors	Detector 2
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	180 seconds
	Number of images	1
	Magnification	0-2.0 (Depending on patient size)
	Patient Orientation	Feet First Supine

STUDY NAME: Esophageal scintigraphy

ORDER NO: Esophaeal Motility(IMG13074)(Performable)

INDICATIONS: Esophageal dysmotility, achalasia, dysphagia, connective tissue diseases.

PATIENT

PREP: NPO for a minimum of one hour prior to the exam, no medications that affect the motility of the esophagus, i.e. Atropine.

RADIOPHARM

AND DOSE: ^99mTc sulfur colloid, total dose divided into 5 doses of 15 cc in plastic or glass test tubes with stopper tops.

Physician prescribed dose or the dose from the standard Nuclear Medicine dose sheet.

INSTRUMENT

AND SET-UP: Large field of view gamma camera peaked on ^99mTc 140 kev with 20% window and LEAP / GP collimation.

Use the Acquisition protocol ' Esophageal', the computer is set to acquire dynamic sets at 0.5 sec/frame for 60 second in a 64X8 matrix.

PROCEDURE: Routine swallow for esophageal motility (see achalasia for other protocol).

Five doses are prepared for each patient.

Patient instruction in the procedure will help in compliance. Each patients is studied in a supine and upright position; two - three acquisitions in the supine position and two in the upright position. It is extremely important that the patient not swallow until you give the command. A total of two swallows per acquisition are required; swallow one at 5 seconds after the computer acquisition is initiated and swallow two at 30 seconds after the first swallow. If the patient has a diagnosis of vomiting or reflux it is necessary to protect the camera and facility from contamination by use of absorbent paper.

Begin with the supine swallows. A marker is placed on the right mid clavicle as a reference point for the proximal esophagus. The patient is instructed to empty one of the 15cc 200 uCi doses into his mouth and not swallow until you give the command. The patient lie supine with his head turned to the left. Position the patient under the camera so that the marker is just off center and in the top quarter of the camera FOV. Start the computer, wait five seconds and have the patient swallow once and then again 30 seconds later. Repeat the supine acquisition. If the patient swallows at any other time the swallow must be repeated (at least two good swallows must be obtained at each position). After two good supine swallows the patient is instructed to stand upright in front of the camera, again placing the dose in his mouth but not swallowing until you command. Start the computer, at 5 seconds tell the patient to swallow once and then swallow again 30 second later. Repeat the upright swallow until two good swallows are obtained.

Patients with a diagnosis of achalasia OR who have abnormal supine and upright swallows, in which the tracer dose remains in the esophagus after swallowing twice, have a 7-minute upright acquisition obtained as follows.

The patient is placed upright in front of the camera with a marker on the right mid clavicle. Set the camera to acquire a dynamic for 720 second at .05 sec/frame in a 64x8 matrix. Given the patient a 200-500 uCi dose (in 250 cc) and instruct him to empty it into his mouth but not to swallow until you command. Position the patient upright in front of the camera for an anterior view. Start the computer, at 5 second instruct the patient to swallow and swallow again at 30 second later. The patient should try not to swallow again for the remaining acquisition time and should remain in the same position for the duration of the acquisition. At the end of the six minutes acquisition the radiologist should review the swallow to determine if a supine swallow is needed. If a supine swallow in required it is obtained as a routine swallow for one minute.

IMAGING SUMMARY: Perform (2) supine acquisitions, each 60 secs at 0.5 sec /frame

Perform (2) upright acquisitions, each 60 secs at 0.5 sec/frame

If achalasia (suspected). Add additional 6 minute upright acquisition.

PROCESSING: Each swallow is analyzed with 4 ROIs The order for drawing the ROI's is 1-total esophagus, 2-upper, 3-middle, 4-distal portions of the thoracic esophagus. Following the creation of the ROI's ; generate two sets of curves; 1- total esophagus (left curve) and 2-upper, mid, and distal curves (right). Send the curves and images (compressed to 2 sec/frame) to PACS

Processing 6 minute swallow

1. Compress the six minutes of 0.5-sec frames to form 1 minute composite images.

2. Create a ROI over the total thoracic esophagus (from the level of the clavicular marker to the distal esophagus … GE junction).

3. Create time activity curve and label.

4. Send curve and Summed images to PACS.

POST EXAM: No precautions or special instructions are necessary following the exam.

DYNAMIC ACQUISITION:

ACQUISTION
CAMERA	Acquisition type	Dynamic
	Collimator	LEUHR or LEHR
	Detectors	Detector 1
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	0.5 sec/frame
	Number of images	120 frames
	Magnification	0-2.0 (Depending on patient size)
	Patient Orientation	UPRIGHT X2 SUPINE X2

DYNAMIC ACQUISITION FOR ACHALASIA:

ACQUISTION
CAMERA	Acquisition type	Dynamic
	Collimator	LEUHR or LEHR
	Detectors	Detector 1
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	0.5 sec/frame
	Number of images	720 frames
	Magnification	0-2.0 (Depending on patient size)
	Patient Orientation	UPRIGHT FOR 6 MINUTES

STUDY NAME: Gastric Emptying (adult): 4 HOUR NATIONAL STANDARD

ORDER NO.: Gastric Emptying Solid 4 Hour (IMG13078) (Performable)

PURPOSE: To access the motility of the stomach.

INDICATIONS: Diabetes, unexplained abdominal pain, Nausea, vomiting, bloating, motility disorders, and evaluation of drug therapy. NOTE: not for inpatients, standard pediatric patients or post-surgery patients.

PATIENT

PREP: NPO for 4-8 hours

RADIOPHARM

AND DOSE: ^99mTc Sulfur Colloid in scrambled egg (national standard meal:3 ounces egg beaters, 2 pieces of toast, strawberry jelly). Meal cut up into sections to estimate percentage ingested.

Physician prescribed dose or the dose from the standard Nuclear Medicine dose sheet.

INSTRUMENT

AND SET-UP: Digirad or other single headed camera with LE collimation, peaked on 140 kev.

PROCEDURE: Instruct the patient to eat as much of the meal as possible (with estimate of ingested volume, then perform 1 minute Anterior and Posterior spot images at times zero, one hour, 2 hours, and 4 hours. Calculation of the geometric mean.

IMAGING SUMMARY: Geometric mean (anterior and posterior 1 minute spot images) at time zero, 1 hour, 2 hours, and 4 hours.

PROCESSING / FILMING:

Calculating of the geometric mean for times, zero, 1 hour, 2 hours, and 4 hours (reporting screen shot template sent to PACS).

Note: % ingested, time to ingest, occurrence or lack of vomiting, serum glucose if available, use of narcotics (drug, time and amount of last dose).

POST EXAM: No special instructions or patient care is necessary following this procedure.

STATIC ACQUISITION:

ACQUISTION
CAMERA	Acquisition type	STATIC
	Collimator	LEUHR or LEHR
	Detectors	Detector 1
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	60 seconds
	Number of images	ANT/POST 0,1,2,4 HR POST INGESTION
	Magnification	0-2.0 (Depending on patient size)
	Patient Orientation	UPRIGHT

STUDY NAME: Gastric Emptying (adult) INPATIENT, Pediatric, or Post-OP

ORDER NO.: Gastric Emptying Solid 90 Minutes (IMG13077)(Performable)

Gastric Liquid (IMG13079)(Performable)

PURPOSE: To access the motility of the stomach.

INDICATIONS: Nausea, vomiting, bloating, s/p Gastric surgery, motility disorders, and evaluation of drug therapy.

PATIENT

PREP: NPO for 4-8 hours

RADIOPHARM

AND DOSE: ^99mTc Sulfur Colloid in scrambled egg/1 piece of toast; other meal may be substituted by the Nuclear Medicine attending. If patient is allergic or can’t tolerate eggs, can be performed with liquid (^99mTc-sulfur colloid in 250 cc of Ensure or Pedisure)

Physician prescribed dose or the dose from the standard Nuclear Medicine dose sheet.

INSTRUMENT

AND SET-UP: Digirad Ergos or other single-headed gamma camera with LE collimator..

Normal gastric anatomy: Imaged supine, 90 images at 1 minute /frame in a 64 X 64 matrix. Camera positioned in 40^o LAO projection. Liquid study can be stopped at 60 minutes vs. 90 minutes for solids.

Lap band/or other banded gastroplasty or Gastric Bypass: Imaged upright, (start camera, and image while eating meal): 60 images at 1 minute/frame in a 64 x 64 matrix.

PROCEDURE: Instruct the patient to eat as much of the meal as possible, then position the patient supine under the camera. The camera is angled to obtain a 40^o LAO image with the stomach positioned in the upper portion of the field of view. Start the acquisition and ask the patient to remain as still as possible.

IMAGING SUMMARY: Non-surgery: 1 minute/frame for 90 minutes, patient supine, camera 40^o LAO

Surgical patient: Start camera for 1 minute/frame for 60 minutes. (image while patient eats the meal). Upright posterior imaging.

Liquid: 1 minute/frame for 60 minutes; patient supine, camera LAO

PROCESSING / FILMING:

Draw ROI around the stomach and create time activity curve. Compress the study into 5 minutes per frame and image the series and the time activity curve as a screen capture. Send screen capture and raw data to PACS.

POST EXAM: No special instructions or patient care is necessary following this procedure.

STUDY NAME: Gastric emptying LIQUID (pediatrics: infant or unable to ingest solids)

ORDER NO: 4060

PURPOSE: To access the motility of the stomach.

INDICATIONS: Reflux, failure to thrive, s/p gastric surgery, motility disorders.

PATIENT

PREP: NPO for 4-8 hours

RADIOPHARM

AND DOSE: ^99mTc-Sulfur Colloid in formula or Pedisure, other meal may be substituted by the Nuclear Medicine attending.

Physician prescribed dose or the dose from the standard Nuclear Medicine dose sheet.

INSTRUMENT

AND SET-UP: Digirad Ergos or other single-headed gamma camera with LE collimator,

peaked on 140 keV. (720) - 10-second images in a 64 X 64 matrix. Feed the infant the same volume of formula or Pedisure that it would consume at a normal feeding. Then the feeding is complete position the infant supine and image in the LAO view. Position the stomach in the central area of the field of view so that reflux up the esophagus can be seen if it occurs.

PROCEDURE: Infants should be placed in a bundle pack to reduce motion as much as possible. The camera is positioned to obtain a 40 degree LAO image of the stomach. The stomach activity should be positioned in the upper portion of the field of view. Start the acquisition after the patient is positioned and ask the patient to remain as still as possible.

IMAGING SUMMARY: 720 frames at 10 sec frame in the LAO projection.

PROCESSING: Sum images into 5 minutes / frame for “screen shot” of emptying. Draw ROI around stomach for creation of time activity curve. Send “raw data” to PACS for review for GE reflux.

The radiologist will play the first 60 minutes of data in cine mode to access for reflux.

POST EXAM: No special instructions or patient care is necessary following this procedure.

DYNAMIC SOLID EGG ACQUISITION:

ACQUISTION
CAMERA	Acquisition type	Dynamic
	Collimator	LEUHR or LEHR
	Detectors	Detector 1
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	60 sec/frame
	Number of images	90 frames LAO
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

DYNAMIC LIQUID ACQUISITION:

ACQUISTION
CAMERA	Acquisition type	Dynamic
	Collimator	LEUHR or LEHR
	Detectors	Detector 1
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	10 sec/frame
	Number of images	360 frames ANTERIOR
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

STUDY NAME: Gastrointestinal bleed; (GI blood loss)

ORDER NO.: GI Bleed Blood Loss (IMG13016)(Performable)

INDICATIONS: Bright red blood per rectum, with plan for “intervention”.

RADIOPHARM

AND DOSE: Ultratag ^99mTc RBC tagging kit, analogous red blood cells, and Glucagon when requested by the Nuclear Medicine physician.

Physician prescribed dose or the dose from the standard Nuclear Medicine dose sheet.

PATIENT

PREP: No patient preparation for this exam.

INSTRUMENT

AND SET-UP: Single headed camera (Digirad or others) with LEHR collimation, peaked on ^99mTc with a 20% window. 120 frames at 1 minute/frame in 64 x 64 matrix.

PROCEDURE: Tag the patient’s red blood cells as described in the “Ultratag RBC” kit tagging protocol. Position the patient under the camera so that the upper abdomen down to the bladder is in the field of view. Inject the labeled red blood cells and start the camera immediately. If you must reposition the patient do it as early in the exam as possible and then instruct the patient not to move for the remainder of the exam. The exam routinely is scheduled for two hours of imaging. If you see a bleed early in the exam, contact the monitoring radiologist to view the exam and determine if the procedure should continue. If at the end of two hours there is no evidence of bleeding the patient is discharged from the department.

The Nuclear Medicine physician may request additional images if he deems necessary. Additional images are done only at the request of the Nuclear Medicine physician, no additional images are performed without this authorization.

IMAGING SUMMARY: 120 frames at 1 minute/ frame in the anterior projection.

PROCESSING: Compress the image files to 5 minutes / frame and obtain a “screen shot” of the 5 minute/frame series. Send screen shot and the entire “raw data” to PACS for cine review by the interpreting radiologist.

POST EXAM: No special instructions or patient care is necessary following this procedure.

DYNAMIC ACQUISITION:

ACQUISTION
CAMERA	Acquisition type	Dynamic
	Collimator	LEUHR or LEHR
	Detectors	Detector 1
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	60 sec/frame
	Number of images	120 frames ANTERIOR
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

PROCEDURE: Gallium

ORDER NO. Abscess Localization Whole Body 24hr (IMG13062)(Performable)

Abscess Localization SPECT (IMG13061)(Performable) Per physician request.

INDICATIONS: All types of infection, soft tissue tumors and abscess, fever of unknown origin:

PATIENT

PREP: Typically, no prep: If requested by the radiologist; high fiber diet if possible, laxatives night of injection and following night if no contraindications, enema morning of exam.

RADIOPHARM

AND DOSE: ⁶⁷Gallium citrate administered IV.

Physician prescribed dose or the dose from the standard Nuclear Medicine dose sheet.

INSTRUMENT

AND SET-UP: Dual headed whole body camera, preset ⁶⁷Ga energy windows (93 keV, 184 keV, 296 keV). Medium energy collimators.

PROCEDURE:

Hyper-acute infection: can be imaged a 2 -4 hours at the monitoring radiologist’s discretion. 24 hour repeat 30 minute WB scan.

Standard infection work-ups: (FUO, osteomyelitis): 24 hour whole body scan for 30 minutes. Further imaging: later WB scans or SPECT-CT at the discretion of the monitoring radiologist.

Tumor imaging: rarely performed anymore because of PET-CT availability: 72 hour whole body scan (30 minute scan), with SPECT-CT at the discretion of the monitoring radiologist.

Lupus Nephritis imaging (or other renal infection/inflammation): 72 hour SPECT-CT

Lung Infection Imaging / TB/ Sarcoidosis: 72 hour SPECT-CT

Temporal Bone Osteomyelitis and Sternal Osteomyelitis: Must include 24 hours SPECT-CT

SPECT-CT: Medium energy collimators, standard “continuous step and shoot” technique for 20 minutes, peaked on 93 keV, 184 keV, 296 keV

CT: Factory set Low Dose for attenuation correction. Pediatric reduce mAs and kVp both to value of 80.

