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CT Intervention Turnover Workbook

CT Intervention Turnover Workbook

SIEMENS User Services www.usa.siemens.com/education CT Intervention Turnover Workbook Answers for life. User Services. Driven by More. More: Our philosophy for a lifelong improvement through continuing education and consulting. Working closely with you, we develop your personalized education and consulting strategy and support you and your staff with our comprehensive User Services to help gain: • More: Routine Confidence • More: Clinical Expertise • More: Superior Performance More: Personalized training, education, and consulting services from Siemens Healthcare Customer Services. For your leading edge in medical care. User Services. Driven by More. More: Personalized More: More: Superior Clinical Performance More: Routine Expertise Confidence 2 I Contact Information Summary Welcome to Siemens Healthcare Discover. Try. Buy. on webShop Siemens Healthcare is dedicated to helping you Do you want to “Discover. Try. Buy.” options, get the most out of your investment throughout accessories, and clinical education to make the most the entire product life cycle and beyond. Our goal of yourimaging equipment? Discover images, case is to enable you to take technology further, studies,and video demonstrations with the latest profitability higher, and patient care to the next clinicalapplications. Try advanced applications level. Find the information, resources, and tools utilizingfree software trials. Buy applications, coils, you need to get the most out of your recent clinicaleducation, and accessories, conveniently at investment and stay up-to-date. Visit any time. Visit www.usa.siemens.com/webShop today! www.usa.siemens.com/Welcome2Healthcare. Clinical Training and Siemens Training Centers Continuing Education Siemens Clinical Education Training Center – TDC2 Siemens Customer Care Center: 110 MacAlyson Court Call 1-800-888-7436 Cary, NC 27511 • Troubleshooting assistance • Immediate assistance for software applications and workflow issues • For Tech Support press option 2 / for applications support, press option 3 • Press the * key or enter the last six digits of your Functional Location Number Functional Location Number ____________________ Clinical Education Offerings: Call 1-888-221-8010 (follow the prompts) Serial Number ________________________________ • Classroom Training (Offerings, Registration& Scheduling) IP Address System _____________________________ • Educational Symposia On-site Training IP Address PACS _______________________________ • • Printed Self-studies • Virtual Education (Offerings & Registration) • Workshops & Fellowships Visit www.usa.siemens.com/clinicaleducation for more information regarding the current Siemens Clinical Training and Continuing Education portfolio. 3 II Contents I Contact Information Summary ............................................................................................... 3 II Contents .............................................................................................................................. 4 III Course Agenda .................................................................................................................... 5 IV Course Objectives ................................................................................................................ 6 I Introduction .......................................................................................................................... 7 1.1 Objectives and disclaimer.............................................................................................. 7 1.2 Siemens’ CT intervention software is unique .................................................................. 7 1.3 CT Intervention software availability.............................................................................. 8 1.4 Overview - CT systems (Somaris 5/Emotion family, Perspective) features ....................... 9 1.5 Overview - CT systems (Somaris 7/Definition family) features ..................................... 13 2 Somaris 5-Emotion and Perspective CT Intervention Workflows............................................. 22 2.1 Objectives .................................................................................................................. 22 2.2 Patient Positioning ..................................................................................................... 22 2.3 Patient Preparation ..................................................................................................... 22 2.4 Protocol Selection....................................................................................................... 23 2.5 Examination............................................................................................................... 23 3 Somaris 7-Definition CT Intervention Workflows................................................................... 27 3.1 Objectives .................................................................................................................. 27 3.2 Patient Positioning...................................................................................................... 27 3.3 Patient Preparation ..................................................................................................... 27 3.4 Protocol Selection....................................................................................................... 28 3.5 Routine workflow ....................................................................................................... 29 3.6 Advanced workflow (Needle Path Planning)................................................................. 35 4 Frequently Asked Questions ................................................................................................ 41 5 Abbreviations ..................................................................................................................... 44 4 III Course Agenda Introduction Software highlights that are unique to Siemens Availability Overview - CT systems (Somaris 5/Emotion family, Perspective) features Overview - CT systems (Somaris 7/Definition family) features SOMARIS 5 Workflow (Emotion Family, Perspective) Patient positioning Patient preparation Protocol selection Examination (step-by-step) Biopsy CARE Vision SOMARIS 7 Workflow (Definition Family) Patient positioning Patient preparation Protocol selection Examination (step-by-step) Routine workflow Advanced (alternative) workflow Frequently asked questions and answers (Q&A) References Abbreviations 5 IV Course Objectives Course Overview: The purpose of this training session is to provide you with the skills and knowledge to safely operate your CT Intervention CT system. Upon completing this training session, you will be able to: • Complete basic and advanced Intervention workflows on the SOMATOM Emotion and SOMATOM Perspective (Somaris 5) as well as on the SOMATOM Definition family (Somaris 7). • Improve your overall confidence. • Operate minimally invasive fluoroscopic interventional procedures with maximum dose reduction according to the ALARA principle. 