CARE RightCommitted to ALARA

Taking low dose to the next level

In medical imaging it is essential to provide sound and sustainable clinical results with highest patient safety. When it comes to applying radiation, ALARA - as low as reasonably achievable - is the overarching principle.

For years, Siemens Healthineers has been at the forefront of radiation reduction. Continuous dedication and unique technological advances have made Siemens CT the low dose leader to catch. Thanks to these efforts, scans at sub-mSv doses found their way into clinical routine.

But as such low doses become achievable, one has to verify whether 1 mSv actually is the right dose for every patient. Obviously, there isn’t one dose level that fits everyone. Every clinical question and every single patient demands an individual and specific dose level. Therefore, while everybody is only talking about low dose, Siemens Healthineers is convinced that what really matters is the right dose.

CARE Right. Committed to the Right Dose in CT

The right dose is the reasonable balance between applied radiation, image quality and patient care. In order to help customers achieve this balance, Siemens Healthineers has introduced CARE Right.

This holistic approach is based on the belief that after the recent innovations in radiation reduction, a singular focus on low dose only is not sufficient anymore. Consequently, efforts must now be targeted towards a comprehensive understanding of the right dose. Thus, CARE Right encompasses three key areas:

Right Dose Technology

Enable the Right Dose with best-in-class technology

In order to reduce radiation to the right dose, of course, the first prerequisite is still the appropriate hardware: healthcare institutions need the right technology. Siemens Healthineers has a long tradition of being an innovation leader in CT technology: whether it was the introduction of CARE (Combined Applications to Reduce Exposure) in the 1990s, Dual Source CT in the 2000s, or the Stellar detector in the 2010s, Siemens Healthineers has continuously been one step ahead. Therefore, it was a logical consequence that Siemens Healthineers was named “the low dose leader to catch” when its SOMATOM^® Definition Flash won the 2011 Best in KLAS award.¹ Overall, this was due to the fact that Siemens Healthineers offers a comprehensive and innovative portfolio of unique dose reduction features.

Focus on the individual patient and examination

In order to achieve the right dose for a patient, there are three important factors to consider: the size and stature of the patient, the type of examination, and the applied radiation dose. With Siemens Healthineers’ technology, all of these aspects can be addressed:

The Tin Filter cuts out lower energies to reduce dose and optimize image quality at the interface between soft tissue and air. This has direct benefits in lung and colon imaging, for example.

Tin Filter

CT – Technologies – ADMIRE – Advanced Modeled Iterative Reconstruction

ADMIRE (Advanced Modeled Iterative Reconstruction) is an advanced iterative image reconstruction algorithm that achieves higher resolution at organ borders and improved delineation of edges.² One advantage of this is that it may potentially allow clinicians to better localize lesions. Fast reconstruction times also mean that ADMIRE can smoothly integrate into daily clinical routines.

SAFIRE (Sinogram Affirmed Iterative Reconstruction) is a unique image reconstruction algorithm that reduces noise³ without affecting image quality or detail visualization. It does this by introducing multiple iteration steps into the raw data during the reconstruction process.

SAFIRE

CARE Dose4D^™ achieves significant dose reductions with automated dose modulation for individual patient size and shape while producing optimal image quality.

CARE Dose 4D^™

CARE kV automated dose-optimized selection

CARE kV offers an automated dose-optimized selection of the X-ray tube voltage (kV) depending on the selected type of examination. It is the industry’s first tool that automatically determines the appropriate kV and scan parameter settings to help deliver the right dose for a particular scan and the user defined image quality.

CARE kV

Low kV
One of the main parameters of a scan protocol is the tube voltage, kV. The SOMATOM scanners offers different kV values from 70 to 150 kV depending on the scanner type. The tube voltage is an important parameter that has an impact on radiation dose and image impression.

CARE Right – Low kV

Adaptive Dose Shield
In spiral CT, it is routine to do an extra half-rotation of the gantry before and after each scan, even though only part of the acquired data is necessary for the image reconstruction. The Adaptive Dose Shield, a technology based on precise, fast, and independent movement of both collimator blades asymmetrically opens and closes at the beginning and end of each spiral scan, temporarily blocking those parts of the X-ray beam that are not used for image reconstruction. As a result, only the targeted tissue is irradiated.