IMAGING SUMMARY:

Hyper-acute infection: 2 – 4 hours spot image, then 24 hour Whole body (30 minutes)

Standard Infection: 24 hour whole body scan (30 minutes); SPECT-CT and further imaging as recommended by monitoring Radiologist

Tumor Imaging: 72 hour whole body scan (30 minutes); SPECT-CT and further imaging as recommended by monitoring Radiologist

Lupus Nephritis/other renal infection-inflammation: 72 hour SPECT-CT

Lung infection Imaging/ TB/Sarcoidosis: 72 hour SPECT-CT; whole body at monitoring radiologist discretion.

Temporal Bond Osteomyelitis and Sternal Osteomyelitis: 24 hour whole body (30 minutes) and 24 hour SPECT-CT

PROCESSING: Screen capture of whole body images and spots sent to PACS.

SPECT: The SPECT images are reconstructed in a 128x128 matrix and saved in all planes. A reprojection image is reconstructed using standard MIPS and sent to PACS. Transverse (AC and NON-AC) reconstructions sent to PACS

POST EXAM: Imaging will continue until terminated by the radiologist. The patient is instructed to return each day at a time determined by the schedule. Special diet instructions may be recommended by the radiologist; otherwise the patient is on a normal diet.

WHOLEBODY IMAGING:

ACQUISTION
CAMERA	Acquisition type	WHOLEBODY
	Collimator	MEGP
	Detectors	Detectors 1 AND 2
	Isotope	GA-67
	Peak	90, 181,300 KeV
	Energy Window	20%
	Matrix	256X1024
	Acquisition time	10 CM/MIN
	Number of images	24/48/72HR POST INJ
	Magnification	NONE
	Patient Orientation	Feet First Supine

TOMOGRAPHIC:

ACQUISTION
CAMERA	Acquisition type	TOMOGRAPHIC
	Collimator	MEGP
	Detectors	DETECTORS 1 AND 2
	Isotope	GA-67
	Peak	90, 181,300 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	30 SEC/STEP
	Number of images	30 STEPS
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

PROCEDURE: Tumor imaging, ^99mTc Sestimibi or ²⁰¹Thallium chloride;

ORDER NO. Tumor Localization (IMG13042)(Performable)

Tumor Localization SPECT (IMG13105)(Performable) Per physician request.

INDICATIONS: Can be used for soft-tissue tumors, brown tumors, thyroid cancer, Kaposi sarcoma, other rare tumors (rarely done in the era of PET-CT with FDG)>

PATIENT

PREP: None

RADIOPHARM

AND DOSE: ^99mTc Sestimibi or ²⁰¹Thallium chloride administered intravenously.

Physician prescribed dose or the dose from the standard Nuclear Medicine dose sheet.

INSTRUMENT

AND SET-UP: Whole body scan using dual headed gamma camera equipped with LEHR collimators, peaked on 140 keV for ^99mTc or 80 keV for ²⁰¹Tl

PROCEDURE: Inject radiopharmaceutical IV. Imaging at 10- 15 minutes after injection, 30 minute whole body scan.

IMAGING SUMMARY:

30 minute Whole body scan at 15 minutes after injection. SPECT-CT at the discretion of monitoring radiologist.

PROCESSING: Wholebody and spot images require no processing. Screen capture sent to

& FILMING PACS.

SPECT-CT: At the discretion of the monitoring radiologist. The SPECT-CT images are reconstructed in a 128x128 matrix and saved in all planes. A reprojection image is reconstructed using standard MIPS. Screen captures sent to PACS. Transverse (AC and NON-AC) sent to PACS

CT: Factory set Low Dose for attenuation correction. Pediatric reduce mAs and kVp both to value of 80.

POST EXAM: No special instructions or patient care is necessary following this procedure.

TOMOGRAPHIC:

ACQUISTION
CAMERA	Acquisition type	TOMOGRAPHIC
	Collimator	LEUHR or LEHR
	Detectors	DETECTORS 1 AND 2
	Isotope	Tc99m OR 201-Tl
	Peak	140 KeV OR 81 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	30 SEC/STEP
	Number of images	30 STEPS
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

WHOLEBODY IMAGING:

ACQUISTION
CAMERA	Acquisition type	WHOLEBODY
	Collimator	LEHR OR LEUHR
	Detectors	DetectorS 1 AND 2
	Isotope	99M-TC OR 201-Tl
	Peak	140 KeV OR 81KeV
	Energy Window	20%
	Matrix	256X1024
	Acquisition time	20 CM/MIN
	Number of images	1
	Magnification	NONE
	Patient Orientation	Feet First Supine

PROCEDURE: ¹¹¹Indium White Blood Cell imaging (or ^99mTc-HMPAO WBCs);

ORDER NO. Labeled Luecocytes (IMG13063)(Performable)

INDICATIONS: All types of infectious processes, particularly acute infections. Never use for suspected spinal infections.

PATIENT

PREP: Patient’s white blood cell count must be greater than 3000/cc.

RADIOPHARM

AND DOSE: ¹¹¹Indium-oxine labeled WBC's, injected intravenously post labeling. Same procedure for ^99mTc-HMPAO WBCs. Choice of label at the discretion of monitoring Radiologist.

Physician prescribed dose or the dose from the standard Nuclear Medicine dose sheet.

INSTRUMENT

AND SET-UP: Dual-headed gamma camera: For ¹¹¹In: medium energy collimators, peaked on 173 keV and 247 keV. For ^99mTc-HMPAO: LEHR collimators peaked on 140 keV.

PROCEDURE: Inject label WBCs through a large bore IV over 90 seconds. Imaging of labeled WBC's is performed at 4 and 24 hours post administration of the labeled cells. 30 minute Whole body scan at each time point. SPECT-CT as needed, at the discretion of monitoring radiologist. 20 minute SPECT using continuous step and shoot technique.

CT: Factory set Low Dose for attenuation correction. Pediatric reduce mAs and kVp both to value of 80.

IMAGING SUMMARY: Whole body (30 minute) scans at 4 and 24 hours. SPECT-CT as needed by monitoring radiologist.

PROCESSING: Whole body and spot images require no processing. Send screen capture to

& FILMING: PACS

SPECT: The SPECT images are reconstructed in a 128x128 matrix and saved in all planes. A reprojection image is reconstructed using MIPS technique. Screen captures sent to PACS. Send transverse reconstruction (AC and NON-AC) to PACS.

POST EXAM: No special instructions or patient care is necessary following this procedure.

WHOLEBODY IMAGING:

ACQUISTION
CAMERA	Acquisition type	WHOLEBODY
	Collimator	MEGP
	Detectors	Detectors 1 AND 2
	Isotope	111-IN
	Peak	174 & 247 KeV
	Energy Window	20%
	Matrix	256X1024
	Acquisition time	15 CM/MIN DAY 1 10 CM/MIN DAY 2
	Number of images	4HR AND 24HR POST INJ
	Magnification	NONE
	Patient Orientation	Feet First Supine

STATIC ACQUISITION:

ACQUISTION
CAMERA	Acquisition type	STATIC
	Collimator	MEGP
	Detectors	Detectors 1 AND 2
	Isotope	111-IN
	Peak	174 & 247 KeV
	Energy Window	20%
	Matrix	256X256
	Acquisition time	300 seconds
	Number of images	ANT, POST, LATS
	Magnification	0-2.0 (or more based on patient size)
	Patient Orientation	Feet First Supine

TOMOGRAPHIC:

ACQUISTION
CAMERA	Acquisition type	TOMOGRAPHIC
	Collimator	MEGP
	Detectors	DETECTORS 1 AND 2
	Isotope	111-IN
	Peak	174 & 247 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	30 SEC/STEP
	Number of images	30 STEPS
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

STUDY NAME: Liver SPECT - Sulfur Colloid

ORDER NO.: Liver SPECT (IMG13083)(Performable)

See Liver -MAA and Liver Hemangioma for other coding.

INDICATION: Hepatocellular disease, increased liver enzymes, enlargement of liver and/or spleen, and primary or metastatic cancers of the liver. Characterization of liver masses (FNH, adenoma)

PATIENT

PREP: If patient has had barium study within three days prior to liver scan, a scout film of the abdomen is suggested.

RADIOPHARM

AND DOSE: ^99mTc Sulfur Colloid administered intravenously.

Physician prescribed dose or dose from standard dose sheet.

INSTRUMENT

AND SET-UP: SPECT-CT using LEHR collimation, peaked on 140 keV (standard “continuous step and shoot” technique for 20 minutes).

CT: Factory set Low Dose for attenuation correction. Pediatric reduce mAs and kVp both to value of 80.

PROCEDURE: Imaging begins at 20 minutes post-intravenous administration of ^99mTc labeled colloid.

SPECT CT: SPECT imaging should be performed whenever possible.

Planar

If planar imaging is necessary due to patient’s condition, the following projections should be acquired; anterior, anterior with costal marker, right anterior oblique, rt. lateral, right posterior oblique, posterior, left posterior oblique, left lateral, left anterior oblique.

IMAGING SUMMARY: If at all possible, SPECT-CT of the upper abdomen. (20 minute scan, continuous step and shoot.)

PROCESSING: Reconstruct the ECT data in the transverse, coronal, and sagittal planes.

& FILMING: Screen capture and transverse reconstructions (AC and NON-AC) to PACS

POST EXAM: No special instructions or patient care is necessary following this procedure.

TOMOGRAPHIC:

ACQUISTION
CAMERA	Acquisition type	TOMOGRAPHIC
	Collimator	LEUHR or LEHR
	Detectors	DETECTORS 1 AND 2
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	30 SEC/STEP
	Number of images	30 STEPS
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

STUDY NAME: Liver Hemangioma SPECT

ORDER NO.: IMG13082(Performable)

INDICATION: Differentiation of liver lesions.

PATIENT

PREP: If patient has had barium study within three days prior to liver scan, a scout film of the abdomen is suggested.

RADIOPHARM

AND DOSE: ^99mTc labeled RBC. Label RBC's with Ultra tag™ kit.

Physician prescribed dose or dose from standard dose sheet.

INSTRUMENT

AND SET-UP: SPECT-CT imaging is performed using a LEHR collimator, energy peaked on ^99mTc energy (140 keV). One scan at 0-10 minutes, and 2^nd scan at 50-60 minutes post injection. 10 minute acquisition using continuous step and shoot technique.

CT: Factory set Low Dose for attenuation correction. Pediatric reduce mAs and kVp both to value of 80.

PROCEDURE: Labeling of red blood cells is by Ultratag™ kit. Following the labeling of the patients RBC's, the patient is positioned on the camera so the region of the liver is in the field of view. The patient’s position is checked by placing a point source 2-3 inches above the xiphoid to mark the top of the liver field of view. Imaging is started immediately post injection of the labeled RBC's. Imaging is repeated 50-60 minutes post injection.

IMAGING SUMMARY:

SPECT-CT (10 minute acquisition using continuous step and shoot technique), performed at time zero, with 2^nd SPECT-CT performed starting at 50 minutes after injection, same technique.

Processing: SPECT

& FILMIng

Reconstruct ALL ECT data sets (2 sets) in the transverse, coronal, and sagittal planes. Reprojection using MIPS. Send transverse reconstructions (AC and Non-AC) to PACS with screen captures.

POST EXAM: No special instructions or patient care is necessary following this procedure.

TOMOGRAPHIC PHASE ONE:

ACQUISTION
CAMERA	Acquisition type	TOMOGRAPHIC
	Collimator	LEUHR or LEHR
	Detectors	DETECTORS 1 AND 2
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	30 SEC/STEP
	Number of images	30 STEPS
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

TOMOGRAPHIC PHASE TWO:

ACQUISTION
CAMERA	Acquisition type	TOMOGRAPHIC
	Collimator	LEUHR or LEHR
	Detectors	DETECTORS 1 AND 2
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	30 SEC/STEP
	Number of images	30 STEPS
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

STUDY NAME: Liver Scan – MAA (macro aggregated albumin)

ORDER NO.: Pre-Y90 (IMG13113)(Performable)

INDICATION: Localization of primary and metastatic tumors in the liver.

This procedure is performed in cooperation with the Angiography section of Radiology. It requires the placement of a hepatic artery catheter through which the dose of ^99mTc MAA is injected.

PATIENT

PREP: Patient is prepped for an angiography procedure. No prep for this Nuclear Medicine.

RADIOPHARM

AND DOSE: ^99mTc MAA, physician prescribed dose or dose from standard dose sheet. The dose is administered through an indwelling angiocatheter placed by the interventional radiologist in the Special Procedures section of Radiology.

INSTRUMENT

AND SET-UP: 10 minute Wholebody imgaing followed by SPECT-CT with LEHR collimator, energy peaked on ^99mTc energy, 20 minute acquisition using “continuous step-and shoot technique”.

CT: Factory set Low Dose for attenuation correction. Pediatric reduce mAs and kVp both to value of 80

PROCEDURE: Imaging begins, as soon as possible, after the angiography procedure.

PROCESSING: Reconstruct the ECT data in the transverse, coronal, and sagittal planes.

& FILMING: Reprojection in MIPS format. Send transverse reconstructions (AC and NON-AC) to PACS, along with screen captures.

IMAGING SUMMARY:

10 minute Wholebody imaging followed by SPECT-CT (20 minute acquisition using continuous step and shoot technique), performed as soon as possible after radiopharmaceutical delivery.

POST EXAM: No special instructions or patient care is necessary following this procedure.

WHOLEBODY IMAGING:

ACQUISTION
CAMERA	Acquisition type	WHOLEBODY
	Collimator	LEHR OR LEUHR
	Detectors	Detectors 1 AND 2
	Isotope	99M-TC
	Peak	140 KeV
	Energy Window	20%
	Matrix	256X1024
	Acquisition time	20 CM/MIN
	Number of images	1
	Magnification	NONE
	Patient Orientation	Feet First Supine

TOMOGRAPHIC:

ACQUISTION
CAMERA	Acquisition type	TOMOGRAPHIC
	Collimator	LEUHR or LEHR
	Detectors	DETECTORS 1 AND 2
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	30 SEC/STEP
	Number of images	30 STEPS
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

STUDY NAME: Lung Aerosol; - ^99mTc DTPA

ORDER NO.: Lung Scan Ventilation Aerosol Multi (IMG13087)(Perfomable) for ventilation study only.

Lung Scan Ventilation Perfusion (IMG13086)(Performable) for Ventilation AND Perfusion exam.

INDICATION: Respiratory disease (ventilation), Pulmonary Emboli, pre-lung transplant

IF THE PATIENT IS PREGNANT SEE THE PROTOCOL FOR LUNG SCANNING ON PREGNANT PATIENTS

PATIENT

PREP: Patients cannot be on a ventilator and must be fully cooperative and cognitive. Aerosol ventilation studies are not performed on children without approval of a Nuclear Medicine physician.

RADIOPHARM

AND DOSE: ^99mTc DTPA, in the nebulizer will deliver approximately 1mci of the radiopharmaceutical to the patient. (30 -40 mCi in nebulizer, breathing for about 4 minutes on 10-12 L of Oxygen).

Physician prescribed dose or the dose from the standard Nuclear Medicine dose sheet.

INSTRUMENT

AND SET-UP: Gamma camera, fine particle nebulizer with shield, and wall oxygen. Multi-headed gamma camera.