6 Turnover Workbook | CT Intervention I Introduction 1.1 Objectives and disclaimer Notes Objectives This workbook is designed as a learning tool to guide you through basic and advanced Intervention workflows on the SOMATOM Emotion and SOMATOM Perspective (Somaris 5) as well as on the SOMATOM Definition family (Somaris 7). Disclaimer Please note that all options available are shown in this workbook. Some are standard to the software and others are purchasable options. Please contact your local sales representative for more information on your scanner specifics. 1.2 Siemens’ CT intervention software is unique • Offers time saving workflows that are designed to streamline intervention cases • Offers several low dose options to reduce scan time for the patient and operator such as: 1.2.1 HandCARE: • Provides dose savings to the operator’s Hand Care hand, while keeping the image quality constant. • Available with i-Sequence and i-Fluoro modes • Options to turn dose off in 10,12,and 2 o’clock positions 1.2.2 i-Precision view: • Used to acquire an image with a higher or lower amount of X-rays and Eff. mAs 110 CARE Dose4D M is set based on percentages i-PrecisionView = 100 % • The value is only used for the next kV 120 Cvo 7.30 mGy scan and returns to the defaulted 5.0 mm Acq. 32 x 1.2 m value after the exposure is completed 7 Turnover Workbook | CT Intervention 1.3 CT Intervention software availability Notes • Available Intervention Packages for Definition, Emotion, and Perspective Scanners: SOMATOM Emotion SOMATOM Definition Flash, Definition & Perspective Definition Edge* & Definition AS/AS+ incl. 2D Basic Intervention with i-Sequence (incl. HandCARE) Advanced Intervention Basic Intervention CT Fluoroscopy path incl. Biopsy Mode Intervention Pro incl. i-Spiral, incl. CAREVision toolbar, layout editor i-Fluoro (incl Adaptive 3D Intervention HandCARE) Adaptive 3D Intervention - Suite incl. i-Control SOMATOM Emotion & Perspective Basic Intervention Advanced Intervention incl. Biopsy Mode incl. CAREVision Summary: 2D CT-guided intervention • For less complex cases such as CT guided spinal injections, 2D CT guidance is well suited. This is offered with the Basic Intervention Package. It typically delivers three axial images in near real-time over the data set. It supports sequential and spiral modes with quick switching in between for better overview and navigation in the dataset. With CT fluoroscopy offered as CARE Vision with the Advanced Intervention Package you can stay at the table side and don’t have to leave the room in between scans. Using CARE Vision you can scan continuously, view images in near real-time, and hit your target in one go. HandCARE reduces dose to the clinician by switching off the X-ray tube in proximity of the hands. • Offered with the SOMATOM Emotion and SOMATOM Perspective. 8 Turnover Workbook | CT Intervention Summary: 3D CT-guided intervention Notes • Interventions with complex anatomies (e.g. lung biopsies, liver ablation, spinal surgery) are best visualized with 3D CT guidance offered with the Adaptive 3D Interventional Suite. It allows you to work freely within a 3D volume-rendered spiral or sequential CT dataset. Full wireless control over table movement and software functions is offered directly at the table side with the i-Control. Working in near real-time 3D offers many advantages: you can see the whole organ using a VRT and view the lesion with sagittal, coronal, and axial MPRs. Always be on track with our smart automatic needle detection algorithms and path planning tools. These automatically select the optimal needle viewing plane, select the optimal entry point for you, and determine the angle for needle insertion. This 3D capability allows for fast and accurate positioning in the most complex anatomies, even at difficult oblique angles. • Offered with the SOMATOM Definition family. 1.4 Overview - CT systems (Somaris 5/Emotion family, Perspective) features 1.4.1 Available scan protocols: Trauma TraumaVol • Biopsy PolyTrauma HeadTrauma • Biopsy Single HeadTraumaSeq • CARE Vision ardia RespSeq Resp • CARE Vision Single RespModBreathRate • CARE Vision Bone ascu RespLowBreathRate NeuroPCT NeuroPCTSingle RT BodyPCT BodyPCTSeq BodyPCTSingleSeq ecia Biopsy BiopsySingle TestBolus CAREVision rivat CAREVisionSingle CAREVisionBone 9 Turnover Workbook | CT Intervention 1.4.2 Scan modes: Notes • CARE Vision: Blow-Up, CARE View Blow-Up, and CARE view • Biopsy: Blow-up, two segments, CARE view • Slice for CARE View mode are displayed in bold • NOTE: If CARE view mode is off, there will only be one slice on the screen. 0.75 1.5 3.0 4.5 9.0 Acq. 12 x 0.75 mm 1.5 3.0 4.5 6.0 9.0 Acq. 12 x 1.5 mm 5.0 10.0 Acq. 2 x 5.0 mm Biopsy mAS 50 kV 120 CTDIvol 35.85 mGy (32 cm) Scan time 0.5 s DLP 51.62 mGycm Delay Slice 4.8 mm Acq. 12 x 1.2 mm 0.6 2.4 Acq. 12× 0.6 mm 0.6 1.2 3.0 6.0 9.0 Acq. 30 x 0.6 mm 1.2 2.4 4.8 Acq. 12 x 1.2 mm 2.4 4.8 9.6 14.4 Acq. 24 x 1.2 mm 5.0 Acq. 1 × 5.0 mm 10.0 Acq. 1 x 10.0 mm CAREVision mAs 30 3 KV 120 - CTDIvol 5.08 mGy/s (32 cm) DLP 0.00 mGycm Slice - 10.0 mm Acq. 1x 10.0 mm 2.4 7.2 Acq. 12 x 0.6 mm 4.8 Acq. 12 x 1.2 mm 6.0 Acq. 30 × 0.6 mm 9.6 Acq. 24 x 1.2 mm 10.0 Acq. 1 x 10.0 mm 1.4.3 Buttonology: • Table control attaches to the front of the patient table. • Joystick controls z-axis movement of the table. - 10 Turnover Workbook | CT Intervention Notes • Intervention toolbar Options System Interventional Windows 1/2/3 Graphics. 