Radiation exposure during cardiac device implantation: Lessons learned from a multicenter registry.

BACKGROUND: Little data are available about radiation exposure during cardiac electrical device implantation, and no dose reference levels have been published. This multicenter, prospective, observational study assesses patient and staff radiation exposure during cardiac device implantations, and aims at defining dose reference levels. METHODS: Patient demographic, procedural, and radiation data were obtained for 657 procedures from nine institutions. Physician and staff exposure were measured using real-time dosimeters worn beneath and above lead apron. Statistical analysis included fluoroscopy time (FT), dose-area product (DAP), and DAP adjusted for FT and body mass index. RESULTS: Pacemakers and cardioverter defibrillators were implanted in 481 and 176 patients, respectively. Of these, 152 were treated with cardiac resynchronization therapy (CRT). Median FTs were 837s (interquartile range [IQR]: 480-1323), 117s (IQR: 69-209), and 101s (IQR: 58-162), and median DAPs were 1410 (IQR: 807-2601), 150 (IQR: 72-338), and 129 (IQR: 72-332) cGy.cm² for biventricular, dual chamber, and ventricular device implantation, respectively. Dose reference levels correspond to the third quartile values. During CRT, higher exposure was observed with four X-ray systems than with the two newer and customizable ones (adjusted DAP of 0.90 [IQR: 0.26-1.01] and 0.29 [IQR: 0.23-0.39], respectively; P < .001). CONCLUSION: Based on real-life measurements, this multicenter registry provides dose reference levels and may help centers assess radiation exposure. Although biventricular device implantation was responsible for the highest radiation exposure, FT was meaningfully shortened compared to previously reported values. For a same FT, the use of new generators and custom settings has significantly reduced DAP.

[Distribution of antimicrobial guidelines: useful but not enough for an antibiotic stewardship]. / Influence de la distribution d'un référentiel anti-infectieux sur la prise en charge des bactériémies : utile mais pas suffisante.

PURPOSE: Evaluate the impact of distribution of antimicrobial guidelines (AG) on anti-infectious prescriptions (AIP) in patients presenting a bacteraemia. Cost evaluation of AIP with and without intervention of an infectious disease specialist. METHODS: The first evaluation of AIP was performed from January to May 2008 in Douai hospital, France, at day 4 after the initial blood sample using French guidelines (FG). An AG based on FG was distributed in June 2008 to all Medical Doctors. A second evaluation of AIP was performed from July 2009 to October 2010 after AG distribution. In May 2009, an infectious disease specialist arrived. He re-evaluated at day 4 the initial AIP and modified it if necessary based on the bacteriologic results and the AG. In the second period of the study, we evaluated the cost of the AIP after day 4. RESULTS: Anti-infectious at day 1 was suitable in 37/50 (74%) cases before vs. 148/206 (72%) cases after distribution of the AG (P = 0.76). At day 4, anti-infectious was suitable in 26/50 (52%) before vs. 103/206 (50%) cases after distribution of the AG (P = 0.80). In the second period, the overall cost of AIP was estimated at 44,000 Euros with the infectious disease specialist intervention and at 51,000 Euros without. CONCLUSION: Distribution of AG did not significantly improve AIP in patients with bacteraemia. Re-evaluation by an infectious disease specialist could lead to a better anti-infectious usage and potential reduction in costs.