Peak on 140 keV; use LEAP or LEAP or LEHR collimator. 256 x 256 matrix. Static images are acquire for 200K counts. Posterior image should be obtained for 200K with noting of time, and then all other images obtained for equal time. Imaging should be Anterior, posterior, right anterior oblique, left anterior oblique, right posterior oblique, and left posterior oblique (NO laterals).

PROCEDURE: Assembly of the fine particle nebulizer is described in the insert found in the box with each nebulizer. Follow the insert exactly.

The dose used in the nebulizer is 40 mCi of ^99mTc DTPA in a volume of 3-4 ml. After installation of the dose into the nebulizer , insert the mouthpiece in the patients mouth and observe that the patient is making a tight seal with his lips around the mouth piece. If the patient cannot make a complete seal the exam should not be performed. At any time during the exam the seal is broken between the patient’s lips and the mouth piece, the airflow should be stopped immediately to reduce the loss of aerosol and contamination of room and personnel. Clamp the patient/s nose with the clamp provided with the nebulizer kit. Instruct the patient to take deep and slow breaths

The patient breathes on the nebulizer unit for 3-5 minutes with an oxygen flow rate of 12-15 ml/minute. The oxygen flow is shut off, then the mouthpiece and nose clamp are removed from the patient.

Image of the lungs in following projections; anterior, posterior, left and right posterior oblique. Left and right anterior obliques. Obtain the posterior image for 200K. Record the time for the posterior image acquisition. Then perform all the other images for equal time.

IMAGING SUMMARY:

Obtain the posterior image for 200K. Record the time for the posterior image acquisition. Then perform all the other images for equal time. Anterior, right and left posterior obliques, right and left anterior obliques.

FILMING

THE STUDY: Use LUNG VQ template to match ventilation and perfusion images, screen capture and send to PACS.

POST EXAM: No special instructions or patient care is necessary following this procedure.

STATIC ACQUISITION

ACQUISTION
CAMERA	Acquisition type	STATIC
	Collimator	LEUHR or LEHR
	Detectors	Detector 2*
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	256x256
	Acquisition time	300 SECONDS/200Kcts
	Number of images	1
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

STUDY NAME: Lung perfusion

ORDER NO: Lung Scan Perfusion (IMG13085)(Performable) If performing perfusion ONLY exam

Lung Scan Ventilation Perfusion (IMG13086)(Performable) for Ventilation AND Perfusion exam.

INDICATIONS: Suspicion of pulmonary emboli or determination of split lung function.

IF THE PATIENT IS PREGNANT SEE THE PROTOCOL FOR LUNG SCANNING ON PREGNANT PATIENTS

PATIENT

PREP: Relative contraindication for patients with right to left shunts or pulmonary hypertension (consider lowering particle numbers).

RADIOPHARM

AND DOSE: ^99mTc MAA.

Physician prescribed dose or the dose from the standard Nuclear Medicine dose sheet.

When possible a bilateral venogram should precede perfusion scans.

EXCEPTION: Patients being evaluated for possible lung transplants do not get a venogram. These patients must have semi-quantitative analysis of both the aerosol and perfusion scans. See lung transplant below for semi-quantitative analysis instructions.

INSTRUMENT

AND SET-UP: Any large field of view camera. Preferrably dual headed whole body system:

256 x 256 matrix. The posterior perfusion image should be obtained for 1 M counts, and the time required should be recorded. The other images should be obtained for equal time. Anterior, right and left posterior obliques, right and left anterior obliques, both laterals.

PROCEDURE: Inject the dose IV (either as a venogram or in the arm).

Collect the following images: Posterior for 1M counts (record the time); then obtain the other images for equal time.

IMAGING SUMMARY:

FILMING
Use the VQ matching template to pair the Ventilation and perfusion pictures and send as a “screen capture” to PACS.

POST EXAM: No special instructions or patient care is necessary following this procedure.

STATIC ACQUISITION

ACQUISTION
CAMERA	Acquisition type	STATIC
	Collimator	LEUHR or LEHR
	Detectors	DETECTORS 1 & 2
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	256x256
	Acquisition time	300 SEC OR 1M cts
	Number of images	1
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

Lung scans on pregnant patients.

The following protocol reduces the exposure to the fetus in pregnant patients when it is determined that a lung scan is medically necessary.

A radiologist must consult with the referring physician prior to starting the lung scan. If approved by the radiologist, use the following modified protocol.

1. No venogram is performed.

2. The perfusion scan is performed first with 1.0 mCi ^99mTc MAA.

3. Obtain standard 8 view perfusion lung scan images.

4. If the perfusion scan is normal the scan is complete.

5. If the perfusion scan is abnormal then the aerosol scan is performed at the option of the monitoring radiologist.

6. The aerosol scan is performed with 30.0 mCi Tc99m DTPA. Position the camera to show the most prominent defect on the perfusion scan.

7. Open the MCA and record the count rate.

8. Have the patient breath on the aerosol nebulizer until the count rate in the MCA is doubled.

9. When the count rate has doubled proceed with imaging all the routine views for the ventilation scan.

10. IF the aerosol scan is performed, the patient should be encouraged to drink fluids or be hydrated with IV fluids and have a bladder catheter inserted for the next 24 hours. Hydration and keeping the bladder activity to a minimum will reduce the exposure to the fetus.

Lung transplant semi quantitative analysis protocol.

Follow the lung perfusion and aerosol imaging protocols with the following exceptions; 1) do not acquire a bilateral venogram, 2) do not acquire lateral perfusion images. Doses for perfusion and aerosol scans are the same as for routine lung scans, i.e. 8.0 mCi ^99mTc MAA and 40mCi ^99mTc DTPA (in nebulizer).

Using anterior and posterior ventilation images, create a geometric mean image, with calculation of whole lung RIGHT vs. LEFT quantitation, then use lung 1/3’s quantitation method, with 3 regions over each lung.

Then, Using anterior and posterior perfusion images, create a geometric mean image, with calculation of whole lung RIGHT vs. LEFT quantitation, then use lung 1/3’s quantitation method, with 3 regions over each lung.

Send the resultant screen captures to PACS.

STATIC ACQUISITION

ACQUISTION
CAMERA	Acquisition type	STATIC
	Collimator	LEUHR or LEHR
	Detectors	DETECTORS 1 & 2
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	256x256
	Acquisition time	300 SEC OR 1M cts
	Number of images	1
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

STUDY NAME: Lung perfusion, Split function; scan

ORDER NO: Split Lung Scan (IMG13035)(Performable)

INDICATIONS: Semi quantification determination of lung function

PATIENT

PREP: Relative contraindication for patients with right to left shunts or pulmonary hypertension (consider lowering the MAA particle number)

RADIOPHARM

AND DOSE: ^99mTc MAA.

Physician prescribed dose or the dose from the standard Nuclear Medicine dose sheet.

INSTRUMENT

AND SET-UP: Using a dual headed gamma camera, obtain anterior and posterior perfusion and ventilation images in a 256 x 256 matrix. First ventilation using the nebulizer system, followed by MAA perfusion (see standard lung scan technique)

PROCEDURE: Follow the lung perfusion and aerosol imaging protocols with the following exceptions; 1) do not acquire a bilateral venogram, 2) do not acquire lateral perfusion images. Doses for perfusion and aerosol scans are the same as for routine lung scans, i.e. 8.0 mCi ^99mTc MAA and 40mCi ^99mTc DTPA (in nebulizer).

Send the resultant screen captures to PACS.

POST EXAM: No special instructions or patient care is necessary following this procedure.

STATIC ACQUISITION

ACQUISTION
CAMERA	Acquisition type	STATIC
	Collimator	LEUHR or LEHR
	Detectors	DETECTORS 1 & 2
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	256x256
	Acquisition time	300 SEC OR 1M cts
	Number of images	1
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

STUDY NAME: Lymphoscintigraphy

ORDER NO.: Lymphatic Scan (IMG13020)(Performable)

INDICATION: To identify lymph node drainage, determine sentinel lymph node location, direction of lymphatic drainage around a tumor site - usually melanoma.

PATIENT:

PREP: NONE

RADIOPHARM

AND DOSE: Filtered (0.1-micron particle size) ^99mTc99m sulfur colloid intra-dermally around tumor site. Physician prescribed dose or the dose from the standard Nuclear Medicine dose sheet.

INSTRUMENT

AND SET-UP: DIGIRAD CAMERA with LEHR collimator and peaked on ^99mTc 140 kev with 20% window. Spot images for 3 minutes each at injection site and drainage beds. (on back or trunk melanoma, image all 4 quadrants; both axillary, and both femoral regions). On leg melanomas, image the groin. On arm melanomas, image the axillary region. For head and neck melanomas, image both axillary regions and lateral skull.

PROCEDURE: The technologist will make four intra-dermal injections around the tumor site (each injection is .25 of the total dose). Do not attempt to clean the area after the injection of tracer, you will contaminate the surrounding area with tracer that leaks out of the intra-dermal injection sites. Tape a 4x4 sterile gauze pad over the injection site immediately post injection to contain this leakage.

Sentinel node localization

The technologist will obtain images, to be reviewed by resident or attending radiologist. Radioactive marker will be utilized to mark the node site on the skin surface (using a sharpie).

FILMING

THE EXAM: All “spot” images will be sent to PACS.

POST EXAM: No precautions or special instruction are required following this exam.

STATIC ACQUISITION

ACQUISTION
CAMERA	Acquisition type	STATIC
	Collimator	LEUHR or LEHR
	Detectors	DETECTORS 1
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	256x256
	Acquisition time	180 seconds
	Number of images	1
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

Patient Instructions:

The Lymphoscintigraphy procedure usually takes between 10-60 minutes and is done as a pre-surgical test to locate the sentinel (primary) lymph node in the area of interest. Nuclear Medicine staff will do between 1-4 small intradermal injections of an inert radiotracer around the area of interest. Usually, 1-2 injections are all that are needed. Imaging of the radiotracer will be performed and a technologist MAY mark on your skin with a permanent marker where a lymph node is found. It is important not to wash this mark off.

Preparing for your study: If you wear a compression sleeve for edema, please discontinue wearing it for two days prior to your Lymphoscintigraphy Scan. Please bring any anti-anxiety, pain, or claustrophobia medication with you. We cannot prescribe or dispense any medication. These are frequently performed just prior to surgery (and surgery may require you to not eat, drink, or take medication for other tests for the same day, please follow those instructions.

If you should need to cancel or reschedule your procedure, please let us know as soon as possible so that others may be scheduled. Please call Nuclear Medicine directly at 352-265-5070.

STUDY NAME: Meckel's (GI Bleed)

ORDER NO: GI Bleed Meckels (IMG13015)(Performable)

INDICATIONS: Gastrointestinal tract bleeding, commonly in children and young adults

Scan for ectopic gastric mucosa as a cause for GI bleed.

PATIENT

PREP: NPO for 8 hours unless stipulated by the Nuclear Medicine Physician.

Cimetidine or any other proton pump inhibiter should be taken for 24 hours prior to exam and on the day of exam.

RADIOPHARM

AND DOSE: ^99mTc Pertechnetate, 100 uCi/kg. Glucagon 1mg (adult) or 50-micrograms/ kg (babies) injected IV immediately after the radiopharmaceutical.

Physician prescribed dose or the dose from the standard Nuclear Medicine dose sheet.

INSTRUMENT

AND SET-UP: Any standard gamma camera, using LEHR collimator and peaked on 140 keV with 20% window.

Computer set to acquire a dynamic study of 25 frames in a 128x128 matrix at 60 sec/frame.

PROCEDURE: Position the patient under the camera for an anterior view of the abdomen from the tip of the xiphoid to the pubis bone. Inject ^99mTc Pertechnetate followed by glucagon. Check positioning and begin scan. Instruct patient to remain still for the 30-minute acquisition. Right and left laterals and posterior spot behind the bladder should be obtained after 20 minutes. SPECT-CT may be requested by the physician; check before dismissing the patient.

IMAGING SUMMARY:

Image the anterior abdomen / pelvis at 1 minute /frame for 25 minutes. Obtain 3 minute spots of posterior pelvis and both right and left lateral abdomen/pelvis. SPECT-CT at discretion of monitoring radiologist.

PROCESSING: Sum images to 3 minutes per frame and display on one page with screen capture. Send screen capture and raw data to PAC.

POST EXAM: No special instructions or patient care is necessary following this exam.

ACQUISTION
CAMERA	Acquisition type	Dynamic
	Collimator	LEUHR or LEHR
	Detectors	Detector 2*
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	60 sec/frame
	Number of images	25 frames
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

STATIC ACQUISITION

ACQUISTION
CAMERA	Acquisition type	STATIC
	Collimator	LEUHR or LEHR
	Detectors	Detector 2*
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	180 seconds
	Number of images	1
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

STUDY NAME: Myocardial function, rest ; (gated blood pool scan)

ORDER NO: Myocardial Function Rest 1 View (IMG13088)(Performable)

INDICATION: Evaluation of left ventricular function (EF), global wall motion, and contraction phase.

PATIENT

PREP: Tagged red blood cells

RADIOPHARM

AND DOSE: ^99mTc tagged red blood cells Use ULTRA-tag kit if possible. (see modified in vitro rbc tagging protocol)

Physician prescribed dose or the dose from the standard Nuclear Medicine dose sheet.

INSTRUMENT: Gamma camera with hi resolution collimator peaked on 140 keV with 20% window.

PROCEDURE: Label patient’s blood with Ultra-tag kit.

After labeling blood, position the patient supine and attach the 3 leads from the ECG monitor to the patient. The configuration of the lead may need to be modified form the standard to obtain a consistent good rhythm.

Open the R-wave display from the acquisition window to see the ECG tracing. Routine acquisitions parameters are 750 beats for LAO projections and 500 beats for ANT, LLAT projections.

Position the patient to obtain the best separation of the chambers of the heart.

On the single head cameras a cephalic tilt of 10-15 degrees is desirable. The degree of LAO obliquity will vary from patient to patient. When proper position is obtained, advise the patient to remain motionless until the acquisition is complete.

Initiate the acquisition. The beat accepted will be displayed in the acquisition window. Aborting the scan will result in the loss of all acquired data.

The following views are obtained: Chemotherapy LAO view only; Cardiac and Surgical (pre op evaluation) LAO, Anterior and Left lateral when specifically requested.

At the end of acquisition the patient is dismissed.

IMAGING SUMMARY:

Obtain anatomical 45^o LAO images for 750 beats. If needed: obtain anterior and Lt lateral for 500 bests.

PROCESSING: Use semi-automatic calculation of LVEF, using the standard software package. Send “raw data” , processed data, parametric images, and LVEF curve to PACS.

POST EXAM: No special precaution or instructions need to be followed after this exam.

STUDY NAME: Myocardial Infarct (same protocol is used for Myocardial AMYLOID scan).

ORDER NO.: Myocardial Infarct (IMG13112)(Performable)

Myocardial Amyloidosis with SPECT/CT (IMG15442)(Performable)

INDICATION: Identify involved heart wall s/p acute MI. The scan should be performed 24-72 hours after the event.

PATIENT

PREP: Patient must be well hydrated during the three hours after injection.

RADIOPHARM

AND DOSE: ^99mTc PYP.

Physician prescribed dose or the dose from the standard Nuclear Medicine dose sheet.

INSTRUMENT: SPECT-CT (standard 20 minute SPECT-CT using standard continuous step and shoot technique). LEHR collimators, peaked on 140 keV

PROCEDURE: SPECT-CT acquisition at three hours post injection. A whole body (20 minute) bone scan should also be obtained after the SPECT-CT.