11213 Image Manipulation ... Iterverdon ... Select All Graphics Auto Stop functions Select Series Salact On Succeeding Hald Graphics Delete Graphics Windgwing Screen layout Windowing On Series ZoonPan Laser Grid • Biopsy CARE view Blow up - One image Biopsy two segments - two images Biopsy CARE view - three images displaying head, center and foot 11 Turnover Workbook | CT Intervention • Icons for CARE vision Notes Blow up - One image CARE View Blow up-center image displayed in blow up mode with F head and foot images displayed in smaller segmentss Biopsy CARE view- three images displaying head, center, and foot of all equal size • Activate Biopsy mode by clicking on the liver icon 0.6S DLP 79.83 mGycm Slice 4.8 mm Acq. 12 x 1.2 mm of scans 10 CARE View f images 30 TI 0.0 9 omments 144 Begin End Table:Position Height Movement -1772.1 -1781.7 -1776.9 - 125.0 Continuous Scan Recon Auto Tasking • Dose scale mGy • Visualization of mGy used during procedure mGy • Configured in Options/Configuration/Examination/ 2000 200 Intervention 1500 150 1000 100 500 50 0 0 12 Turnover Workbook | CT Intervention 1.4.4 Examination Configuration: Notes • Accessed in Options/Configuration/Examination/Intervention • Allows you to change widow settings, dose scale values, and image storage of CARE Vision images Examination Configuration Application Patient Topogram Intervention windowing| Messages Contrast Interventional Window 1 Abdomen Interventional Window 2 Lung Interventional Window 3 Bone CARE Vision max. Dose Display 2000 mGy Biopsy max. Dose Display 2000 mGy Auto save last displayed images as key images CARE Vision image storage rate 1 -| image / s Interventional auto load OK Apply Default Settings Cancel Help 1.5 Overview - CT systems (Somaris 7/Definition family) features 1.5.1 Available scan protocols • Head Intervention • Thorax Intervention • Abdomen Intervention • Spine Intervention ardia • Note: Protocols are housed in the corresponding body region BSCC . AbdMMub Phase Customi . Abdomenintervention CL Abdomenintervention_CL Abdomenintervention Cu AbdomenRoutine_Custo . AbdomenSeq Customiz . AbdomenVoll Customize AbdomenRoutine AbdomenVoll AbdMub Phase AbdomenSeq Colonography Abdomen niemention 13 Turnover Workbook | CT Intervention 1.5.2 Scan Modes Notes • i-Sequence: axial scan acquisition Topogram CTDIvol (32cm): 3.80 mGy DLP: 5.5 mAS 50 - CARE Dos i-Sequence i-Precision View Off 200% kV 120M Slice 4.8 mm Acq. 12 x 1.2 mm 1.2 2.4 2.4 48 7.2 Acq. 12 x 1.2 mm 4.8 6.0 Acq. 32 x 1.2 mm 5.0 Acq. 1×5.0 mm 10.0 Acq. 1x 10.0 mm • i-Spiral: spiral scan acquisition Topogram CTDIvol (32cm): mGy DLP: Eff. MAS CARE Dose4D i-Spiral i-Precision View Off 100% kV 120 Slice ~ 5.0 mm Acq. 32 x 1.2 mm 1.5 2.0 3.0 4.0 6.0 7.0 8.0 10.0 Acq. 32 x 12 mm • i-Fluoro: real-time scan acquisition Topogram CTDIvol (32cm): 3.80 mGy DLP: 5.5 mAS 50 - CARE Dose i-Sequence i-Precision View Off 200% KV Slice 4.8 mm Acq. 12 x 1.2 mm 120 1.2 7.2 Acq. 12 x 1.2 mm 6.0 Acq. 32 × 1.2 mm 5.0 Acq. 1×5.0 mm 10.0 Acq. 1 × 10.0 mm 1.5.3. Buttonology i-Spiral 3 interventional i-Sequence = Biopsy modes i-Fluoro = CARE Vision Topogram CTDIvol (32cm): 3.80 mGy DLP: 5.5 mB. 50 - CARE Dose HandCARE None |-Sequence MAS 120 Slice 4.8 mm Acq. 12 x 1.2 mm Layout Three segments No. of images 3 MPR Slice 5 mm Tilt Kemel B30s medium smooth i-NeedleSharp Window -Abdomen Scan start | Start button Key Images None Range: Begin End Position Height Movement Load -1717.7 2 -1727.3 -1466.5 - 125.0 2.5 mm +] Routine Scan Recon Auto Tasking | Intervention • i-Control: • Mounts to Right or Left side of table for control of the scanner during intervention procedures. • i-Control can operate table wirelessly, or tethered to gantry. • Green icon appears at bottom right segment of acquisition workplace when i-control is properly mounted to table 14 Turnover Workbook | CT Intervention Notes • Here is an image of the i-control device with all buttons and controls labeled: Manual selection gantry left / right Toggle between side of i-control Toggle pre-defined windows segment Save table Laser Move to position on / off Move to last Scroll scan table saved table image position position on/off Joystick for table movement Joystick mouse Incremental or continuous Gantry tilt table move Move to selected table Table up / down position • Window toggle buttons: • The software provides a quick way to toggle through favorite window/level values. • These are programmable under Options/Configuration/Intervention Li Somal15/7 - Configuration Pa Options System Help File Version ... A License ... DICO Life Card print number File Browser ... Patient Patient Patient Search Transfer Conversion Auto Delete Switch to External Simulator Browser Registration Hide Simulation Taskcard CFLOS Maintenance ... Auto Expose Expert-i ImageText Scan Protocol E-Logbook Examination Bolus Configuration ... Editor Assistant Configuration Tracking Service 12 Notes Respiratory HeartView ntervention 3D Viewing Filming Study Gating Layout Filming Filming Repo Intervention Configuration General Storage Interventional window 1 Abdomen Interventional window 2 Lung Interventional window 3 Bone 15 Turnover Workbook | CT Intervention • Scan Mode Toolbar: Notes i-3D: switches to the 3D intervention mode (i-sequence and i-spiral) i-Refresh: repeats the previous 3D scan automatically in order to refresh the displayed 3D projection i-Precision view: activates the increase or decrease of dose for the next scan Enlarges the scan range by one slice @ the begin and end position (i-spiral only) it- Shortens the scan range by one slice @ the begin and end position (i-spiral only) • Move Scan Range to Displayed Table Position: • This moves the scan range to the corresponding table position based on an image. • Hint: use this button instead of placing the scan range over an area. Scan direction Craniocaudal Scan start Start button 18 Table control -No Feed Range Table: Begin End Position 81.0 2 219.0 182.0 Move scan range to displayed table position Routine Scan Recon A Last Checkup 53 h ago. Select Setup/Checkup • Move Chronicle and STC Out/In: • Toggles between the chronicle screen and Load the interventional screen. • The chronicle screen automatically moves out of the way when a scan is started. 16 Turnover Workbook | CT Intervention Notes • Intervention Toolbar: • Opens or hides the intervention toolbar by clicking on triangle icon. • Figures next describe each tab of the toolbar. Total mAs: 415 0.7 mGy*cm • Favorites tab: a configurable short-cut to your most used buttons. Right mouse click to customize favorites bar. ntervention Hint: Please click with the right mouse button to add or to remove button! Favorites Workflow 2D 3D Path • Workflow tab: options to save key images and table positions during the procedure Intervention 1/2/3 orites Work low 2D 3D Path Save all displayed Set Home TP Auto Stop as Key Images Last Scan TP Toggle Window 1/2/3/ Save as Key Image Auto Stop Home TP • 2D tab: common measurement and crosshair tools Intervention vorites Work TOW 2D Path Laser Grid Angle Crosshair Distance Home Laser Crosshair Zoom/Pan Show/Hide Graphics 17 Turnover Workbook | CT Intervention • 3D tab: manipulation of MPR images while using i-spiral Notes Intervention avorites Work ow 2D Path Show/Hide Rotate Object Free Mode Default=On Reference Lines VRT-Gallery Default Orientation Lock/Unlock Reference Lines • Path tab: path planning with auto needle detection for greater detection and efficiency of needle guidance Intervention auto auto vorites Wo Tlow 2D Path Delete Needle System View Mark Path Mark Target Entry Point Toggle Needles Needle orientated View Mark Needle Tip Auto detect Needle 18 Turnover Workbook | CT Intervention Notes • In Segment Tools: axial Toggle between axial and Virtual Gantry Tilt (VGT) in the axial MPR segment. This is a fast way to switch between the traditional coronal and VGT sagittal views and the virtual tilted images on the secondary monitor. VRT Activate VRT view-turns the 3D volume image on and off MPR Toggle between MPR and VRT coronal/ sagittal segments. This is a fast way to view the images on the secondary VRT monitor in an MPR or VRT display. . 