Right Dose Levels

Scan at the Right Dose Levels

Next to having access to the right technology, it is essential to know the right dose levels to perform an examination according to ALARA (as low as reasonably achievable). The right dose level is the best possible balance between image quality and required amount of radiation.

Absolute Dose Values in Computed Tomography

Absolute dose values - essential for the right dose

A prerequisite for users to know whether they apply the right dose levels is an understanding of absolute dose values. This is why Siemens Healthineers provides them along with their protocols. Users can then use these values as a reference to compare their current dose level with regional recommendations and guidelines, scientific publications, or the dose levels delivered by Siemens Healthineers CT standard scan protocols.

Siemens CT standard scan protocols

These scan protocols apply these recommendations to each examination. Along with international guidelines and reference values, Siemens Healthineers’ dedicated protocol development team continuously incorporates the feedback from panels into a sophisticated library of scan protocols.

Right Dose Management

Continuously optimize dose with the Right Dose Management

In order to establish consistent dose levels, organizations need to be able to sustainably manage dose across their institutions. They may also be required to document and report dose applied to patients due to regional regulations.

The right tools for sustainable dose management

All of these requirements rely on the availability of dose data and adequately educated personal. These two aspects are at the core of Right Dose Management, which further optimizes dose reduction.

DoseMAP - Siemens Healthineers CT Dose Management Program - creates transparency in dose values and makes it possible to assess the dose situation. It provides functionalities like CARE Analytics to report, document and analyze dose. It lets the user access dose values per case, per examination type, or per patient.
DoseMAP may also help to protect our patients from over radiation - thanks to its alert function that warms the operator in case set dose thresholds are exceeded.
Additionally, to protect the set dose levels, access to scan protocols can be restricted to prevent unauthorized changes to the scan parameters.

EduCARE bundles dedicated trainings from Siemens Healthineers that focus on key technologies and their application in clinical practice. Exclusive tutorials, webinars, e-trainings, and brochures cover a wide range of topics related to achieving the right dose.
Clinical Webinars
“How to guides”

Optimize CARE CT is a consultancy program offered by Siemens Healthineers Customer Service. Over the course of the program, Siemens Healthineers professionals guide users towards optimizing the use of radiation in order to reduce dose. Through onsite and offsite support and trainings, users learn how to use the right dose technology to deliver the right dose levels for every patient.⁴

CRADLE - This comprehensive consultancy program advances and optimizes medication safety and dose management.¹

Cases

Clinical Examples: Scanning with the right dose

CARE Right aims at finding the right dose for every individual patient. What matters is the right balance between image quality and radiation dose. All of CARE Right’s individual areas – Right Dose Technology, Right Dose Levels, and Right Dose Management – come together in the following examples.

Case 1: CT chest angiography pediatrics

SOMATOM Drive

Diagnosis: Coarctation of the aorta
(Image: Shandong Medical Imaging Research Institute / Shandong, P. R. China)

Used iterative reconstruction method: SAFIRE

Collimation: 128 x 0.6 mm	70 kV, 130 mAs
Flash scan mode	CTDI_vol: 0.37 mGy
Scan time: 0.32 s	DLP: 8 mGy cm
Scan length: 144 mm	Eff. dose: 0.35 mSv
Rotation time: 0.28 s

Case 2: CT chest abdomen pelvis angiography

SOMATOM Force

Diagnosis: A re-evaluation CTA using only 20 mL of contrast media confirmed a Stanford B aortic dissection, beginning behind the junction of the left subclavian artery and stretching to just below the diaphragm, with a new partially thrombotic occlusion of the false lumen.
(Image: University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University)

Used iterative reconstruction method: ADMIRE

Collimation: 192 x 0.6 mm	80 kV, 140 mAs
Flash scan mode	CTDI_vol: 2.09 mGy
Scan time: 0.91 s	DLP: 154.6 mGy cm
Scan length: 673.6 mm	Eff. dose: 2.3 mSv
Rotation time: 0.25 s

Case 3: CT abdomen pelvis

SOMATOM Perspective

Diagnosis: The radiologists found the right balance between applied radiation and image quality. As the habitus of the patient is larger than the reference patient, 5.6 mSv was the right effective dose to achieve this balance. CT images showed a cauliflower-like, broad-based soft tissue mass located on the left-posterior wall of the rectum. It measured 25 x 22 mm and was causing luminal narrowing.
(Image: Department of Radiology, Panshi City Hospital, Lilin, P. R. China)