CT: Factory set Low Dose for attenuation correction. Pediatric reduce mAs and kVp both to value of 80.

IMAGING SUMMARY:

SPECT-CT (20 minute acquisition) at 3 hours after injection, followed by a 20 minute whole body bone scan.

PROCESSING: Reconstruct using standard technique, sending transverse (AC and NON-AC) reconstructions and MIPS to PACS.

POST EXAM: No special instructions or patient care is necessary following this procedure.

WHOLEBODY IMAGING:

ACQUISTION
CAMERA	Acquisition type	WHOLEBODY
	Collimator	LEHR OR LEUHR
	Detectors	Detectors 1 AND 2
	Isotope	99M-TC
	Peak	140 KeV
	Energy Window	20%
	Matrix	256x1024
	Acquisition time	15 CM/MIN
	Number of images	1
	Magnification	NONE
	Patient Orientation	Feet First Supine

TOMOGRAPHIC:

ACQUISTION
CAMERA	Acquisition type	TOMOGRAPHIC
	Collimator	LEUHR or LEHR
	Detectors	DETECTORS 1 AND 2
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	30 SEC/STEP
	Number of images	30 STEPS
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

STUDY NAME: Myocardial Perfusion, Stress/rest

ORDER NO.: Myocardial Perfusion Rest and Stress (IMG13092)(Performable)

Myocardial Perfusion Rest or Stress(IMG13095)(Performable for single image only)

INDICATION: Detection of coronary artery disease, myocardial ischemia

PATIENT

PREP: NPO for 4-6 hours and without Caffeinated or Decaffeinated products for 12 hours.

RADIOPHARM : Tc-SESTAMIBI :Patients less than 250 pounds: Resting injection 10 mCi with 30 mCi injection for Stress imaging.

Patients greater than 250 pounds: Resting injection 15 mCi with 45 mCi injection for Stress imaging.

AND DOSE: Regadenoson 0.4mg/5mL

Physician prescribed dose or the dose from the standard Nuclear Medicine dose sheet.

INSTRUMENT: GE DISCOVERY OR SIEMENS SPECT GAMMA CAMERAS:

PROCEDURE: Minimum 45 min post injection to perform imaging. Regadenoson infused over 10-15 seconds during stress administration.

IMAGING SUMMARY: Patients less than 250 pounds: Resting injection 10 mCi with 30 mCi injection for Stress imaging.

Patients greater than 250 pounds: Resting injection 15 mCi with 45 mCi injection for Stress imaging.

GE: Cardiac 90 orientation 180 degress rotation beginning RAO rotating towards LPO. 15 MIN image for Rest, 10 min for Stress/Prone.

SIEMENS: Cardiac 90 orientation 180 degress rotation beginning RAO rotating towards LPO. 15 MIN image for Rest, 10 min for Stress/Prone.

SIEMENS: IQ Spect 76 degree detector orientation with Focused Collimators. Focus the heart on P-Scope and start RAO with rotation LPO. 8 MIN Rest image, 6 MIN Stress/Prone image.

All collimation peaked 140 KeV.

PROCESSING: SPECT reconstruction in standard technique. Send reconstructed data to Symbia.Net. Create screen captures of display pages and send all imaging to PACS.

POST EXAM: No special instructions or patient care is necessary following this procedure

TOMOGRAPHIC REST:

ACQUISTION
CAMERA	Acquisition type	TOMOGRAPHIC
	Collimator	LEUHR or LEHR
	Detectors	DETECTORS 1 AND 2
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	25 SEC/STEP, CARDIAC 90
	Number of images	32 STEPS
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

TOMOGRAPHIC STRESS GATED:

ACQUISTION
CAMERA	Acquisition type	TOMOGRAPHIC
	Collimator	LEUHR or LEHR
	Detectors	DETECTORS 1 AND 2
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	20 SEC/STEP CARDIAC 90
	Number of images	32 STEPS
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

TOMOGRAPHIC STRESS PRONE:

ACQUISTION
CAMERA	Acquisition type	TOMOGRAPHIC
	Collimator	LEUHR or LEHR
	Detectors	DETECTORS 1 AND 2
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	20 SEC/STEP CARDIAC 90
	Number of images	32 STEPS
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Prone

STUDY NAME: Myocardial Perfusion Viability

ORDER NO.: Myocardial Rest MultiView (IMG13111)(Performable)

INDICATION: Detection of viable Myocardium

PATIENT PREP No patient Preparation

RADIOPHARM : Thallous Chloride- 201-Tl

AND DOSE: 4 mCi

INSTRUMENT: GE DISCOVERY OR SIEMENS SPECT GAMMA CAMERAS:

PROCEDURE: Minimum 15 min post injection to perform Rest imaging Day 1. 20-24 hour delay with 30 minute Rest Redistribution Day 2.

IMAGING SUMMARY: GE: Cardiac 90 orientation 180 degress rotation beginning RAO rotating towards LPO. 15 MIN image for Rest Day 1, 30 min Rest Redistribution Day 2

SIEMENS: Cardiac 90 orientation 180 degress rotation beginning RAO rotating towards LPO. 15 MIN image for Rest Day 1, 30 min Rest Redistribution Day 2

Collimation peaked 81 KeV.

PROCESSING: SPECT reconstruction in standard technique. Send reconstructed data to Symbia.Net. Create screen captures of display pages and send all imaging to PACS.

POST EXAM: No special instructions or patient care is necessary following this procedure

TOMOGRAPHIC REST/REDISTRIBUTION:

ACQUISTION
CAMERA	Acquisition type	TOMOGRAPHIC
	Collimator	LEUHR or LEHR
	Detectors	DETECTORS 1 AND 2
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	25 SEC/STEP, CARDIAC 90 45 SEC/STEP-DAY TWO
	Number of images	32 STEPS
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

STUDY NAME: ¹¹¹In-Octreotide tumor imaging Wholebody and SPECT-CT

ORDER NO.: IMG13001 or IMG13044, (radiopharm must be added) - Somatostatin

INDICATIONS: Assessment of patients with Neuroendocrine tumors: pheochromocytomas, neuroblastomas, paragangliomas, gatrinomas, carcinoid tumors and other tumors containing somatostatin receptors.

NOTE: THE VAST MAJORITY OF THE INDICATIONS FOR THIS EXAMINATION HAVE BEEN REPLACED BY ⁶⁸GA-DOTATATE PET-CT

PATIENT

PREP: Recommended that therapy with octreotide acetate be suspended for two days prior to administration of ¹¹¹In Octreotide.

RADIOPHARM

AND DOSE: ¹¹¹In Octreotide Physician prescribed dose or the dose from the standard Nuclear Medicine dose sheet.

INSTRUMENT

AND SET-UP: Routine imaging begins at 4 hours post dosing with wholebody planar images of the head, chest, abdomen, and pelvis and a SPECT of the abdomen. Repeat imaging is performed at 24 hours. For imaging, the MCA set on proper photo peak for ¹¹¹In with MEGP collimation.

STATIC IMAGES: Static planar images are acquired for 10 minutes each in a 256x256 matrix.

WHOLE BODY IMAGES: Imaging from head to toe for 30 minutes.

SPECT-CT: SPECT images of the abdomen are collected in a 128x128 matrix, 60 steps at 3 degree increment for 25 seconds per step. Reconstruction is in a 128x128 matrix. Reconstruct all the routine planes and generate a reprojection image.

CT: Factory set Low Dose for attenuation correction. Pediatric reduce mAs and kVp both to value of 80.

PROCEDURE: Routinely, the patient is instructed to return at 4 hours post dosing. Whole body static images and SPECT-CT are obtained and evaluated by the attending, fellow, or resident upon completion for additional imaging. The patient is instructed to return at 24 hours for repeat imaging, which must be reviewed by a physician prior to release of the patient.

IMAGING SUMMARY: 30 minute whole body scans at 4 and 24 hours.

SPECT-CT as ordered by monitoring radiologist.

WHOLEBODY IMAGING:

ACQUISTION
CAMERA	Acquisition type	WHOLEBODY
	Collimator	LEHR OR LEUHR
	Detectors	Detectors 1 AND 2
	Isotope	111-IN
	Peak	174 & 247 KeV
	Energy Window	20%
	Matrix	256X1024
	Acquisition time	15 CM/MIN DAY 1 10 CM/MIN DAY 2
	Number of images	4HR AND 24HR POST INJ
	Magnification	NONE
	Patient Orientation	Feet First Supine

STATIC ACQUISITION:

ACQUISTION
CAMERA	Acquisition type	STATIC
	Collimator	LEUHR or LEHR
	Detectors	Detectors 1 AND 2
	Isotope	111-IN
	Peak	174 & 247 KeV
	Energy Window	20%
	Matrix	256X256
	Acquisition time	300 seconds
	Number of images	ANT, POST, LATS
	Magnification	0-2.0 (or more based on patient size)
	Patient Orientation	Feet First Supine

TOMOGRAPHIC:

ACQUISTION
CAMERA	Acquisition type	TOMOGRAPHIC
	Collimator	LEUHR or LEHR
	Detectors	DETECTORS 1 AND 2
	Isotope	111-IN
	Peak	174 & 247 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	30 SEC/STEP
	Number of images	30 STEPS
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

PROCESSING &

FILMING

THE STUDY: PLANAR: Display all planar images on one page. Annotate for type of exam, orientation, view, name, medical record number, and date of exam, make a snapshot and send snapshot to PACS.

SPECT-CT: Reconstruction is in a 128x128 matrix. Reconstruct transverse and coronal planes and generate a reprojection image. Compressed to 5 slice per frame warped to the largest size permitted. Annotate for type of exam, orientation, view, name, medical record number, and date of exam, on all snapshots and send snapshots and reprojection images to PACS. Send transverse reconstruction (AC and Non-AC)

WHOLE BODY: Display the whole body images on one page and make a snapshot. Annotate for type of exam, orientation, view, name, medical record number, and date of exam, on all snapshots and send to PACS.

POST EXAM: No special instructions or precautions.

STUDY NAME: Parathyroid Scan (IMG13026)(Performable)

ORDER NO.:

INDICATION: Localization of parathyroid tissue.

PATIENT

PREP: No iodine contrast within 6 weeks of this exam, no thyroid suppression drugs, thyroid supplement drugs.

RADIOPHARM

AND DOSE: ^99mTc sestamibi

Physician prescribed dose or the dose from the standard Nuclear Medicine dose sheet.

INSTRUMENT

AND SET-UP: Use standard gamma camera with LEHR collimator, peaked on 140 keV. Perform planar spot images at 5 minutes and 2 hours post injection for 5 minutes.

SPECT-CT: Immediately after the early planar image, perform SPECT-CT (20 minute scan, using continuous Step and shoot), with LEHR collimation, peaked on 140 keV

PROCEDURE: Inject radiopharmaceutical, obtain 5 minute planar spot at 5 minutes after injection, followed by SPECT-CT (to cover from mouth to level of the origin of the thoracic aorta), then with delayed planar image at 2 hours post injection.

CT: Factory set Low Dose for attenuation correction. Pediatric reduce mAs and kVp both to value of 80.

IMAGING SUMMARY:

Planar (5 minute) at 5 minutes after injection, followed by SPECT-CT (20 minute acquisition), followed by a 2 hour delayed (5 minute) spot image.

PROCESSING Display early and late planar images side by side and sent to PACS as screen capture. Reconstruct the SPECT CT, sending transverse (AC and NON-AC) reconstructions, as well as screen captures in all 3 planes and MIPS.

POST EXAM: No special instructions or patient care is required after this exam.

TOMOGRAPHIC:

ACQUISTION
CAMERA	Acquisition type	TOMOGRAPHIC
	Collimator	LEUHR or LEHR
	Detectors	DETECTORS 1 AND 2
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	256X256
	Acquisition time	30 SEC/STEP
	Number of images	30 STEPS
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

STATIC ACQUISITION IMMEDIATE AND DELAY:

ACQUISTION
CAMERA	Acquisition type	STATIC
	Collimator	LEUHR or LEHR
	Detectors	Detector 1
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	256X256
	Acquisition time	5 MIN IMMEDIATE 8 MIN DELAY
	Number of images	1
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

STUDY NAME: PET, FDG Imaging for Tumor

ORDER NO.: PET CT Whole Body (IMG13202) PET CT Skull to Thigh (IMG13203) (Performable)

INDICATION: Detect, stage, and restage malignancy

PATIENT PREP:

· Study Takes 2.5 hrs. 4h for lung delay patients (single pulmonary nodule).

· Diabetic Patients scheduled in first 3 slots in am

· Blood sugar needs to be below 220. Do you take diabetic medications? If so:

· Take all oral diabetes meds as usual

· Take full dose of long acting insulin morning of scan

· Take ½ dose of short acting insulin the morning of scan

· Otherwise usual instructions that patient normally follows

· IF contrasted CT is desired simultaneously, NO IODINE ALLERGIES. Otherwise must be pre-medicated and scanned at UCT after PET.

· All patients need to be contacted by NUC MED. Not clinic.

· Note weight on schedule

· HIQ/syngo for PI/PS

· Bring pain or claustrophobia meds with them. Bring diabetic meds if needed.

· NPO for 8h except plain water, can take meds with plain water, no exercise for 48h

· Drs. To fill out protocol sheet

· Head/neck CT’s are at hospital, except lymphoma

· Need 24h cancellation notice

· Take ½ long acting insulin, no short acting insulin, take metformin if no CT w/contrast

RADIOPHARM

AND DOSE: ¹⁸F-FDG given IV dosing 0.08 mCi/ml max 14 mCi up to 250 pounds

250-300 pounds use 16 mCi. 300+ pounds use 18 mCi

Physician prescribed dose or dose from standard dose sheet.

Pediatric minimum dose 5 mCi.

INSTRUMENT

AND SET-UP: PET-CT peaked on 511 keV

PROCEDURE: Inject FDG, wait 90 minutes, perform Whole Body PET-CT

Protocols are tumor type specific:

CT: Factory set Low Dose for attenuation correction. Pediatric reduce mAs and kVp both to value of 80.

IMAGING SUMMARY:

15-20 minute (tumor specific) PET-CT obtained 1.5 hours after injection.

PROCESSING: Standard reconstruction. Transverse (AC and NON-AC) reconstructions sent to PACS.

STUDY NAME: PET, FDG Imaging for Cardiac Sarcoidosis

ORDER NO.: PET Cardiac (IMG13201)

INDICATION: Detect, stage, and restage malignancy

PATIENT PREP:

· Study Takes 2.5 hrs. Diabetic Patients scheduled in first 3 slots in am

· Blood sugar needs to be below 220. Do you take diabetic medications? If so:

· Take all oral diabetes meds as usual

· Take full dose of long acting insulin morning of scan

· Take ½ dose of short acting insulin the morning of scan

· Otherwise usual instructions that patient normally follows

· IF contrasted CT is desired simultaneously, NO IODINE ALLERGIES. Otherwise must be pre-medicated and scanned at UCT after PET.

· All patients need to be contacted by NUC MED. Not clinic.

· Note weight on schedule

· HIQ/syngo for PI/PS

· Bring pain or claustrophobia meds with them. Bring diabetic meds if needed.

· NPO for 8h except plain water, can take meds with plain water, no exercise for 48h

· Must have Myocardial Perfusion at UF within last 12 months.