19 Turnover Workbook | CT Intervention • i-needle sharp: Notes • Predefined gantry tilts of -2, -5, and -8 degrees Tilt -5.0 0 • Reconstructed in an axial plane to reduce needle artifact (i-sequence I-NeedleSharp M . ] only) • Monitor position and image order determines how the image order is displayed on the monitor after the images are scanned • Example: Head-center-feet or feet-center-head • Dose scale-visualization of mGy used during procedure • Configured in Options/Configuration/Examination/ Sc Intervention/General 100 100 = = 20 Turnover Workbook | CT Intervention 1.5.4 Layout with Workflow Assistant Notes • Options/Configuration/Intervention • Interventional auto load allows the protocol to move directly into intervention mode as soon as a topogram and pre-scan are acquired Intervention Configuration Storage Layout Interventional window 1 Abdomen Interventional window 2 Lung Interventional window 3 Bone Maximum dose display 2000 - mGy Interventional auto load Cancel Help • Image Storage allows you to prescribe which key images are to be saved during i-fluoro mode. Intervention Configuration General Storage Layout Auto save last displayed images as key images i-Fluoro image storage rate nocenter images/s Store thin slice images Transfer thin slice images None OK Apply Default Settings Cancel Help • Layout Editor allows you to create a new layout or edit an existing layout based upon a template. Intervention Configuration Layout 2D Layout Name Layout Name Layout Name Layout Name Layout Name Layout Name Layout Name Layout Name Layout Name Layout Name Layout Name Layout Name Layout Name OK Apply Default Settings Cancel ntervention Configuration Layout 2D 2D User ONE 2D User TWO 2D User THREE One Segment Two Segments Three Segments Four Segments Stk Segments Eight Segments 3D JD User ONE 3D User TWO 3D User THREE OK Apply Reteuit Settings Cancel Help 21 Turnover Workbook | CT Intervention 2 Somaris 5-Emotion and Perspective CT Intervention Workflows Notes SOMATOM Emotion & Perspective Basic Intervention Advanced Intervention incl. Biopsy Mode incl. CAREVision 2.1 Objectives By the end of this section, the technologist will be able to • Identify the steps it takes for a biopsy procedure using the Biopsy Mode and CARE Vision mode on the Emotion Family of CT scanners as well as the Perspective CT scanner line. • Apply features to improve workflow with confidence. • Perform ALARA using Hand CARE. 2.2 Patient Positioning • Place the patient in the proper SIEMENS position, per the radiologist’s request. In the Patient Model Dialog, ensure the patient orientation matches actual patient position. • Isocenter the patient in the standard manner. • Set a table zero using either gantry keypad or from the Topogram > Routine tab. 2.3 Patient Preparation • Due to the sometimes extended nature of an interventional procedure, it is very important to ensure that the patient is a position of comfort and will be able to remain in the position for the duration of the examination. • Provide the patient with as much bedding, blankets, pillows, positioning aids, etc. as possible to create the most comfortable position possible. NOTE: It is important not to provide any obstruction to the interventional area of the body. • Educate and inform the patient of duration of exam, processes, and what their role will be during the exam to complete it safely and successfully. • If a breath hold will be used, either API or by tech/rad, it is important to practice this with the patient to ensure they understand the direction. • Provide the nursing staff appropriate access to connect vital signs monitors and IV access to administer medications as needed. 22 Turnover Workbook | CT Intervention 2.4 Protocol Selection Notes • A Routine Biopsy protocol is commonly created to improve workflow and consists of: • Topogram • Routine Spiral- Diagnostic in quality, to be used for localization of target. • Biopsy- a low dose sequential • Available scan protocols: • Biopsy Trauma • Biopsy Single TraumaVol PolyTrauma • CARE Vision HeadTrauma • CARE Vision Single ardi HeadTraumaSeq RespSeq Resp • CARE Vision Bone RespModBreathRate ascul RespLowBreathRate NeuroPCT NeuroPCTSingle RT BodyPCT BodyPCTSeq BodyPCTSingleSeq Biopsy Deci BiopsySingle TestBolus CAREVision ivat CAREVisionSingle CAREVisionBone 2.5 Examination 2.5.1 Step 1: Prim HeadTraumaSeq NeuroPCT • Topogram (If API is used set on BodyPCT BodyPCTSeq this and all succeeding modes) Biopsy TestBolus OK Cancel CAREVision 2.5.2 Step 2: CAREVisionBone ABDOMEN_PELVIS_WO_W (Adult) 13.09.05-11:25:07-DST-Specials PolyTraum 13.09.05-11:25:07 • Routine: Topogram Open scan range to cover Prescan • Pause desired anatomy. Biopsy 2 • Make an FoV that will include all skin surfaces in the area of interest. • NOTE: A grid marking device sometimes applied prior to this scan. 2.5.3 Step 3: • Planning: • Locate the area of interest by scrolling through the Spiral images. • Open the Graphics Toolbar (IMAGE > GRAPHICS) • Select the distance tool. • Place the cursor on the target, hold LMB down and drag to entry point. 23 Turnover Workbook | CT Intervention 2.5.4 Step 4: Notes • Move the table to the MAS 50 determined position for entry KV 130 - CTDIVO. 