Used Iterative Reconstruction Method: SAFIRE

Collimation: 64 x 0.6 mm	110 kV, 86 mAs
Scan time: 13 s	CTDI_vol: 6.36 mGy
Scan length: 518 mm	DLP: 374.27 mGy cm
Rotation time: 0.6 s	Eff. dose: 5.6 mSv

Case 4: Pediatric case

SOMATOM Definition Flash with Stellar detector

Diagnosis: Septum defect with impact on lung perfusion?
(Image: Erasmus MC - University Medical Center Rotterdam / Rotterdam, the Netherlands)

Scan method: thorax Dual Energy scan and Flash Spiral scan

Thorax Dual Energy scan:

Collimation: 64 x 0.6 mm	80/140 Sn kV, 26/16 mAs
Spatial resolution: 0.30 mm	DLP: 18 mGy cm
Scan time: 2 s	CTDI_vol: 1.28 mGy
Scan length: 118 mm	Eff. dose: 1.58 mSv
TI: 0.28 s

Flash Spiral scan:

Collimation: 128 x 0.6 mm	70 kV, 14 mAs
Spatial resolution: 0.30 mm	DLP: 3 mGy cm
Scan time: 0.29 s	CTDI_vol: 0.15 mGy
Scan length: 118 mm	Eff. dose: 0.26 mSv
TI: 0.28 s

Case 5: CT abdomen

SOMATOM Definition Edge

Diagnosis: EVAR with persistent aortic endoleak
(Image: Clinique CIMOP Bizet / Paris, France)

Collimation: 128 x 0.6 mm	100 kV, 83 mAs
Spatial resolution: 0.30 mm	DLP: 190 mGy cm
Scan time: 3 s	CTDI_vol: 3.29 mGy
Scan length: 543 mm	Eff. dose: 2.85 mSv
TI: 0.28 s

Case 6: CT abdomen

SOMATOM Definition AS

Diagnosis: obese patient after cholecystectomy
(Image: C.I.M. Laennec / Cesson Sevigne, France)

Collimation: 64 x 0.6 mm	100 kV, 300 mAs
Spatial resolution: 0.30 mm	DLP: 529 mGy cm
Scan time: 10 s	CTDI_vol: 13.55 mGy
Scan length: 373 mm	Eff. dose: 7.9 mSv
TI: 0.5 s

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KLAS “CT 2011: Focused On Dose” report, 11/2011

Best in KLAS and Leader in the CT 64-slice and above category

“Best in KLAS Awards Medical Equipment and Infrastructure” report, June 2012

Image quality as defined by low contrast detectability using a model observer method for evaluation. Equivalent low contrast detectability can be achieved with 80% to 85% less dose using ADMIRE at highest strength level for thin (0.6 mm) reconstruction slices in measured and simulated body and head phantoms for low contrast objects with different contrasts. See ADMIRE data sheet for further information.

In clinical practice, the use of ADMIRE may reduce CT patient dose depending on the clinical task, patient size, anatomical location, and clinical practice. A consultation with a radiologist and a physicist should be made to determine the appropriate dose to obtain diagnostic image quality for the particular clinical task.

In clinical practice, the use of SAFIRE may reduce CT patient dose depending on the clinical task, patient size, anatomical location, and clinical practice. A consultation with a radiologist and a physicist should be made to determine the appropriate dose to obtain diagnostic image quality for the particular clinical task. The following test method was used to determine a 54 to 60% dose reduction when using the SAFIRE reconstruction software. Noise, CT numbers, homogeneity, low-contrast resolution and high contrast resolution were assessed in a Gammex 438 phantom. Low dose data reconstructed with SAFIRE showed the same image quality compared to full dose data based on this test. Data on file.

The products/features and/or service offerings here mentioned are not commercially available in all countries and/or for all modalities.If the services are not marketed in countries due to regulatory or other reasons, the service offering cannot be guaranteed

* teamplay is a cloud-based network, running independently from the CT Scanner, that brings together your imaging modality users, the systems' dose and utilization data, and the users' expertise to help you improve the delivery of care to your patients. Basic features are provided free of charge. Premium features are provided on a trial basis for a certain period of time at no charge, and may be used thereafter on a subscription fee basis.