· Atkin’s Diet 24 hr prior to appointment

· 50 units/kg Heparin injection regardless of anticoagulant regiment.

· Drs. To fill out protocol sheet

· Head/neck CT’s are at hospital, except lymphoma

· Need 24h cancellation notice

· Take ½ long acting insulin, no short acting insulin, take metformin if no CT w/contrast

RADIOPHARM

AND DOSE: ¹⁸F-FDG 10 mCi standard dose IV.

INSTRUMENT

AND SET-UP: PET-CT peaked on 511 keV

PROCEDURE: Inject FDG, wait 60 minutes, perform Whole Body PET-CT

CT: Factory set Low Dose for attenuation correction. Pediatric reduce mAs and kVp both to value of 80.

IMAGING SUMMARY:

15-20 minute (tumor specific) PET-CT obtained 1 hour after injection.

PROCESSING: Standard reconstruction. Transverse (AC and NON-AC) reconstructions sent to PACS.

STUDY NAME: PET, FDG Imaging for Dementia or Seizure Disorder

ORDER NO.: PET Metabolic Brain (IMG13108)(Performable)

INDICATION: Detection and characterization of dementia or localization of cause for focal (partial) seizures.

PATIENT PREP:

· Study Takes 1.5 hours.

· NPO for 1 hour

· Take all meds as usual

· Note weight on schedule

· HIQ/syngo for PI/PS

· Bring pain or claustrophobia meds with them. Bring diabetic meds if needed.

· NPO for 1 hour except plain water, can take meds with plain water

· Drs. To fill out protocol sheet

· Need 24h cancellation notice

RADIOPHARM

AND DOSE: ¹⁸F-FDG given IV

Physician prescribed dose or dose from standard dose sheet.

INSTRUMENT

AND SET-UP: PET-CT peaked on 511 keV

PROCEDURE: Inject FDG, wait 45-60 minutes, perform Head only PET-CT

Protocols are tumor type specific:

CT: Factory set Low Dose for attenuation correction.

IMAGING SUMMARY:

15 minute PET-CT of head obtained 45-60 minutes after injection.

PROCESSING: Standard reconstruction. Transverse (AC and NON-AC) reconstructions sent to PACS.

STUDY NAME: PET, Amyloid-avid (AMYVID or equivalent) Imaging for Dementia

ORDER NO.:PET CT Brain Amyloid IDEAS Study (IMG15361)(Performable)

INDICATION: Detection and characterization of dementia

PATIENT PREP:

· Study Takes 1.5 hours.

· NPO for 1 hour

· Take all meds as usual

· Note weight on schedule

· HIQ/syngo for PI/PS

· Bring pain or claustrophobia meds with them. Bring diabetic meds if needed.

· NPO for 1 hour except plain water, can take meds with plain water

· Drs. To fill out protocol sheet

· Need 24h cancellation notice

RADIOPHARM

AND DOSE: ¹⁸F-Amyvid or equivalent given IV

Physician prescribed dose or dose from standard dose sheet.

INSTRUMENT

AND SET-UP: PET-CT peaked on 511 keV

PROCEDURE: Inject amyvid, wait 45-60 minutes, perform Head only PET-CT

Protocols are tumor type specific:

CT: Factory set Low Dose for attenuation correction

IMAGING SUMMARY:

15 minute PET-CT of head obtained 45-60 minutes after injection.

PROCESSING: Standard reconstruction. Transverse (AC and NON-AC) reconstructions sent to PACS.

STUDY NAME: PET, Amyloid (NEUROCEQ/ PEACEOFMND) Imaging for Dementia

ORDER NO.: PET CT Brain – PEACEOFMND Study (IMG15437)(Performable)

INDICATION: Detection and Amyloid plaque.

PATIENT PREP:

· Study Takes 1.5 hours.

· NPO for 1 hour

· Take all meds as usual

· Note weight on schedule

· HIQ/syngo for PI/PS

· Bring pain or claustrophobia meds with them. Bring diabetic meds if needed.

· NPO for 1 hour except plain water, can take meds with plain water

· Drs. To fill out protocol sheet

· Need 24h cancellation notice

RADIOPHARM

AND DOSE: ¹⁸F-Neuroceq IV

Standard dose 8.1 mCi ordered by Research coordinator

INSTRUMENT

AND SET-UP: PET-CT peaked on 511 keV

PROCEDURE: Inject Neuroceq, ideal wait time 70 minutes, perform Head only PET-CT.

CT: Factory set Low Dose for attenuation correction.

IMAGING SUMMARY:

15 minute PET-CT of head obtained 45-60 minutes after injection.

PROCESSING: Standard reconstruction. Transverse (AC and NON-AC) reconstructions sent to PACS.

R-99 research dictation.

STUDY NAME: PET, Axumin Imaging for recurrent prostate CA

ORDER NO.: CPT code:

INDICATION: Detection of recurrent prostate cancer after prior therapy with rising serum PSA level

PATIENT PREP:

· Study Takes 1.5 hours.

· NPO for 4 hour

· Take all meds as usual

· Note weight on schedule

· HIQ/syngo for PI/PS

· Bring pain or claustrophobia meds with them. Bring diabetic meds if needed.

· NPO for 1 hour except plain water, can take meds with plain water

· Drs. To fill out protocol sheet

· Need 24h cancellation notice

RADIOPHARM

AND DOSE: ¹⁸F-Axumin given IV

Physician prescribed dose or dose from standard dose sheet.

INSTRUMENT

AND SET-UP: PET-CT peaked on 511 keV

PROCEDURE: Inject FDG, wait 3.5 minutes, scan from thighs to head: (15-20 minute scan)

Protocols are tumor type specific:

CT: Factory set Low Dose for attenuation correction.

IMAGING SUMMARY:

15-20 minute PET-CT from thighs to head at 3.5 minutes after injection.

PROCESSING: Standard reconstruction. Transverse (AC and NON-AC) reconstructions sent to PACS.

STUDY NAME: PET, DOTATATE Imaging for neuroendocrine tumors

ORDER NO.: PET CT Dotatate Wholebody (IMG15372)(Performable)

INDICATION: Detection, staging, and restaging of neuroendocrine tumors.

PATIENT PREP:

· Study Takes 1.5 hours.

· NPO for 4 hour

· Take all meds as usual

· Note weight on schedule

· HIQ/syngo for PI/PS

· Bring pain or claustrophobia meds with them. Bring diabetic meds if needed.

· NPO for 1 hour except plain water, can take meds with plain water

· Drs. To fill out protocol sheet

· Need 24h cancellation notice

· Though controversial, should likely be off of somatostatin

RADIOPHARM

AND DOSE: ⁶⁴Cu-DOTATATE given IV

Physician prescribed dose or dose from standard dose sheet.

INSTRUMENT

AND SET-UP: PET-CT peaked on 511 keV

PROCEDURE: Inject DOTATATE, wait 60 minutes, scan from top of head to toes (15 minute scan)

CT: Factory set Low Dose for attenuation correction. Pediatric reduce mAs and kVp both to value of 80.

IMAGING SUMMARY:

15-20 minute PET-CT of whole body 1 hour after injection.

PROCESSING: Standard reconstruction. Transverse (AC and NON-AC) reconstructions sent to PACS.

STUDY NAME: Renal Captopril

ORDER NO. : Pre captopril - Renal Scan DTPA (IMG13102)

Renal Scan Mag3 (IMG13103)

Post captopril - Renal Scan DTPA (IMG13102)

Renal Scan Mag3 (IMG13103)

INDICATION: Uncontrollable high blood pressure with suspicion of renal artery stenosis. Peripheral vascular disease. This is a test of “physiologic significance” of stenosis.

PATIENT

PREP: Day 1 - Normal diet.

Patient to receive 0.7mg/kg of captopril, not to exceed 50 mg dose given PO. Patient should have an IV KVO prior to taking captopril. Blood pressures taken Q 15 minutes post dosing with captopril.

Day 2- Normal diet, no prep. (the without captopril scan should be performed at the discretion of the monitoring radiologist). If the post-captopril scan is normal, the pre-captopril scan is not need.

RADIOPHARM

AND DOSE: Adult: Pre and post captopril

^99mTc MAG-3, ^99mTc DTPA

Infants: pre and post captopril

^99mTc MAG-3, ^99mTc DMSA

INSTRUMENT: Use a standard gamma camera equipped with LEHR collimators on both the pre and post captopril procedure days. Use a SPECT-CT camera for imaging of ^99mTc DMSA on both pre and post captopril procedure days.

PROCEDURE: Adult

Day 1 - The patient receives 0.7mg/kg captopril not to exceed 50 mg PO one hour prior to the scheduled imaging time. Blood pressure monitoring at Q 15 minutes post captopril for outpatients is performed by radiology nursing in holding, and for inpatients by either the nurse on the patients floor or by radiology nursing. If nurses on the floor are to monitor the patient, the technical staff should coordinate the administration time of captopril with the nurse and the patient’s transportation to Nuclear Medicine.

Patient under goes a ^99mTc MAG-3 renal scan (2 mCi adult dose) without lasix followed immediately by a ^99mTc-DTPA scan using a LEHR collimator. See Renal scan - DTPA and Renogram – MAG-3 for procedure and processing information.

Day 2 - Same procedure, but without captopril administration, if needed.

Infants

Day 1 - The patient receives 0.7mg/kg captopril PO one hour prior to the scheduled imaging time. At 1 hour after captopril, the patient undergoes a ^99mTc-MAG-3 scan without lasix and is injected with ^99mTc DMSA immediately after the completion of the MAG-3 scan. SPECT-CT of the DMSA is obtained 2 hours later.

Day 2 - The patient undergoes a ^99mTc-MAG-3 scan without lasix and is injected with ^99mTc DMSA immediately after the completion of the MAG-3 scan. SPECT-CT of the DMSA is obtained 2 hours later.

For outpatients, the Radiology nursing staff administers the captopril and monitors blood pressure at Q 15 minutes for one hour post captopril at Q 15 minutes. For outpatients monitoring is performed by Radiology's nurses.

For inpatients, the nursing staff on the patient’s floor administer the captopril and monitors blood pressure at Q 15 minutes for one hour post captopril. The technical staff should coordinate the administration time of captopril with the nurse, and the patients transportation to Nuclear Medicine. Arranged to have captopril ordered for the patient and at the nursing station the day prior to the captopril study in order to void delays.

Image acquisition and processing is the same as day one with the exception of appropriate day annotation.

PROCESSING: Pre and Post captopril ^99mTc DTPA and ^99mTc-MAG-3 scans are processed in the same manner as routine renal scans with the exception of annotation of the images and curves. Image and curve sets must be identified as pre or post captopril.

See the processing steps for DTPA and MAG-3 renal scans in this manual for standard processing and filming procedures.

SPECT-CT of DMSA scans are processed as described in the standard protocol for DMSA scans. Check this manual's table of contents for the page number.

DYNAMIC RENOGRAM ACQUISITIONS:

ACQUISTION
CAMERA	Acquisition type	Dynamic FLOW
	Collimator	LEUHR or LEHR
	Detectors	Detector 2
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	2 sec/frame
	Number of images	30 frames
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine
ACQUISTION
CAMERA	Acquisition type	Dynamic EXCRETION
	Collimator	LEUHR or LEHR
	Detectors	Detector 2
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	60 sec/frame
	Number of images	29 frames
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

STATIC ACQUISITION DELAYED IMAGING:

ACQUISTION
CAMERA	Acquisition type	STATIC
	Collimator	LEUHR or LEHR
	Detectors	Detector 2*
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	60 seconds
	Number of images	1
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

STUDY NAME: Renal scan - DTPA; with or without lasix (if transplant add renal transplant

ORDER NO: Renal Scan DTPA (IMG13102)

Renal Scan Mag3 (IMG13103) (If creatinine over 2.0 or existing transplant

INDICATIONS: Evaluation of renal function and blood flow and transplant rejection. Performed with lasix to R/O obstructive process in renal excretion. Differential function can be obtained from the quantitation of the activity in the kidneys at 2-3 minute post injection.

PATIENT

PREP: Patient should be hydrated with 200-400cc of water immediately prior to the exam.

RADIOPHARM

AND DOSE: ^99mTc DTPA. (if creatine over 2.0, or if renal transplant, performed with ^99mTc-MAG-3

Physician prescribed dose or the dose from the standard Nuclear Medicine dose sheet.

INSTRUMENT

AND SET-UP : Gamma camera with a LEAP or LEHR collimator. Variable frame dynamic involving (30) - 2 sec frames, 1 - 6 sec frame, and (26) - 1 min frames.

PROCEDURE: Position the patient supine with the camera under the table for patients with native kidneys and over the patient (anterior) for imaging transplanted kidneys. Use a point source to check the positioning of the patient in relation to the camera. The patient’s xiphoid should be positioned 3-4 inches from the top of the field of view on a LFOV camera. Check right and left sides of the patient to center their midline over the camera.

Position transplanted kidney patients with the camera anterior over the transplanted kidney.

A butterfly needle with a T-connector is used for all injections to assure positive placement of the needle and eliminate the problem of infiltration. When the needle is in place, inject the radiopharmaceutical dose and start the camera/computer.

When lasix is requested, the butterfly needle is left in place and used for the injection of 40 mg of lasix (adult , two kidney dose) at 12 minutes post injection of the radiopharmaceutical dose. After the lasix is administered the butterfly assemble is removed.

All patients are then allowed to ambulate for 20 minutes with a delayed spot image to calculate the effect of gravity on collecting system emptying.

IMAGING SUMMARY:

Flow at 2 seconds per frame for 30 frames, followed by standard renogram at 1 minute/ frame for 26 minutes. Delayed posterior spot after ambulation, 20 minutes after the completion of the standard renogram.

PROCESSING:

The flow study is summed to 6 second composite images and “screen captured”. The renogram phase is composited into 3 minute images and screen captured. Using the standard renal processing program, a region of interest is drawn of the aorta and each kidney, with background regions around the bottom of each kidney with calculation of background corrected time activity curves. The Lasix time is annotated on the curves. Differential function is provided from the 1 -3 minutes. Post gravity change is calculated by comparison of the last image of the standard renogram (image 27 minute) vs. the post gravity delayed image. The resultant curves and images are screen captured and sent to PACS.

POST EXAM: No special instructions or patient care is requires following this procedure.

DYNAMIC RENOGRAM ACQUISITIONS:

ACQUISTION
CAMERA	Acquisition type	Dynamic FLOW
	Collimator	LEUHR or LEHR
	Detectors	Detector 2
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	2 sec/frame
	Number of images	30 frames
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine
ACQUISTION
CAMERA	Acquisition type	Dynamic EXCRETION
	Collimator	LEUHR or LEHR
	Detectors	Detector 2
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	60 sec/frame
	Number of images	29 frames
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

STATIC ACQUISITION DELAYED IMAGING:

ACQUISTION
CAMERA	Acquisition type	STATIC
	Collimator	LEUHR or LEHR
	Detectors	Detector 2*
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	60 seconds
	Number of images	1
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

STUDY NAME: Renal scan - PEDIATRIC – ^99mTc-MAG-3; with lasix

ORDER NO: Peds Renogram Mag 3 Lasix (IMG15406)(Performable)

INDICATIONS: Renal imaging is performed to evaluate kidney function and the genitourinary system. A radiotracer is followed from perfusion and uptake in the kidneys, where filtration and excretion occurs, and then through the ureters to the bladder

Evaluation of renal function and blood flow; evaluate for obstruction. Performed with lasix to R/O obstructive process in renal excretion. Differential function can be obtained from the quantitation of the activity in the kidneys at 2-3 minute post injection.