72.32 mGy (32 cm) DLP: 52.07 mGycm using the Move Table to Scan time 0.6 s Delay Displayed Table position button Slice 2.4 mm Acq. 12 x 0.6 mm or TABLE > SAME TP command. No. of scans 10 CARE View No. of images 30 • This will move the target Tilt .00 anatomy to the center of the Comments ants gantry and in line with the Move Out Range: Begin End Table: Same TP Height Movement center laser light. It will also -1175.6 -1180.4 -1178.0 - 125.0 Continuous place the scan range so that this Routine Scan Recon Auto Tasking eRatio position is in the center of the scan range. • If a grid, or other marking device, was placed prior to Spiral scan, either the tech or radiologist will mark the patient at the desired location for entry. (Go to Step 6) • If not marking device was used, place a grid or marker on the laser marker in the area of desired entry 2.5.5 Step 5: Load the protocol and acquire the Press MOVE • first Sequential images. • Confirm proper location. • Adjust windowing, FoV, and centering as desired. • These parameters will be inherited on future scans within this series. • Mark the patient at the desired location of entry. 2.5.6 Step 6: • Move the patient out of the gantry using Table Feed button on gantry, Intervention Joystick (if purchased) or for Routine card Table: Position > Move Out. • If available, a Saved TP position can be set here and Auto Stop at Saved TP can be activated. • This will provide an automatic stopping point when using the Intervention joystick and improve workflow. • The radiologist will begin the procedure by prepping the insertion area, administering local anesthetic, etc. 24 Turnover Workbook | CT Intervention 2.5.7 Step 7: Notes • Return the patient to scan position by using Table Feed button on gantry, Move Table to Displayed Table Position, the Interventional Joystick, Table: Position > Same TP, or Table: Position > Last SP (If the last scan has been performed at the desired position). • Make sure that the table has returned to the desired position before scanning. Topogram mAS 50 Prescan kV 130 - CTDIvol 54.43 mGy Scan time 0.8 s Biopsy Press START Feed = 0 Slice 10.0 mm Acq. 2 × 5.0 mm No. of scans 10 No. of images 10 Tilt 0.0 Comments Range: Begin End Table:Position Height Load Cancel Recor -270.5 -270.5 -270.5 - 86.0 KDI Routine Scan Recon Auto Tasking Archive request for MOD_DICOM successfully completed for patient 05-Sep-2013 11:51:47 -- 2.5.8 Step 8: • If in-room monitors are available, Scan Start can be changed to FOOT PEDAL to allow the radiologist to initiate a new scan as needed. • If no in-room monitors are available, Scan Start > Start Button will remain the option for initiating a scan. • As a patient safety feature, the default biopsy protocol contains 10 sequential acquisitions and will require this series to be repeated to continue with the examination. (NOTE: This option is configurable at the customer discretion, and prior to start of examination) • If Scan Limit is reached, use RMB click on Biopsy mode in chronicle > Repeat, load protocol and proceed as needed. • Remember to confirm the table is in the proper position prior to scanning. • If the patient is in the proper position, and a Move Table command is present, use the Cancel Table Move button. This will allow scan to be performed at current/desired table position. 2.5.9a Step 9a: • Repeat Steps 6-8 as needed. 25 Turnover Workbook | CT Intervention 2.5.9b Step 9b: Notes • If CARE Vision is available and needed: • Open Patient Model Dialogue Trauma TraumaVol PolyTrauma HeadTrauma ardi HeadTraumaSeq RespSeq Resp RespModBreathRate scu RespLowBreathRate NeuroPCT NeuroPCTSingle RT BodyPCT BodyPCTSeq BodyPCTSingleSeq eci BiopsySing TestBolus CAREVision Privat AREVision gle CARLINIBone • Select Specials >CARE Vision CAREVision (Adult) 13.04.30-11:51:02-DST-Specials PolyTraum 13.04.30-11:51:02-DST-" Total mAs: CAREVision MAS 30 % KV 30 -J CTDIvol 8.75 mGy/s (32 cm) DLP 8,40 mGycm's Sice _ 4.8 mm Acq. 16 x 0.6 mm CARE View Comments Table:Position Height Movement Load .800.0 - 125.0 Continuous Recon Auto Tasking • Scan Start: Foot Switch is the only available option for this mode. Scan start Foot switch HandCARE None None 10 o'clock position 12 o'clock position 2 o'clock position • Activate HandCARE based upon needle entry point (10, 12 or 2 o’clock) to reduce direct exposure to the radiologist’s hand. • Real-time CT fluoroscopy will be initiated when the when the foot pedal is pressed and terminates when full pressure is released. • During each active fluoroscopy session, it is possible to move the table, if desired, during the exposure. • If the patient is in the proper position, and a Move Table command is present, use the Cancel Table Move button. This will allow scan to be performed at current/desired table position. • Return to Steps 6-8 as needed or proceed to Step 10 2.5.10 Step 10: • Complete Procedure: • When the procedure has been completed, and a post-procedure scan is desired, use RMB over original Spiral series and select Repeat. • Adjust ranges as requested to cover desired anatomy. 2.5.11 Step11: • End Exam: • Go to Patient > Browser > Local Database > select the patient and images to transfer to PACS. • Send to desired archival destination. 26 Turnover Workbook | CT Intervention 3 Somaris 7-Definition CT Intervention Workflows 3.1 Objectives Notes By the end of this section, the technologist/ radiologist will be able to • Identify and apply the steps it takes for a biopsy procedure using the 3D interventional modes on the Definition family of CT scanners. • Appreciate 3D volume intervention looking at coronal, sagittal, and oblique MPR views as well as VRT for better volume overview. • Appreciate full wireless control over table movement and software functions directly at the table side with the i-Control. • Access on the fly all relevant scan parameters in 2D and 3D. • Learn precise positioning with CT image guidance tools. • Improve your confidence. • Operate minimally invasive fluoroscopic interventional procedures with maximum dose reduction according to the ALARA principle. 3.2 Patient Positioning • Place the patient in the proper position, per the radiologist’s request. In the Patient Model Dialog, ensure the patient orientation matches actual patient position. • Isocenter the patient in the standard manner. • Set a table zero using either gantry keypad or from the Topogram > Routine tab. 3.3 Patient Preparation • Due to the sometimes extended nature of an interventional procedure, it is very important to ensure that the patient is in a position of comfort and will be able to remain in the position for the duration of the examination. • Provide the patient with as much bedding, blankets, pillows, positioning aids, etc. as possible to create the most comfortable position possible. NOTE: It is important not to provide any obstruction to the interventional area of the body. • Educate and inform the patient of duration of exam, processes, and what their role will be during the exam to complete it safely and successfully. • If a breath hold will be used, either API or by tech/rad, it is important to practice this with the patient to ensure they understand the direction. • Provide the nursing staff appropriate access to connect vital sign monitors and IV access to administer medications as needed. 