MIBG rules from CHOP

Radiation Safety Information for Parents of Children Treated with 131I-MIBG at Children’s Hospital of Philadelphia (CHOP)

This information is designed for parents (or family members) providing care for their
children undergoing treatment of neuroblastoma with 131I-MIBG.
This information must be viewed by each parent (or family member) that will provide care during the treatment. Federal requirements stipulate that only parents or family members may provide care during the treatment.

Terms
radiation – In this case, it is a shortened term for “ionizing radiation” and is used to describe the wave or particle emitted or “given off” by a substance. 131I is the part of 131I-MIBG that emits radiation. 131I emits both gamma (wave) and beta radiation (particle). The radiation emitted or given off by 131I-MIBG is known as ionizing radiation. Ionizing radiation is tasteless, colorless, and odorless. 131I-MIBG emits two types of ionizing radiation - gamma radiation and beta radiation. For more information on ionizing radiation, see http://hps.org/publicinformation/radfactsheets/
gamma radiation – A type of ionizing radiation in the form of a wave. Gamma radiation is capable of traveling long distances through air and most other materials. The gamma radiation is useful for imaging studies that will be performed in the Nuclear Medicine department at the end of the treatment.
beta radiation – A type of ionizing radiation in the form of a particle. Beta radiation can
travel only short distances. For example, beta radiation from iodine can only travel about ½ inch through body tissue. The beta radiation is what is actually providing the therapeutic part of the treatment.
radioactive – A term used to describe a substance that emits or “gives off” radiation. 131I is radioactive.
radioisotope – A radioactive substance. In this case, 131I is the radioisotope.
half-life – As radioisotopes emit radiation, they “decay” or become weaker. The half-life is the amount of time it takes for a radioisotope to decay thereby emitting only half as much radiation. The half-life of 131I is 8 days. Other radioisotopes have half-lives that range from seconds to many years.
mrem (millirem) – A unit of radiation dose. Most radiation meters and dosimeters are used to measure the radiation dose in units of mrem. 1 mrem = 10 µSv.
µSv (microSievert) – A unit of radiation dose. Some dosimeters use this unit of measurement. 10 µSv = 1 mrem.
dosimeter – a small device worn near the collar that is used to measure the radiation dose in a manner similar to an odometer in a car.
radiation meter – An electronic device used to detect the presence of radiation and measure radiation levels.
contamination – The presence of a radioisotope (131I) in an undesired area. For example, on the soles of shoes or in the hallway outside the room. Contamination, in this case, is
essentially the presence of 131I anywhere but in your child’s body or in the toilet (where the urine is disposed of).
lead shield – Used to stop gamma radiation. Since lead shields are very thick and lead is a very dense material, it stops or “absorbs” almost all of the gamma radiation from 131I.