PATIENT PREP: Patient should be hydrated Lactated Ringer or normal saline 15-20 ml/kg, rounded up to the nearest 50 ml

Route of administration: Intravenous

RADIOPHARM

AND DOSE: ^99mTc-MAG-3

Physician prescribed dose or the dose from the standard Nuclear Medicine dose sheet. Dose is given under the direction of the authorized user

Furosemide (Lasix) 1mg/kg, up to a maximum of 40mg
Route of administration: Intravenous

INSTRUMENT

AND SET-UP : Gamma camera with a LEAP or LEHR collimator.

Procedure:

Arrival

1. Upon arrival, the patient check into radiology reception

2. The patient will be brought back to radiology holding for nursing to establish:

a. IV access

b. Foley Catheter (IF INDICATED BY ORDERING PHYSICIAN)

c. Lactated Ringer or Normal Saline

3. Radiology Nursing will notify the charge technologist when the patient is ready

Renogram

1. The technologist will ask two identifiers, usually DOB and full name, ensuring the correct patient

2. The patient will be positioned using the tracer to ensure proper positioning

3. The radiopharmaceutical will be injected through the IV.

4. Imaging will be acquired for the flow, excretion, immediate delay, gravity delay, and unclamped delay (if necessary)

a. If patient has a nephrostomy drain it will be clamped

b. Flow images will be acquired

c. Followed immediately by the pre-Furosemide excretion phase.

d. 30 minutes into the renogram imaging will be stopped and patient allowed to void.

e. Phase 2 Excretion the Furosemide will be administrated over approximately 1-2 minutes at beginning of imaging.

f. Immediate delay imaging will be acquired after the excretion phase is complete

g. The patient will be upright approximately 15 to 20 minutes

h. Gravity delay will then be acquired.

i. If patient has a nephrostomy drain it will be unclamped

j. The patient will be upright approximately 15 to 20 minutes

k. Unclamped delay image will then be acquired

IMAGE ACQUISITION PARAMETERS: FLOW

ACQUISTION
CAMERA	Acquisition type	Dynamic
	Collimator	LEUHR or LEHR
	Detectors	Detector 2*
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	2 sec/frame
	Number of images	30 frames
	Magnification	2.0**
	Patient Orientation	Feet First Supine

*Both Detector1 and Detector 2 may be used in cases of transplant kidney, horseshoe kidney, or pelvic kidney

** Magnification settings will be adjusted based on patient size

IMAGE ACQUISITION PARAMETERS: PRE-LASIX EXCRETION

ACQUISTION
CAMERA	Acquisition type	Dynamic
	Collimator	LEUHR or LEHR
	Detectors	Detector 2*
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	60 sec/frame
	Number of images	29 frames
	Magnification	2.0
	Patient Orientation	Feet First Supine

*Both Detector1 and Detector 2 may be used in cases of transplant kidney, horseshoe kidney, or pelvic kidney

** Magnification settings will be adjusted based on patient size

IMAGE ACQUISITION PARAMETERS: POST-LASIX EXCRETION

ACQUISTION
CAMERA	Acquisition type	Dynamic
	Collimator	LEUHR or LEHR
	Detectors	Detector 2*
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	60 sec/frame
	Number of images	30 frames
	Magnification	2.0
	Patient Orientation	Feet First Supine

*Both Detector1 and Detector 2 may be used in cases of transplant kidney, horseshoe kidney, or pelvic kidney

** Magnification settings will be adjusted based on patient size

IMAGE ACQUISITION PARAMETERS: IMMEDIATE DELAY

ACQUISTION
CAMERA	Acquisition type	STATIC
	Collimator	LEUHR or LEHR
	Detectors	Detector 2*
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	60 seconds
	Number of images	1
	Magnification	2.0 (or more based on patient size)**
	Patient Orientation	Feet First Supine

*Both Detector1 and Detector 2 may be used in cases of transplant kidney, horseshoe kidney, or pelvic kidney

** Magnification settings will be adjusted based on patient size

IMAGE ACQUISITION PARAMETERS: DELAY

ACQUISTION
CAMERA	Acquisition type	STATIC
	Collimator	LEUHR or LEHR
	Detectors	Detector 2*
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	60 seconds
	Number of images	1
	Magnification	2.0 (or more based on patient size)**
	Patient Orientation	Feet First Supine

*Both Detector1 and Detector 2 may be used in cases of transplant kidney, horseshoe kidney, or pelvic kidney

** Magnification settings will be adjusted based on patient size

IMAGE ACQUISITION PARAMETERS: UNCLAMPED DELAY

ACQUISTION
CAMERA	Acquisition type	STATIC
	Collimator	LEUHR or LEHR
	Detectors	Detector 2 only*
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	60 seconds
	Number of images	1
	Magnification	2.0 (or more based on patient size)**
	Patient Orientation	Feet First Supine

*Both Detector1 and Detector 2 may be used in cases of transplant kidney, horseshoe kidney, or pelvic kidney

** Magnification settings will be adjusted based on patient size

IMAGING SUMMARY:

30 minute renogram, break point; Lasix given, 2^nd 30 minute renogram; then 15 minute gravity delayed spot.

IMAGE PROCESSING:

1. Raw flow and excretion data will be put into the Renal Analysis program creating time activity curve, and compressed flow images.

2. Immediate delay and gravity delay data will be put into the Renal Delay program creating time activity graphs

3. Gravity delay and unclamped delay will be put into the Renal Delay program creating time activity graphs

4. Excretion images will be compressed into 3 min/frame and displayed separately pre and post Furosemide injection.

5. Refer to attending Radiologist for Region of Interest locations and interpretations.

Screen captures sent to PACS.

POST EXAM: No special instructions or patient care is requires following this procedure.

STUDY NAME: Renal, Cortical SPECT-CT

ORDER NO.: Renal SPECT DMSA (IMG13031)(Performable)

INDICATION: Assess loss of cortical function from acute or chronic infection, renal disease, and renal tumors.

PATIENT

PREP: No patient preparation is required

RADIOPHARM

AND DOSE: ^99mTc DMSA or ^99mTc Glucoheptonate administered intravenously.

Physician prescribed dose or dose from standard dose sheet.

INSTRUMENT

AND SET-UP: SPECT-CT using LEHR collimation, peaked on 140 keV

PROCEDURE: Inject DMSA, wait 2 hours, perform SPECT-CT imaging (20 minute acquisition using standard continuous step and shoot technique)

CT: Factory set Low Dose for attenuation correction. Pediatric reduce mAs and kVp both to value of 80.

IMAGING SUMMARY:

20 minute SPECT-CT obtained 2 hours after injection followed by posterior static image for differential function.

PROCESSING: Standard reconstruction. The radiologist will perform volume rendering on the PACS workstation. Technologist will create anterior and posterior reprojection images, with geometric mean calculation of split renal function.

FILMING: Screen captures of split renal function will be sent to PACS. Transverse reconstructions (AC and NON-AC) will be sent to PACS.

TOMOGRAPHIC:

ACQUISTION
CAMERA	Acquisition type	TOMOGRAPHIC
	Collimator	LEUHR or LEHR
	Detectors	DETECTORS 1 AND 2
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	30 SEC/STEP
	Number of images	30 STEPS
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

STATIC ACQUISITION

ACQUISTION
CAMERA	Acquisition type	STATIC
	Collimator	LEUHR or LEHR
	Detectors	Detector 2
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	60 seconds
	Number of images	1
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

STUDY NAME: Renal, Glomerular Filtration Rate (GFR)

ORDER NO.:

INDICATION: Determine accurate total renal function

PATIENT

PREP: No patient preparation is required

RADIOPHARM

AND DOSE: ^99mTc DTPA IV (no extravasation)

Physician prescribed dose or dose from standard dose sheet.

INSTRUMENT

AND SET-UP: Gamma camera peaked on 140 keV immediately after injection to observe for extravasation.

PROCEDURE: Inject DTPA, wait 1 hour, obtain a serum sample; wait until 3 hours after injection, and obtain a 2^nd serum sample (hopefully from a “clean” stick).

Separate plasma and count activity as listed below:

IMAGING SUMMARY:

1 minute static of injection site confirming absence of extravasation.

PROCESSING: Send screen capture of arm image with annotated GFR data to PACS.

STATIC ACQUISITION

ACQUISTION
CAMERA	Acquisition type	STATIC
	Collimator	LEUHR or LEHR
	Detectors	Detector 1
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	60 seconds
	Number of images	1
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

STUDY NAME: Shunt patency exam (.c2.DENVER, LAVEEN; SHUNTS)

ORDER NO. : 4315

PURPOSE: To assess the patency of a peritoneal-venous (LeVeen or Denver) shunt.

Ventricular-peritoneal or ventricular-atrial shunts evaluation

PATIENT

PREP: No patient preparation is required.

RADIOPHARM

AND DOSE: LaVeen or Denver shunt ^99mTc MAA (macroaggregated albumin)

Ventricle-peritoneal (or atrial) shunt: ^99mTc pertechnetate.

Physician prescribed dose or the dose from the standard Nuclear Medicine dose sheet.

INSTRUMENT

AND SET-UP: All type of shunts: Single headed Gamma camera and computer; camera peaked on 140 kev with 20% window and LEAP or LEHR collimator

LaVeen or Denver shunt; Set the computer to acquire a dynamic set of images in a 128x128 matrix for 60 sec/frame for 60 frames; post static spot maybe required and can be collected in the same matrix for 3-5 minutes each.

Intraventricular - peritoneal shunts; Set the computer to acquire fast dynamic frames 120 at 10 sec/frame for 20 minutes.. If static images are needed collect in 256x256 matrix.

PROCEDURE: LaVeen or Denver shunt; The radiopharmaceutical is injected by a radiologist into the peritoneal space under aseptic conditions. (use a 25G spinal needle). Patient is instructed to slowly roll around to disperse the radionuclide throughout the peritoneal space. Dynamic images are obtained over the chest until activity is seen in the lungs or at the end of one hour. Further imaging is coordinated by the monitoring radiologist.

Ventricular shunts; Evaluated by the injection of tracer into the shunt reservoir. The Neurosurgeon or his /her representative must be present to access the shunt for injection of tracer.

Most of these shunts have a pump mechanism which can be activated by the patient. Fast dynamic images .5-1.0 sec/frame are acquired as the patient or Neurosurgeon activates the pump. Occlusion with finger distally allows activity to end the proximal shunt and ventricle if the proximal limb is patent. Imaging to show the activity in the peritoneal cavity is performed. The patient is allowed to ambulate or rocked back and forth to prove free flow of radiopharmaceutical in the peritoneal cavity.

Imaging Summary: LaVeen or Denver Shunt: Image 1 minute per frame / 1 hour over the upper abdomen and lungs. Later spots as needed, as directed by monitoring radiologist.

VP Shunt: Image at 10 sec/ frame for 20 minutes. Delayed spots of distal limb and abdomen (pre and post ambulation as needed).

PROCESSING: LaVeen or Denver shunt; The dynamic images are compressed to 5 minute images for filming. Areas are drawn over the lung fields and curves are generated using the 60 dynamic images. The curves help to determine shunt patency if there is an increase in activity (^99mTc MAA) in the lungs over time.

Ventricular shunts; compress the dynamic frames to 2 sec/frame for display. Delayed spot are filmed together in a screen capture, sent to PACS.

POST EXAM: Patient should follow orders of physician administering the tracer.

DYNAMIC ACQUISITION FOR LEVEEN/DENVER:

ACQUISTION
CAMERA	Acquisition type	Dynamic
	Collimator	LEUHR or LEHR
	Detectors	Detector 1
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	60 sec/frame
	Number of images	60 frames
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

DYNAMIC ACQUISITION VENTRICULOPERITONEAL:

ACQUISTION
CAMERA	Acquisition type	Dynamic
	Collimator	LEUHR or LEHR
	Detectors	Detector 1
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	10 sec/frame
	Number of images	120 frames
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

STATIC ACQUISITION

ACQUISTION
CAMERA	Acquisition type	STATIC
	Collimator	LEUHR or LEHR
	Detectors	Detector 1
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	180 seconds
	Number of images	1
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

PROCEDURE: Testicular scan with vascular flow

ORDER NO. : NM Testicular Scan (IMG13036) (Performable)

INDICATION: Testicular pain and/or swelling due to possible torsion, trauma, hydrocele, infection.

PATIENT

PREP: 400 mg Sodium perchlorate (adult), adjust for pediatric patients

RADIOPHARM

AND DOSE: ^99mTc pertechnetate.

Physician prescribed dose or the dose from the standard Nuclear Medicine dose sheet.

INSTRUMENT: Gamma camera with LEAP or LEHR collimation, peaked on 140kev with 20% window. Computer set to acquire dynamic with post static images. Dynamic images in a 64x64 matrix at 2 sec/frame for 60 seconds. Static images in a 256x256 matrix for 180 seconds.

PROCEDURE: Patient should be given sodium perchlorate when possible to block the thyroid from trapping Tc99m pertechnetate.

The patient is positioned supine with the legs abducted (frog leg), The penis is positioned cephalad and tapped to the abdomen. The scrotum is elevated with towels or foam. The testes are arranged in a positioned to eliminate overlapping and a thin lead attenuator is tapped between the testes. Position the camera as close and parallel to the testes as possible

The ^99mTc pertechnetate is injected as a compact bolus with a 15 ml flush of saline. The dynamic acquisition is started upon injection.

A single 500k static image with the lead in place is obtained immediate post dynamic. The radiologist should be consulted to determine if images with markers are necessary).(e.g marker over palpable testicle).

Imaging Summary: 2 sec/frame for 30 frames, then 3 minute static spot image.

PROCESSING: The dynamic images can be read from image review into display and viewed in cine mode. Dynamics are compressed to 6 sec/frame and imaged as series. Spot images and imaging series sent to PACS as screen capture.

POST EXAM: No precautions or special instructions are required for this exam.

DYNAMIC ACQUISITION:

ACQUISTION
CAMERA	Acquisition type	Dynamic FLOW
	Collimator	LEUHR or LEHR
	Detectors	Detector 1
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	128 x 128
	Acquisition time	2 sec/frame
	Number of images	30 frames
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

STATIC ACQUISITION

ACQUISTION
CAMERA	Acquisition type	STATIC
	Collimator	LEUHR or LEHR
	Detectors	Detector 1
	Isotope	Tc99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	256X256
	Acquisition time	180 seconds
	Number of images	1
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

PROCEDURE: Thyroid Scan ; (^99mTc99m pertechnetate)

ORDER NO.: 4270

INDICATIONS: Assessment of thyroid trapping, measurements of gland size, and thyroid anatomy. Thyroid function. (Graves Disease and functioning nodules) Technetium does not evaluate thyroid organification mechanism.

PATIENT

PREP: Check to see if the patient has had any medications or contrast materials that will interfere with the scan. Iodine contrast used in CT and angiography can suppress radioactive Iodine uptake for up to 6 weeks. Exogenous thyroid hormone will also suppress radioactive iodine uptake for up to 6 weeks.