27 Turnover Workbook | CT Intervention 3.4 Protocol Selection Notes • Protocols are listed under the corresponding body region. These are often saved with the desired parameters for the region such as window/level and dose. Doses may need to be adjusted to provide desired image quality. • Three scan modes are available in the intervention mode including: • i-Spiral: • Provides most z-axis coverage Topogram • Is best for complex needle angles i-Spiral • MPR segments are generated automatically • Used for localizer scan • i-Sequence: • Lowest dose • i-Needle Sharp available Topogram limited range MPR segments -Sequence O • can be generated automatically • HandCARE available • i-Fluoro: • Dynamic imaging Topogram • HandCARE available i-Fluoro 28 Turnover Workbook | CT Intervention 3.5 Routine workflow Notes • A routine workflow begins in i-Spiral mode. 3.5.1 Step 1: • Topogram (If API is used set on this and all succeeding modes) 3.5.2 Step 2: • Select the appropriate side for the intervention monitors. • This ensures correct orientation of the patient images (head/center/ foot). 3.5.3 Step 3: • i-Spiral scan is performed. • This provides routine axial images as well as coronal, sagittal, VRT and i-Virtual Tilt/Axial images for procedure planning. NOTE: Intervention scans are often performed with decreased doses. To ensure that the initial i-Spiral planning scan is of desired image quality, i-Precision View may be enabled for the initial planning scan. CTChel (52cm. 16.27 mG-/ MAS CARE DOCC i Precisionview = 200 % 120 - Sice _ 4.Bon Acg 12 x 1.2 mm No. of images 3 .00 Scan star: Foot switch Rande Tible. 29 Turnover Workbook | CT Intervention 3.5.4 Step 4: Notes • Planning: • Scroll through the axial images until the desired target is located. • Distance may be measured by opening the 3D. intervention tool bar and selecting the distance tool. • Place the cursor on the target, hold LMB down and drag to entry point. Intervention Favori Workflow 2D 3D Path MAYO CLINIC CT TH Head • Ensuring that the desired axial target image is selected (blue border), select the table position drop-down and use the Same TP button. • This will move the target skin entry point to the center of the gantry and in line with the transverse laser light. Move Out Same TP Last SP ht 496.5 * 160.0 • If a grid, or other marking device, was placed prior to the i-Spiral scan, either the tech or radiologist will mark the patient at the desired location for entry. • f no marking device was used, place a grid or marker on the transverse laser marker in the area of desired entry. 30 Turnover Workbook | CT Intervention 3.5.5 Step 5: Notes • Switch to the i-Sequence mode (or i-Fluoro). • These modes provide a limited scan range and are useful for procedures with limited z-axis angulation. • i-Sequence scans may also provide minimal dose. • i-Fluoro scans are often useful when dynamic scanning ability is required. MAS 55 | CARE Dose Procicionivion 08 200% KY 120 | CTDMdl 140.66 mGy Slice [-] 4.8 mm Acq. 12x 1 2 mm No. of images • HINT: • i-Fluoro scans can only be initiated via the foot pedal. • i-Sequence scans may be initiated from in the scan room via the foot control or by using the start button. • i-Spiral scans may be initiated from in the scan room via the foot control or by using the start button. • Activate HandCARE based upon needle entry point (10, 12 or 2 o’clock) to reduce direct exposure to the radiologists hand. 120 mGy'cms HandCARE -| 12 o'clock position 3.5.6 Step 6: • Ensuring that the desired axial target image is selected (blue border), use the move scan range to displayed position button. • This precisely centers the scan range over the desired target area. • Scan the grid or marking device if needed and mark desired skin entry point. 31 Turnover Workbook | CT Intervention 3.5.7 Step 7: Notes • Move the patient out of the gantry using the intervention joystick or under the Routine tab Table > Position > Move Out. • The radiologist will begin the procedure by prepping the insertion area, administering local anesthetic, and placing the needle. Manual selection gantry left/right Toggle between side of i-Control Toggle predefined windows segment Save table Laser Move to last Move to position on/o Scroll scan table saved table mage position position on/off Joystick for table movement + Joystick mouse Incremental or continuous table move Gantry tilt Move to selected table Table up/down position Move Out Same TP Last SP tht 496.5 -] 160.0 32 Turnover Workbook | CT Intervention 3.5.8 Step 8: Notes • Return to the desired scan location by using the Last SP button on the i-Control or under the Routine tab Table > Position > Last SP or by reselecting the desired target image and using the move scan range to displayed position button. Manual selection gantry left/right Toggle between side of i-Control Toggle predefined windows segment Save table Laser position on/off Move to last Move to Scroll scan table saved table mage position position on/off Joystick for table movement + Joystick mouse Incremental or continuous Gantry tilt table move Move to selected table Table up/down position Move Out Same TP Last Sp. 496.5 -] 160.0 33 Turnover Workbook | CT Intervention 3.5.9 Step 9: Notes • Perform subsequent scans and correct the needle path toward the target. • NOTE: If the patient is in the proper position, and a Move Table command is present, use the Cancel Table Move button. This will allow the scan to be performed at current/desired table position. • Activated Key images may be saved in the intervention tool bar under Workflow > Save Key Image Intervention -O- 1/2/3 Favorites Workflow 2D Path 3.5.10 Step 10: • Complete Procedure: • When the procedure has been completed, and a post- procedure scan is desired, return to i-Spiral or use the i-Refresh button to reload the last i-3D scan. • Adjust ranges as requested to cover desired anatomy. • This may be done by centering the scan range and using the using the expand/contract scan range buttons. the expand/ contract scan range buttons. • NOTE: Scan range in i-Sequence/i-Fluoro can only be altered by changing acqistion parameters 3.5.11 Step 11: • End Exam: • Go to Patient > Browser > Local Database > select the patient and images to transfer to PACS. • Send to desired archival destination. 