What is 131I-MIBG?
Metaiodobenzylguanidine (MIBG) is a substance that concentrates in neuroblastoma tumors. A type of radioactive iodine (131I ) is chemically attached to the MIBG forming 131I-MIBG. 131I-MIBG is a clear liquid that looks like water.
Where does 131I-MIBG come from?
131I-MIBG for this treatment is produced at the University of Michigan. The University
of Michigan ships the frozen 131I-MIBG to CHOP within approximately 24 hours of the
treatment.
How is the 131I-MIBG administered?
After the frozen 131I-MIBG is thawed, it is placed in a large (60 cc) syringe. A cart will be brought into the room shortly before the 131I-MIBG treatment begins. An infusion pump will be located on the cart and will be surrounded by lead bricks covered with drapes. The syringe is placed in an infusion pump. The pump slowly pushes the plunger of the syringe. It typically takes about 90 minutes for the administration and another 20
minutes to flush the line with saline. An injection port (e.g., IV port) already established in your child will be used for administration.
What will happen to the 131I-MIBG after it is administered?
The 131I-MIBG will enter into your child’s bloodstream during the administration process and a portion of it should then go to the neuroblastoma lesion(s). Most of the remaining 131IMIBG will be eliminated through the urine over the next several days while your child is in the hospital. The 131I-MIBG will also be in other bodily fluids such as saliva and even the oils secreted by the skin. A small amount 131I-MIBG will remain in your child even after he or she leaves the hospital.
Why must my child stay in the hospital?
Federal regulations require patients receiving designated quantities of radioisotopes to stay in the hospital until a specified amount of the radioisotope has been eliminated. The regulations also stipulate restrictions on these patients while they are in the hospital.
Typical diagnostic nuclear medicine procedures do not require a stay in the hospital or any other restrictions because they involve much lower amounts of radioisotopes. Once your child is released from the hospital, there are no regulatory restrictions that apply.
How will the room be prepared?
The room used for 131I-MIBG treatments will be a typical hospital room with the addition of ¼ inch of lead in the walls and door. There will be three large mobile lead shields that will surround the bed. There will be a lead box at the foot of the bed that will shield urine bag (if one is used).
Most surfaces of the room (floors, bedrails, etc) will be covered with plastic. Equipment, such as the telephone, that your child may touch will also be covered with plastic. There will be several large cardboard boxes lined with red bags.
Basic instructions
•Keep the following items in the room for monitoring by Radiation Safety staff:
1) Food items
2) Catheters
3) Bedding
4) Trash
5) Patient dressings
•Nurses caring for this patient must be properly trained by the Radiation Safety staff.
•Pregnant nurses should not care for this patient.
•No visitors under 18 years or pregnant.
•No housekeeping or dietary personnel should enter the room.
•Use disposable table service for patient.
•All staff entering room must wear a personnel dosimeter.
•Visitors, other than parents, should not stay more than 60 minutes per day.
•Wear disposable gloves and paper gown when caring for patient.
•Wear shoe covers when entering room.
Why is a Foley catheter used during the treatment?
To reduce the radiation exposure to your child’s body and especially to his/her bladder, a Foley catheter system is used to directly eliminate urine. Older children may not be required to have a Foley catheter system. This decision will be made by the medical staff. The Foley catheter is connected to a plastic collection container.
How is the urine handled?
Because the urine will contain 131I, the urine container needs to be stored in a lead box until it is emptied. The urine is collected in a plastic container that is connected to the Foley catheter. The bag is kept in the lead box until it is periodically emptied into the toilet by a member of the nursing staff.
What items can I bring into the room?
You can bring your luggage and belongings into the room. However, these items will need to be stored away from the bed such as behind the chair that you will be sitting and sleeping on. The concern is to keep these items from becoming contaminated during the treatment.
Contamination can only occur by the transfer of body fluids from your child.
What about items that are special to my child?
You should plan to leave anything at home that you do not want to end up in the trash. Any item that your child handles, including clothing worn, will most likely become contaminated with 131I and will be treated as radioactive. These items can not be returned to you.
It is recommended that you bring disposable toys, etc. for your child to play with during the treatment.
What may I do during the treatment?
You may care for your child and assist them with taking medications, going to the bathroom, eating and other necessary activities. Most of your time should be spent in the designated chair. This chair also extends so that it may be used for a bed.
What may my child do during the treatment?
Your child may play video games, watch TV or play with toys, etc. However, you will need to change the TV channels or put movies in the DVD player for your child. A video game controller will be wrapped in plastic so that your child may use it to play video games that are available in the room.
What restrictions will my child have to follow during the treatment?
Your child will have to remain in bed most of the time during the treatment. Exceptions
include using the toilet, going to the Nuclear Medicine department for a scan and, in cases of medical necessity, being moved to another area of the hospital such as the Intensive Care Unit (ICU).
You will be allowed unlimited time in the room during the treatment.