PATIENT MUST NOT HAVE HAD IV CONTRAST FOR 6 WEEKS PRIOR TO SCAN (i.e., cannot have had recent (within 6 weeks) CT scan with contrast or angiography).

PATIENT MUST NOT BE ON THYROID REPLACEMENT THERAPY SYNTHROID (T4), CYTOMEL (T3)]. (Must be off synthroid for 4 - 6 weeks or off cytomel for 2 weeks).

PATIENT MUST NOT BE ON ANTITHYROID MEDICATIONS (PTU or Tapazol). These drugs must be discontinued for a least 2 days.

RADIOPHARM

AND DOSE: ^99mTc as Pertechnetate, injected intravenously.

Physician prescribed dose or the dose from the standard Nuclear Medicine dose sheet.

INSTRUMENT: Gamma camera with pinhole collimator (Digirad or Siemens).. The high resolution parallel hole collimator is used when imaging marker on nodules to avoid the problem of parallax encountered with the pinhole collimator.

Spot anterior image for 50K (record time). Anterior obliques for equal time.

PROCEDURE: With pertechnetate, At 15-20 minutes post injection, 5 minute static images are acquired in the anterior LAO, and RAO views. Marker images are obtained in the anterior view with the thyroid cartilage, suprasternal notch, and rt side marked.

Position the pinhole collimator for the routine views as close to the patients neck as possible and still see the entire thyroid gland in the field of view. This provides for the maximum magnification of the gland. The position of the pinhole for the marker view must be at a distance that allows the markers on the suprasternal notch and the thyroid cartilage to be imaged.

When marking a nodule the high resolution parallel hole collimator must be used to avoid the distortion of position caused by parallax

Imaging Summary: Anterior spot for 50K (record time), the LAO and RAO spots for equal time.

PROCESSING: The gland size can be measured by obtaining an image of the gland and a set of point sources at a known distance from one another with the hi resolution collimator When filming the two images annotate the point source image with the distance between the sources.

FILMING

THE STUDY: Images sent as screen capture to PACS

POST EXAM: No precautions or special instructions are required for this exam.

STATIC ACQUISITION:

ACQUISTION
CAMERA	Acquisition type	STATIC
	Collimator	PINHOLE
	Detectors	Detector 1
	Isotope	123-I
	Peak	159 KeV
	Energy Window	20%
	Matrix	256X256
	Acquisition time	300 seconds
	Number of images	4
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

PROCEDURE: Thyroid Uptake and Scan (¹²³I- NaI)

ORDER NO.: 4290

INDICATIONS: Assessment of thyroid function, measurements of gland size, and thyroid anatomy. Diagnosis of Grave’s Disease and functioning nodules.

PATIENT

PREP: Check to see if the patient has had any medications or contrast materials that will interfere with the scan. Iodine contrast used in CT, and angiography can suppress radioactive Iodine uptake for up to 6 weeks. Exogenous thyroid hormone will also suppress radioactive iodine uptake for up to 6 weeks.

PATIENT MUST NOT HAVE HAD IV CONTRAST FOR 6 WEEKS PRIOR TO SCAN (ie.,can not have had recent (within 6 weeks) CT scan with contrast, or angiography).

PATIENT MUST NOT BE ON THYROID REPLACEMENT THERAPY SYNTHYROID (T4), CYTOMEL (T3)]. (Must be off synthroid for 6 weeks or off cytomel for 2 weeks).

PATIENT MUST NOT BE ON ANTITHYROID MEDICATIONS (PTU or Tapazol). These drugs must be discontinued for a least 2 days.

RADIOPHARM

AND DOSE: ¹²³I- NaI, administered orally.

This procedure falls under our Quality Management Program.

A written directive by Director of Nuclear Medicine or his designee is required. Patient identity verification by two means is required. Copies of the written directive must be kept in the department as documentation for HRS Inspection

Spot anterior image for 50K (record time). Anterior obliques for equal time.

PROCEDURE: Uptake; See Appendix A to this procedure for Uptake protocol on the Capintec thyroid uptake probe.

To obtain the standard count for an uptake calculation the ¹²³I- NaI capsule must be counted in the neck phantom using either the thyroid uptake probe or a camera with the pinhole collimator. Obtain for equal time one capsule counts for the standard and a single background. Record the time the counts were taken. Administer the capsules to the patient and instruct the patient to return at 6 hours for a neck count and thyroid gland imaging to follow.

At six hours obtain a thyroid gland counts and a single thigh background count on the patient. Record the time. Decay correct the standard count to the time the patient was counted. Divide the patient counts by the corrected standard count to obtain the fraction uptake.

At 6 hours after oral administration of radiopharmaceutical, static images are acquired in the anterior, LAO, and RAO views. Marker images are obtained in the anterior view with the thyroid cartilage, suprasternal notch, and rt side marked. The anterior view should be for 50K, the time recorded, and the obliques obtained for equal time.

Imaging; For routine views, position the pinhole collimator as close to the patients neck as possible and still see the entire thyroid gland in the field of view. This provides for the maximum magnification of the gland. The position of the pinhole for the marker view must be at a distance that allows the markers on the suprasternal notch and the thyroid cartilage to be imaged.

When marking a nodule the high resolution parallel hole collimator must be used to avoid the distortion of position caused by parallax

Imaging Summary: Anterior spot for 50K (record time), the LAO and RAO spots for equal time.

STATIC ACQUISITION:

ACQUISTION
CAMERA	Acquisition type	STATIC
	Collimator	LEHR OR LEUHR
	Detectors	Detector 1
	Isotope	123-I
	Peak	159 KeV
	Energy Window	20%
	Matrix	256X256
	Acquisition time	300 seconds
	Number of images	4
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

PROCESSING: The gland size can be measured by obtaining an image of the gland and a set of point sources at a known distance from one another with the high resolution collimator. When filming the two images annotate the point source image with the distance between the sources.

FILMING

THE STUDY: The images are captured as screen captures and sent to PACS.

POST EXAM: No precautions or special instructions are required for this exam.

STUDY NAME: Venogram Bilateral or Venogram Unilateral (NM Extremity upper/lower)

ORDER NO.: IMG13075 Bilateral (CPT 78458); IMG13076 Unilateral (CPT 78457).

INDICATIONS: When a DVT is suspected or as protocol for ruling out pulmonary emboli and evaluation of venous flow.

RADIOPHARM

AND DOSE: ^99mTc MAA.

Physician prescribed dose or the dose from the standard Nuclear Medicine dose sheet. Patients with single lower extremities receive one-half dose.

When indicated for DVT, a Bilateral Venogram should precede perfusion imaging of the lungs.

INSTRUMENT

AND SET-UP: Can be performed on any large field of view camera.

Collect 50,000 counts anterior static images in a 256x256 matrix.

PROCEDURE: Bilateral venogram

The patient is positioned supine with no supports under the legs. Tourniquets are tied tightly above the ankle and below the knee to force venous blood flow to the deep veins. On occasion a third tourniquet may be required at the mid calf. Radioactive markers are positioned on the lateral and medial aspects of both knees as reference points. The feet are positioned with the toes straight up.

Insert a 25ga butterfly needle into a small vein in each foot. Selection of the vein should be as low and medial on the foot as possible. To the butterfly attach a three way stopcock and a 12-20 ml syringe of saline flush.

When the butterfly sets are in place two 20ml syringes each containing 4 mCi of ^99mTc MAA diluted to 15-20 ml total volume are attached to the butterfly sets.

Position the camera over the legs with the knee markers at the bottom of the field of view. Simultaneously begin to slowly push 5 ml of the ^99mTc MAA into each foot. When the tracer appears at the level of the knees begin imaging for 50k counts. The calves may be massaged to advance the tracer up the deep veins (over massaging the calf will move the tracer up the deep veins rapidly and cause poor image statistics). This technique of injection of 5cc and 50k count imaging is performed from the knee to the base of the lungs and is usually accomplished in three sets of images on a large field of view camera. If the venogram shows abnormal areas of flow a delay image is taken of the area after the perfusion images of the lungs.

When the venogram is complete the camera is set to acquire 1M-count static images of the lungs. Images include the following views; anterior, posterior, right and left lateral, right and left anterior and posterior oblique. (See lung perfusion)

Upon completion of the perfusion lung images the camera is set acquire an area scan of the lower extremities. This is a 5 min scan looking for MAA labeled clots in the lower extremities.

IMAGING SUMMARY: Spot images of the lower extremities at the level of the knees, thighs and pelvis as activity is injected in the venous system. Delayed “half-whole body” scan of the lower extremity for 5 minutes (at the discretion of the monitoring radiologist)

FILMING

THE STUDY: PLANAR: Display all planar Venogram images on one page. Annotate for type of exam, orientation, view, name, medical record number, and date of exam, make a snapshot and send snapshot to PACS.

POST EXAM: No special instruction or patient care is required following this procedure.

STATIC ACQUISITION:

ACQUISTION
CAMERA	Acquisition type	STATIC
	Collimator	LEHR OR LEUHR
	Detectors	Detectors 1 & 2
	Isotope	TC99m
	Peak	140 KeV
	Energy Window	20%
	Matrix	256X256
	Acquisition time	50Kcts
	Number of images	6
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Head First Supine

Appendix A Capintec uptake probe

Thyroid uptake protocol

.c2.Daily Quality Control Cesium 137 calibration

Go to the main menu and select "System Set-up", select Calibration . Place the Cs137 rod source in the neck phantom. Place the neck phantom in front of the probe so that it touches the distance measurer. The MCA calibration screen should be displayed, press the F1 key to start count acquisition. After approximately 30 seconds enough counts are acquired to display an adequate spectrum to analyze for system calibration, press F1 again to terminate the count acquisition. In the display are two red markers one positioned at channel 32 the other at channel 332, and a white cursor that can be moved through the channels by using the CTRL key and the arrow keys (the CTRL key in conjunction with the arrow key move the cursor faster). Move the white cursor to channel 331 (the channel the cursor is in is displayed in the upper right portion of the header of the display. When the white cursor is positioned at channel 331 depress and hold the CTRL key and press the "R" key (this positions the red marker at channel 331. Move the white cursor to the peak count channel of the 662kev peak of cesium. The channel number of the peak count must be within channels 326 and 335. If the peak count channel is out of this window the system must be calibrated. A printout of the calibration spectrum will be obtained each day of use and placed in the blue folder labeled Thyroid Probe Quality Control. To print the display screen type "U" or arrow across the menu at the bottom of the screen to highlight the UTILITY selection and press enter. Select "PRINT" form the menu, then "SCREEN". At the message "Output path specification [PRN], press enter. The screen will be printed.

Press the ESC key to back through the menus to the Thyroid Uptake option in the main menu.

To perform a Thyroid uptake. (Calibration should be performed at least once a day before counting standards or patients).

NOTE: Menu options in the footer of the display are selected by typing the highlighted letter.

Select Thyroid Uptake from the main menu. A list of patients is displayed with menu options at the bottom of the display ( Select , Add, Delete, Print, and Exit). If a new patient is to be started select "Add" to obtain the patient data entry screen, or if the patient is returning for thyroid counts use the arrows to highlight his name and use "SELECT" to obtain the count data screen.

Adding a patient: Initial capsule counts

Fill in the information requested in each field and press enter to advance to the next field. Some fields have default value such as dose and time that can be changed only when adding a patient. Some fields require input others do not. Fields requiring input will not allow you to advance to another field before you type information into them. After filling in the required fields, the system will prompt you for background and capsule counts through messages displayed in the footer of the display . After background and capsule counts are obtained, and no patient counts are required, you can return to the directory screen by pressing the "ESC" key. At this point you may select any option from the menu or press "ESC" to return to the Main Menu.

Patient counts: The system will calculate uptakes for any interval of elapse time between standard capsule counts and the patient count.

Select Thyroid Uptake from the main menu. A directory of patients is displayed with options in a menu at the bottom of the display to; Select , Add, Delete, Print, and Exit. Use the arrow keys to advance through the list of patients and highlight the patient to be counted, then press enter. (NOTE THAT THERE ARE TWO COLUMNS OF PATIENTS).

You are prompted with messages in the footer of the display for the type of count to obtain, ie. patient background or capsule. When prompted for a capsule count press enter to see the message "Do you want to calculate capsule count?" This message must be answered by typing "Y" if you are decay correcting counts from a capsule that was used to dose a patient. The computer will decay correct the count and prompt you for the next type count to obtain. If a capsule has been saved for a standard answer "N" to this message and proceed to count the standard capsule. When the capsule count is completed a prompt for the next count will appear in the footer of the display.

When all counts are obtained the computer calculates a background corrected uptake for the elapse time between dosing and patient counting. Select print from the menu to obtain a printed report of the thyroid iodine uptake. Submit the thyroid uptake report with the imaging portion of the thyroid procedure for interpretation.

PROCEDURE: Thyroid Scan with perchlorate washout ; (¹²³I NaI)

ORDER NO.: 4250

INDICATIONS: Assessment of thyroid organification mechanism, measurements of gland size, and thyroid anatomy.

PATIENT

PATIENT MUST NOT HAVE HAD IV CONTRAST FOR 6 WEEKS PRIOR TO SCAN (ie., cannot have had recent (within 6 weeks) CT scan with contrast or angiography).

PATIENT MUST NOT BE ON THYROID REPLACEMENT THERAPY SYNTHROID (T4), CYTOMEL (T3)]. (Must be off synthroid for 6 weeks or off cytomel for 2 weeks).

PATIENT MUST NOT BE ON ANTITHYROID MEDICATIONS (PTU or Tapazol). These drugs must be discontinued for a least 2 days.

RADIOPHARM

AND DOSE: ¹²³I- NaI, administered orally.

1.0 grams of potassium perchlorate; administered orally after the 6 hr baseline uptake and scan.

Physician prescribed dose or the dose from the standard Nuclear Medicine dose sheet.

INSTRUMENT: At 6 hours, standard thyroid scan with Anterior spot for 50K (record time), the LAO and RAO spots for equal time. Then, using a Gamma camera with LEAP or LEHR parallel hole collimator for the washout portion of the examination.

PROCEDURE: Uptake; See Appendix A to this procedure for Uptake protocol on the Capintec thyroid uptake probe.

Imaging At 6 hours post dosing, 5 minute static images are acquired in the anterior, LAO, and RAO views. Marker images are obtained in the anterior view with the thyroid cartilage, suprasternal notch, and rt side marked.

Following the standard views, switch to a parallel hole collimator; set the computer to acquire 60 one minute frames. Give the patient 1.0 grams of potassium perchlorate orally. At 15 minutes after giving potassium perchlorate, position the patient for an anterior view of the neck with a zoom of at least 2.0. Instruct the patient to remain still and start the acquisition. At the end of the acquisition have the patient remain in the department until the curves are evaluated by the monitoring physician.

Imaging Summary: At 6 hours, Anterior spot for 50K (record time), the LAO and RAO spots for equal time.

Switch to parallel hole collimator, using zoomed image, and image at 1 minute per frame for 1 hour, beginning 15 minutes after perchlorate administration.

PROCESSING: A washout curve is generated by drawing an AOI around the thyroid gland using the ROI program. Draw the area and include all the frames when generating the time activity curve.

Create a summed series at 5 minute per frame. Image the series as a screen capture and send the series and curves to PACS.

POST EXAM: No precautions or special instructions are required for this exam.