34 Turnover Workbook | CT Intervention 3.6 Advanced workflow (Needle Path Planning) Notes • An advanced workflow is an alternative workflow that begins in i-Spiral mode. 3.6.1 Step 1: • Topogram (If API is used set on this and all succeeding modes) 3.6.2 Step 2: • Select the appropriate side for the intervention monitors. • This ensures correct orientation of the patient images (head/center/foot). 3.6.3 Step 3: • i-Spiral scan is performed. • This provides routine axial images as well as coronal, sagittal, VRT and i-Virtual-tilt/Axial images for procedure planning. • NOTE: Intervention scans are often performed with decreased doses. To ensure that the initial i-Spiral planning scan is of desired image quality, i-Precision view may be enabled for the initial planning scan 35 Turnover Workbook | CT Intervention 3.6.4 Step 4: Notes • Planning: • Review the axial images as well as coronal, sagittal, VRT and i-Virtual Tilt/ Axial images for procedure planning. • Reference lines may be rotated in any plane until the desired needle path is achieved CTDel (52cm. 16.27 mG-/ [ MAS 100 CARE Doce i Precision View - 200 % 120 ] Slice 4.B Tm Acc 12x 1.2 mm No. of images Tit = Scan star: - Foot switch Range Tible. • Once the desired path is planned, open the interventional tool bar Path tab. Using the first icon (Needle Target Point), mark the area of interest (Red Circle) • Using the second icon (Needle Entry Point), mark the desired skin entry location (Light Blue Dot). In this instance the saggital image is used allowing for inferior-superior angulation. The CT scanner now displays the distance from the skin entry point to the target, x-axis angulation (left/ right), and z-axis angulation (head/foot). 36 Turnover Workbook | CT Intervention 3.6.5 Step 5: Notes • Scroll through the axial images to find the desired entry point. • The marked skin entry point will be designated by a light blue dot. • Ensuring that the desired target image is selected (Blue Border), select the table position drop-down and use the Same TP button. • This will move the table to the desired skin entry point with the center of the gantry in-line with the transverse laser light. 3.6.6 Step 6: • If a grid, or other marking device, was placed prior to the i-Spiral scan, either the tech or radiologist will mark the patient at the desired location for entry. • If no marking device was used, place a grid or marker on the laser marker in the area of desired entry and repeat the scan. The scan range may be decreased but must include both the skin entry point and target. 3.6.7 Step 7: • Once the skin entry point is determined and marked, move the patient out of the gantry using the intervention joystick or under the Routine tab Table > Position > Move Out. The radiologist will begin the procedure by prepping the insertion area, administering local anesthetic, and inserting the needle. Manual selection gantry left/right Toggle between side of i-Control predefined Toggle segment windows Save table Laser position on/off Move to last Move to Scroll scan table saved table image position position on/off Joystick for table movement Joystick house Incremental or continuous Gantry tilt table move Move to selected table Table up/down osition Move Out Same TP Last Sp" ht 496,5 -] 160.0 Move Out Same TP E 496,5 -] 160.0 37 Turnover Workbook | CT Intervention 3.6.8 Step 8: Notes • Return to the desired scan location and scan by using the Last SP button on the i-Control or under the Routine tab Table > Position > Last SP or by reselecting the desired target image and using the move scan range to displayed position button. • NOTE: Ensure the scan range covers both the skin entry point and the target. Move Out Same TP Last SP. 496.5 -] 160.0 Manual selection gantry left/right Toggle between side of i-Control Toggle predefined windows segment Save table Laser position on/of Move to last Move to Scrol scan table saved table image position position on/off Joystick for table movement + Joystick mouse Incremental or continuous Gantry tilt table move Move to selected table Table up/down position 3.6.9 Step 9: • Activate Auto Needle Detection. • The needle path can be adjusted to the planned path using Auto Needle Detection. • Auto Needle Detection attempts to find both the needle skin entry point as well as the needle tip (21g or larger needles work best). Intervention auto auto Favorites Workflow 2D 3D Path • If not found by Auto Needle Detection, the needle tip may be manually marked as needed using the Needle Tip Point icon. • Scroll through the axial images until the needle tip is visible and mark using the Needle Tip Point icon. • Adjust as necessary. • Once the tip is marked the scanner now displays updated distance to target, x-axis angulation (left/right), and z-axis angulation (head/foot). Intervention auto auto Favorites Wo TOW 2D 3D Path 38 Turnover Workbook | CT Intervention 3.6.10 Step10: Notes • Perform subsequent scans and correct the needle path toward the target. Needle Path Planning will update the required angle adjustments upon completion of each scan (multiple needle paths may be toggled). Intervention auto Favorites |Workflow 2D Path Llases Core CTS Ostanze 585 cm Arge (o-direction): 3 degrees Arge (E-Freclin" .J cejrses 17/0014 • Image view orientation may be toggled from standard views orthoganol to the patient or views oriented to the path of the needle. auto auto auto Favorites |Workflow Path Favorites Workflow Meses Cone CT3 Ustanze: 589 3.6.11 Step 11: • Repeat scans as needed until target is reached. i-Sequence may also be used with needle path planning (in i-3D mode). • NOTE: Scan range in i-Sequence/i-Fluoro can only be altered by changing acqistion parameters 39 Turnover Workbook | CT Intervention 3.6.12 Step 12: Notes • Complete Procedure: • When the procedure has been completed, and a post-procedure scan is desired, return to i-Spiral or use the i-Refresh button to reload the last i-3D scan. 3.6.13 Step 13: • End Exam: • Go to Patient > Browser > Local Database > select the patient and images to transfer to PACS. • Send to desired archival destination. 