However, the following will apply to you while in the room:
􀂾No eating or drinking;
􀂾Wear appropriate protective clothing (discussed below);
􀂾Follow other radiation safety precautions (discussed below);
􀂾Wear a dosimeter (discussed below);
􀂾Do not use the toilet or shower in the room;
􀂾Only one parent is allowed in the room at a time (except for brief periods of time for
transition).
What precautions will I have to take when entering the room?
Once the treatment has started, you will need to take some precautions. Before entering the room everyone must put on, at a minimum, disposable booties (shoe covers) and an electronic dosimeter. If you will assist your child or will handle anything your child has touched, you will also need to put on a disposable gown and gloves.
If you are sitting in the chair, you do not need to keep your gloves and gown on. However, it is a good idea to keep them next to the chair in case you need to quickly assist your child. Protective clothing will be available in the yellow cart in the hallway across from the room.
What will I have to do when leaving the room?
When leaving the room, booties are removed first. If you aren’t wearing gloves, remove
the booties without touching the outside of the bootie. Booties are placed in the trash boxes by the doorway. As each bootie is removed, place the uncovered foot on the hallway floor. Do not step or walk on the plastic without booties.
After booties have been removed, remove the gown and then finally, the gloves. Place
them in the waste boxes at the doorway.
Checking Hands
A radiation monitor is available on the yellow cart in the hallway to check your hands for contamination. It is probable that any bodily contamination that occurs will involve the palms of the hands. However, it is very unlikely that hand contamination would occur if you follow the precautions outlined.
Why do I have to follow the radiation precautions?
By following the precautions outlined, you will not only minimize your radiation dose, but you will minimize the radiation dose to others (e.g., by not spreading contamination). Also, by not following the recommended precautions (which are stipulated by federal regulations) our permission to perform these treatments may be jeopardized.
Will I be exposed to radiation?
You will be exposed to radiation during the treatment. However, we will help keep your
exposure as low as possible. How well you follow the recommended precautions will greatly
affect the radiation dose you receive.
What ways can I be exposed to radiation?
Exposure to radiation can be divided into the following two basic categories:
􀂾External radiation exposure
􀂾Internal radiation exposure
External Radiation Exposure
You will be exposed to gamma radiation being emitted from the 131I that is in your child. The gamma radiation is emitted from your child in all directions similar to a light
bulb giving off light. The closer you are to your child, the higher level of gamma
radiation. Another source of gamma radiation exposure is the urine. This is why it is stored in a lead box during collection.
Internal Radiation Exposure
This type of exposure mainly results from 131I hand contamination. Any contamination
on the hands can be transferred to food items which, in turn, can transfer the contamination (131I) inside your body. Once the 131I is in your body, exposure from the beta and gamma radiation occurs. Because of the precautions taken during treatments, this type of exposure is highly unlikely.
How can I prevent or reduce my exposure to radiation?
The extent of your radiation dose during the treatment will be determined by how well you follow guidelines listed in the next few paragraphs.
External Radiation Exposure
External radiation exposure can be minimized in the following ways:
􀂾 Minimize the time you spend near your child
􀂾 Maximize your distance from your child as much as possible (the radiation level falls off rapidly with distance)
􀂾 Stay behind the mobile lead shields as much as possible (during the treatment, the
mobile shield at the bedside should be positioned so that you can only see your child’s
head when you are sitting in the chair)
Internal Radiation Exposure
Internal radiation exposure can be prevented in the following ways:
􀂾 Wear gloves when touching your child or anything that your child has touched
􀂾 Do not eat or drink while in the room
􀂾 Wash your hands after leaving the room
􀂾 Check your hands with the hand monitor after leaving the room
How much radiation exposure will I receive?
Typically, parents receive between 100 and 300 mrem (1000 and 3000 µSv) during a
treatment. The federal government limits parents (or family members that are providing care) to 2000 mrem (20,000 µSv) per year. The occupational limit for nurses, doctors and other medical staff is 5000 mrem (50,000 µSv) per year.
For comparison, the typical person living in the United States receives a radiation dose of
about 360 mrem (3,600 µSv) per year. A breakdown of the sources and amounts of this
radiation dose is shown below.
Sources
cosmic =8% Medical =15%
internal = 11% (K-40, C-14, H-3, Be-7, Na-22)
nuclear weapon testing =0.3%
terrestrial =8% nuclear power =0.1%
Radon =55% consumer products =3%
air travel =0.6%
source: NCRP 93
How will I know how much radiation exposure I have received?
You will be provided with an electronic dosimeter. This is a device that measures
cumulative radiation dose similar to how an odometer measures mileage in a car.
The electronic dosimeter reads out in units of microsievert (µSv). A µSv is a unit of
radiation dose as is the mrem (10 µSv = 1 mrem).
How is radioactive waste handled?
All the waste collected in the boxes during the treatment is probably contaminated and,
therefore, must be treated as radioactive waste. This waste is collected daily and taken to a specialized waste storage facility and held for approximately 3 months. At this time, the 131I will be gone and the waste can then be disposed of as normal medical waste.
What about pregnancy?
If you are pregnant, you will not be allowed in the room at all during the treatment.
What about other visitors beside parents?
Visitors, other than parents or family members who are participating in the treatment, are
limited to 60 minutes a day and must remain behind the mobile lead shields and wear the
appropriate protective clothing. No individuals who are pregnant or under 18 years old are allowed in the room at any time.
How will emergencies be handled?
Your child will receive the same level of care as any patient would receive in an emergency situation. If your child needs to be moved to the Intensive Care Unit, radiation safety precautions will need to be followed and the mobile lead shields may also be used. Radiation Safety, Nuclear Medicine and other medical staff are available 24 hours a day for assistance.
When will my child be eligible for release from CHOP?
Federal regulations require patients treated therapeutically with 131I to remain in the hospital until the radiation level at 1 meter (about 3 feet) is below a specified level. Radiation Safety staff will check the radiation level at least daily and will notify the nursing staff when it is below the specified level. Your child will have a measurable radiation level when he/she leaves the hospital. However, it is at a level that is not thought to be unsafe for others around them.
What precautions should I take after leaving the hospital?
Regulatory restrictions on your child only apply while your child is in the hospital. Once your child leaves the hospital, the restrictions will no longer apply. However, you will be given verbal and written recommendations before the treatment. The purpose of these recommendations is to minimize radiation exposure to others especially small children. The recommendations list precautions to be followed for 5 days and a list to be followed for 7 days. The first day in both of these time periods is the day the MIBG is administered. In other words, if a treatment begins on a Tuesday then all recommended precautions would end by the following Tuesday (i.e., 7 days later).
You will also be given a pamphlet produced by the Society of Nuclear Medicine which gives additional information about the use of 131I for medical treatments.
Written Recommendations
These guidelines should be followed for 5 days.
Minimize the time you spend in close contact with other individuals at home or work (no closer than 3 feet for more than 1 hour per day).
Use good hygiene habits, bathe daily and wash your hands frequently, especially after urinating.
Flush the toilet twice after each use (males should sit for urinating to avoid splashing).
Do not handle or prepare any food which might be consumed by another person.
Use separate eating utensils and do not share personal items such as combs, toothbrushes, etc
Use separate towels and washcloths. Launder all of your bath towels, bed linens, and clothing separately after 5 days.
Sleep alone.
Written Recommendations
These guidelines should be followed for 7 days.
Avoid kissing or intimate contact with another person.
Minimize close contact with pregnant women and young children.
If you are in need of any medical care, the medical personnel should be informed about these instructions.