STATIC ACQUISITION:

ACQUISTION
CAMERA	Acquisition type	STATIC
	Collimator	PINHOLE
	Detectors	Detector 1
	Isotope	123-I
	Peak	140 KeV
	Energy Window	20%
	Matrix	256X256
	Acquisition time	300 seconds
	Number of images	4
	Magnification	2.0
	Patient Orientation	Feet First Supine

PROCEDURE: Whole body ¹³¹iodine scan

ORDER NO. NM Total Body Scan I-131 (IMG13041) (Performable)

INDICATIONS: Metastatic survey for papillary, mixed, and follicular cell thyroid carcinomas

PATIENT PREP

Off thyroid hormones supplements for minimum of 6 weeks.

Conversely: Use thyrogen stimulation:

RADIOPHARM

AND DOSE: ¹³¹I- sodium iodide administered orally.

This procedure falls under our Quality Management Program.

INSTRUMENT

AND SET-UP: Dual headed gamma camera with high energy collimators, peaked over 364 keV

With thyroid replacement withdrawal: Scan at 72 hours, (30 minute scan), plus 5 minute spot image of neck. SPECT-CT at the discretion of the monitoring radiologist. Uptake performed at 72 hours with canberra uptake system with ¹³¹I window.

With thyrogen stimulation, scan at 48 hours. (30 minute scan), plus 5 minute spot image of neck. SPECT-CT at the discretion of the monitoring radiologist

Post-high dose therapy scans: Performed 1 week after high dose therapy. (30 minute whole body scan).

PROCEDURE: Whole body scan is performed at 72 hours post oral administration of ¹³¹I-for a thyroid withdrawal metastatic survey, at 48 hours after thyrogen stimulated metastatic survey, or at one week after high dose radioablation.

Routine metastatic surveys includes; a whole body survey, spot image of the neck (thyroid bed) and an ¹³¹Iodine uptake calculation of residual thyroid tissue in the neck. Image are checked by a radiologist prior to release of the patient.

Uptakes are performed in the same manner as ¹²³I uptakes with the exception that the ¹³¹I window is selected. A measured standard is obtained by assaying an aliquot of ¹³¹I with an activity of approximately 10 uCi. Perform routine QC on the uptake probe. Select the thyroid program. Enter the required `information for patient demographics. Obtain bkg count, the standard count, a patient thigh and neck count. Ignore the computer calculation for the uptake, you must manually calculate the uptake using the acquired counts and the formula below.

¹³¹I-uptake calculation:

patient neck count - thigh bkg x 100

[((pt. dose in uci x decay factor) ÷ std activity) x std count]

Imaging Summary: 30 minute whole body scan and 5 minute spot of the neck.

PROCESSING: Whole body and spot images require no processing. Screen capture and sent to PACS

POST EXAM: A physician must review the films prior to release of the patient.

WHOLEBODY IMAGING:

ACQUISTION
CAMERA	Acquisition type	WHOLEBODY
	Collimator	HEGP
	Detectors	Detectors 1 AND 2
	Isotope	131-I
	Peak	364 KeV
	Energy Window	20%
	Matrix	256X1024
	Acquisition time	8 CM/MIN
	Number of images	1
	Magnification	NONE
	Patient Orientation	Feet First Supine

STATIC ACQUISITION:

ACQUISTION
CAMERA	Acquisition type	STATIC
	Collimator	HEGP
	Detectors	Detector 1
	Isotope	131-I
	Peak	364 KeV
	Energy Window	20%
	Matrix	256X256
	Acquisition time	300 seconds
	Number of images	1
	Magnification	0-2.0(Depending patient size)
	Patient Orientation	Feet First Supine

SUBJECT: Patient Restraints and the routine use of passive immobilization devices during diagnostic imaging exams in Nuclear Medicine.

PURPOSE: To provide for patients safety and reduction of artifacts on diagnostic Nuclear Medicine images caused by motion, while protecting the patient’s health and safety and preserving the patient’s dignity, rights and well-being.

POLICY: A. Inpatients that have been physically restrained under the Hospital Policy PM 02-26 will have physical restraint continued while in Nuclear Medicine for diagnostic imaging exams. The Nuclear Medicine staff will assess the need for modification of standard imaging protocols to accommodate the type of restraint devices used and the use of passive devices used routinely during Nuclear medicine imaging to reduce motion artifacts.

If additional physical restraints or sedation is required for the diagnostic procedure, then the referring physician must be contacted to assess the need and write the orders. Verbal orders for sedation orders may be taken by a radiology physician or radiology nurse.

B. The use of passive devices to reduce motion, stabilize body part positioning, keep clothing and linen safely out of mechanical motion of equipment, and provide for patients general safety are routinely used as standard protocol during all diagnostic imaging exams performed in Nuclear Medicine.

Patients, patient’s parents, and/or guardians are educated and informed on the need and use of passive devices prior to their use for imaging examinations.

Patient have the right to refuse the use of passive restraints.

Staff routinely checks patients and makes adjustments to passive devices when necessary for the patients comfort.

DEFINITIONS: Passive devices: Mechanical devices that allow movement but serve to stabilize or support the body or body parts or secure clothing and lines from equipment for the purpose of enhancing diagnostic image quality Velcro straps, lead aprons, sand bags, bean bags and wedges.

Shands Nuclear Medicine Standard Dose Sheet

The following are standard adult dose for routine scans performed in the Nuclear Medicine department. Doses for pediatric patients are calculated as a percent of the standard adult dose based on the patient’s age or weight.

Dr. Drane or this designee may prescribe dose that vary from this standard list. Prescribed doses will be in written form on the consult for the exam ordered.

SCAN DOSE PHARMACEUTICAL

BILIARY TRACT 5-12 mCi Tc99m MEBROFENIN

Biliary /gastric(dual iso) 2-4 mCi Tc99m MEBROFENIN

50 - 150 uCi Ga-67 Citrate

BONE SCAN 20-30 mCi Tc99m MDP

BONE - MARROW 10-15 mCi Tc99m Sulfur Colloid- Tc99m Microlite

WHOLE BODY SCAN MET SURVEY 5-10 mCi I131

WHOLE BODY SCAN MEDULARY CA 15 mCi DMSA

BRAIN - FUNCTIONAL 25-35 mCi Tc99m HMPAO or

5-6 mCi I-123 IMP

BRAIN - HMPAO/THALLIUM 2-3.0 mCi Tl-201

10.0 mCi Tc99mHMPAO

BRAIN - TUMOR/DEATH 15-30 mCi Tc99m DTPA

ESOPHAGEAL .1-.3 mCi/swallow Tc99m Sulfur Colloid

CISTERNOGRAM .5-1.0 mCi In-111 DTPA

F-18 Flourdeoxyglucose

Tumor, Brain, Heart 5-15 mCi F-18 FDG

GALLIUM-67 5-12 mCi Ga-67 citrate

TUMOR imaging 20mCi Tc99m Sestimibi (cardiolite)

TUMOR imaging 2-4mCi Tl 201 Thallius chloride

GALLIUM-68 5.4mCi GALLIUM-68 DOTATATE

GASTRIC EMPTYING .3-1.0 mCi Tc99m Sulfur Colloid

GI BLEED 25-30 mCi Tc99m labeled RBC

INDIUM LABELED WBC .5-1.0 mCi In-111 oxine labeled WBC

LIVER - MAA single vessel 4 mCi in 6cc vol Tc99m MAA @ 100mCi/8ml

2 vessel 4 mCi Rt./2 mCi Lt Tc99m MAA @ 100mCi/8ml

LIVER HEMANGIOMA 25-30 mCi Tc99m labeled RBC

LIVER/SPLEEN 4-6 mCi Tc99m Sulfur Colloid

LUNG PERFUSION (incl. venogram) 2-8 mCi Tc99m MAA

LUNG VENTILATION 10-20 mCi Xe-133

LUNG AEROSOL 40-50 mCi Tc99m DTPA 1 mCi to

in Nebulizer Pt. from Nebulizer

LYMPHOSCINTIGRAPHY 1-2 mCi Tc99m (MICROLITE)colloid

MYOCARDIAL FUNCTION 20-30 mCi Tc99m labeled RBC

MYOCARDIAL INFARCT 25 mCi Tc99m Pyrophosphate

MYOCARDIAL PERFUSION stress 2.5-4mCi Tl 201 Thallius chloride

reinj. 1-1.5mCi Tl 201 Thallius chloride

MYOCARDIAL perf cont washout 40-60mCi Tc99m Cardiotec

MYOCARDIAL perf cont stress 15-20mCi Tc99m Cardiolite

rest 20-40mCi Tc99m Cardiolite

Shands Nuclear Medicine Standard Dose Sheet

Dr. Drane or this designee may prescribe dose that vary from this standard list. Prescribed doses will be in written form on the consult for the exam ordered.

MECKEL'S 100uCi/kg Tc99m Pertechnetate

PARATHYROID

TCc99m sestimibi/Tc 10 mCi Tc99m Sestemibi

2 mCi Tc99m Pertechnetate

Tl/Tc 2 mCi Tc99m Pertechnetate

4 mCi Thallium chloride

PERITONEAL SCINTIGRAPHY 1-2 mCi Tc99m Sulfur Colloid

PROSTASCINT 5-8mCi In111 Capromab Pendetide

30 mCi Tc99m Ultratag RBC

PLATELETS SURVIVAL .5-1.0 Indium -111 Oxine

RED CELL VOLUME 100 uCi Cr-51 Chromate

RED CELL SURVIVAL/

SEQUESTRATION 200 uCi Cr-51 Chromate

RENAL-ERPF ONLY 30-50 uCi I-131 Hippuran

RENAL SCAN-FLOW/FUNCTION 5-10 mCi Tc99m DTPA (or Tc99m

(or 5-10 mCi) Glucoheptonate

RENAL SCAN - CORTICAL 0.5-3 mCi Tc99m DMSA

RENAL TRANSPLANT 2-5 mCi Tc99m Sulfur Colloid

RENOGRAM - ADULT 150 uCi/kidney I-131 iodohippuraate or 5-10 mCi Tc99m MAG-3

RENOGRAM AGES 6-15 YRS. 100 uCi/kidney I-131 iodohippurate

or 5-10 mCi Tc99m MAG

RENOGRAM AGES 1-6 YRS. 100 uCi total I-131 iiodohippurate or 5-10 mCi Tc99m MAG-3

RENOGRAM AGES <1 YR. 50 uCi total I-131 iodohippurate

or 5-10 mCi Tc99m MAG

SHUNT-LEVENE 1 mCi Tc99m MAA

SPLIT LUNG 2 mCi Tc99m MAA

TESTICULAR SCAN 15-30 mCi Tc99m pertechnetate

THYROID SCAN 5-10 mCi Tc99m pertechnetate

THYROID UPTAKE/SCAN 200-400 uCi I-123 Sodium iodide

VOIDING CYSTOGRAM .5-1.0 mCi Tc99m Sulfur Colloid

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Procedure for weekly swipe testing for radioactive contamination

Contamination swipe surveys are performed weekly by the technologist designated on the call schedule. On routine weeks the swipes are performed at the end of the day on Thursday. Friday morning the call technologist will review the swipe results for contaminated areas and decontaminate, rewipe and count areas as necessary.

Responsible persons: Initial swipe test-Thursday evening will be by the technologist designated on the call schedule.

Review and retesting-Friday morning is the Call technologist

Multisample Counting System

Operation instructions for Swipe test

IMPORTANT:

1. Always leave at least 4 blank tube holders in front of the counting chamber, then start with a background sample followed by samples.

2. In the "Edit Batch Configuration File for AMS" the Isotope Library field must always be "survey".

Revised:‑

Page 2 of3

System Menus - Menu and the option for proceeded to the swipe configuration file are in bold

Menu title: Micrad, Inc. AutoGamma Measurement System

Nuclear Medicine Gamma Scanner

Radiochromatography Scanner

Quit-return to DOS

Menu title: Micrad Automated Isotope Counter

QA check

Operate the MCA

Exit

Nuclear Medicine

Radiation Protection

Menu Title: Nuclear Medicine Counting Applications

General Counting

RIA

Schillings

Blood Volume

Cell Survival

Return to base menu

Menu title: Gamma Counting

Measure samples

Data manipulation

Other functions

Return to Nuclear Medicine menu

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Page 3 of3

Selection of the measure sample option will bring up the "Edit Batch Configuration File for sample counting. Instructions for setting the configuration file to count are as follows.

Press the Enter key. A pop up menu will ask if you want to append the file, answer by typing Y. A second question will appear asking if it is OK to erase the file, answer by typing Y

You can now use the enter key or arrow keys to navigate through the fields in the Edit batch configuration file. The field entries are as follows.

Batch file name: swipe

First sample position: (the number of the holder of the background sample)

(Note: The first sample must be at least 4 holder from the counting chamber.)

Number of samples: (enter the # of samples including background )

Subject: Swipes

User: (enter your name)

Comments: (scan rooms)

Batch protocol name: (Swipes)

Count time seconds: (60)

Isotope Library: (Survey)

Decay correction: (N)

Decay date: ( can be any date if decay correction is No)

Time: (can be any time if decay correction is No)

Number of cycles: (1)

Total time: (1)

After you change the necessary fields, depress the 'CNTRL' key and 'END' key simultaneously to accept the Configuration file. You are asked to strike 'any key' to initiate the counting process.

Attached is a copy of the final print out of the raw and background corrected counts. Each column of counts is labeled with a description of the count data. The column labeled 'Bkgnd Corr survey' are the counts used for determining contamination. Any count in this column greater than 91 cpm is greater than the 200 dpm cutoff level for contamination when it is converted to account for the efficiency of the counting system. All areas greater than 91cpm must be decontaminated, rewiped, and counted until the contamination level is below 91cpm.

Revised: ‑

Page 1 of 1

Daily radiation surveys in Scanning and Dosing areas within the Nuclear Medicine and Department and Radiopharmacy.

Radiation surveys are performed daily in the Rooms G509, G511, G507, G508

This procedure manual is a technical guide for routine clinical exam performed in the UF Health Nuclear Medicine Department. This manual will be reviewed annually by the Director of Nuclear Medicine, Associate Professors, and Supervisor of the Nuclear Medicine. Routine procedures will be updated with permanent changes as they are made. New procedures will be added to the manual at the time the procedure is designated by the Director of Nuclear Medicine as a clinical exam.

As a minimum, a procedure protocol will provide; name of the procedure, a reference to the standard radiopharmaceutical and dose activity, route of administration, preferred imaging equipment, and acquisition and processing parameters.

I have reviewed the above revisions and additions to the Nuclear Medicine Procedure Manual.

Date:28 APRIL 2021

Walter E. Drane, MD, FACR.

Director of Nuclear Medicine

Jason Norton

Date: 4/28/2021

Jason Norton, CNMT, RT(N)(CT)

Supervisor, Nuclear Medicine

Potassium Iodide DOSING
Age/Weight	Thyroshield dose
Neonates (birth to 1 month)	16.25 mg (0.25 mL)
Children over 1 month to 3 yrs	32.5 mg (0.5 mL)
	Iosat Tablet Dose
Children over 3 yrs to 12 yrs	65 mg (½ tablet)
Children over 12 yrs to 18 yrs who weigh less than 68 kg (150 lbs)	65 mg (½ tablet)
Children over 12 yrs to 18 yrs who weigh at least 68 kg (150 lbs)	130 mg (1 tablet)
Adults greater than 18 yrs	130 mg (1 tablet)