40 Turnover Workbook | CT Intervention 4 Frequently Asked Questions Question: Notes How do I set a new center position during the intervention scans? Answer: Select the appropriate axial image and hit the move scan range to displayed table position button. The displayed image will now be the new center position for the next scan. Scenario: The radiologist marks an area on the patient to insert the needle. When we move the patient into the scanner for the intervention scan, why does the scan start range not line up with the marked position? Answer: The marked position on the patient’s skin is the center point, or the target position. You need to acquire a few images above and below that position to plan a path to the target. Also, the acquisition mode you are using (i-Spiral, i-Sequential, or i-Fluoro) will also determine how much distance above and below the center slice will be acquired. Question: How to acquire a Single image in CARE Vision? Answer: You get a different number of images using different slice thickness/detector configuration combinations. A 5 or 10 mm slice is the only mode with 1 single image. The other slice thicknesses in bold are more than 1 image due to detector configurations but can be used with Care View layouts. Question: The images are reversed when they reconstruct in the Intervention mode. Answer: The location of the head and foot image are dependent on the radio button on the Intervention task card; this is apparent when using a Three Segment Layout. When the Layout is switched to a One Segment and the radio button is selected wrong, you have to scroll the opposite direction since the images will be in reverse order. The image order is as follows: Patient orientation Monitor left of the gantry Monitor right of the gantry Head first Feet-Center-Head Head-Center-Feet Feet first Head-Center-Feet Feet-Center-Head Click the radio button of the real monitor position: The images are labeled according to the image order. 41 Turnover Workbook | CT Intervention Question: Notes How do I tilt in the i-Spiral mode? Answer: You cannot tilt the gantry in intervention i-spiral mode. Question: Can we use the i-Spiral scan as the localizer scan? Answer: Yes and here is an advice: after the localizer scan, reduce the dose for subsequent scans to save dose to the patient. Once the lesion is localized, the radiologist generally does not need as high quality of a scan for needle placement unless the lesion is very small. Question: How to disable auto-range in biopsy mode? Answer: This is only possible with the Enhanced Intervention License: For the Somaris 5 systems (Emotion, Perspective) this is done by selecting Options > Configuration > Examination >Intervention > Deselect Interventional auto Load > Apply > Ok For the Somaris 7 systems (Definition Edge and Definition AS) you would select Options > Configuration > Intervention > Deselect Interventional auto Load > Apply > Ok Question: How do you review the fluoro time after ending the patient? Answer: Scanners with the DICOM Dose SR; total fluoro time show on the dose report. For systems that do not create a DICOM Dose SR the fluoro time would need to be reviewed prior to closing the patient. Question: How to save windows and change windows with the software? Answer: Go to Options > Configuration > Intervention > Intervention Window 1 > Choose Organ window > apply > ok. You may need a restart to apply this change. (Can select all Window 1, Window 2, and Window 3 before applying) Question: How to load the original series of the intervention to display while scanning other series and keep this series loaded? Answer: Only a prior study can be loaded and this can be done with certain layout configurations; options>configuration>intervention>layout>choose layout editor>forward to step 2 and toggle through the available layouts in 2D and/or 3D. If a segment shows “Reference” that is for an old study. Once in the Intervention Mode, open the patient browser, Left click and hold the left mouse button down, drag and drop into the reference segment box. 42 Turnover Workbook | CT Intervention Question: Notes Why do you need to draw 2 points to create the angle? Answer: It can be configured so that 2 points are not required. Select Options>configuration>graphic tools>distance>can add the angle to horizontal or angle to vertical. Only 1 line would need to be drawn. This is a global setting and would be on for anytime you draw a distance measurement. Question: How to create more z-axis coverage, with basic intervention mode? Answer: You are limited to your detector coverage. The only option for more coverage is to do a short spiral scans at a low dose. 43 Turnover Workbook | CT Intervention 5 Abbreviations Somaris 5 – Siemens’ marketing term is related to SOMATOM Emotion and Notes SOMATOM Perspective CT scanners Somaris 7 – Siemens’ marketing term is related to SOMATOM Definition family of CT scanners CARE – Siemens’ marketing acronym for Combined Applications to Reduce Exposure ALARA – Acronym for As Low As Reasonably Achievable. It means making every reasonable effort to maintain exposures to ionizing radiation as far below the dose limits as practical while still achieving diagnostic image quality. RMB – right mouse button LMB – left mouse button VGT – virtual gantry tilt TP – table position PACS - picture archiving and communication system Multi-Planar Reformat (MPR) - Reformatting image volume data into different planes, i.e., coronal and sagittal. Volume Rendered Technique (VRT) - reconstruction technique to view an entire volume X-axis - The plane that goes from right to left. Y-axis - The plane that extends from the anterior to posterior of patients on their backs. Z-axis - The plane that correlates to the long axis of the patient lying on the table. Also, refers to the depth or thickness of a standard transaxial CT image slice. 44 Workbook | Workbook Name Notes 45 On account of certain regional limitations of sales rights and service availability, we cannot guarantee that all products included in this brochure are available through the Siemens sales organization worldwide. Availability and packaging may vary by country and is subject to change without prior notice. Some/All of the features and products described herein may not be available in the United States. The information in this document contains general technical descriptions of specifications Local Contact Information and options as well as standard and optional Siemens Medical Solutions USA, Inc. features which do not always have to be 51 Valley Stream Parkway present in individual cases. Malvern, PA 19355-1406 Siemens reserves the right to modify the USA design, packaging, specifications and options Telephone: +1-888-826-9702 described herein without prior notice. Please www.usa.siemens.com/healthcare contact your local Siemens sales representative for the most current information. Global Business Unit Note: Any technical data contained in this Siemens AG document may vary within defined tolerances. Medical Solutions Original images always lose a certain amount Computed Tomography & of detail when reproduced. 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  • CT Intervention Turnover Workbook