Patient Preparation for PET Imaging Online Training

Continue Continue Untitled Scene Patient Preparation for PET Imaging This online training will provide an in-depth overview of preparing a patient for oncology, cardiology, and neurology PET imaging. 1 List the steps of preparing patients for PET neurology imaging 3 List the steps of preparing patients for PET cardiology imaging 2 Master Template HOOD05162003052540 | Effective Date: 26-Nov-2019 List the steps of preparing patients for PET oncology imaging Welcome Welcome to the online training for Patient Preparation for PET imaging. By the end of this course, you will be able to: List the steps of preparing patients for PET oncology imaging, List the steps for preparing patients for PET cardiac imaging, and List the steps for preparing patient for PET neurology imaging. PET Oncology Imaging In this section, we will discuss the steps of patient preparation for PET oncology studies and take a closer look at common tracers. Image Courtesy of University of Tennessee Medical Center - Knoxville, TN, USA PET Oncology Imaging In this section, we will discuss the steps of patient preparation for PET oncology studies and take a closer look at common tracers used for PET oncology imaging. Common Oncology Tracers First, we will review the concepts of Sodium Fluoride, Fluorine and Fludeoxyglucose ( 18 F FDG)* Metabolism. Select the tab arrows to learn more about these common tracers in PET Oncology Imaging. Fluorine Sodium Fluoride Sodium Fluoride Patient Prep FDG Metabolism *See full indication and Important Safety Information at the end of this course. Please see accompanying full prescribing information at petnetsolutions.com Common Oncology Tracers Base Layer: First, we will review the concepts of Sodium Fluoride, Fluorine and Fludeoxyglucose metabolism. Please see the full indication and important safety information for each of these tracers at the end of this course, as well as the full prescribing information in the resources tab in the upper right hand corner. Fluorine Layer: Fluorine 18 is a very common radioisotope that is used in PET imaging. It is cyclotron produced and is created from a proton bombardment of Oxygen 18 water. After emitting electrons, it decays back to a stable Oxygen 18 water. It is a hydrogen analog with a half-life of approximately 110 minutes. Sodium Fluoride Layer: Sodium Fluoride was introduced as a bone imaging agent in 1962, and was later FDA approved for bone imaging in 1972. The FDA then approved it for PET bone imaging for the evaluation of altered osteogenic activity in 2000. Although it is not used as often as Nuclear Medicine or SPECT Technetium phosphate agents due to cost and availability, it has excellent specificity and sensitivity. It also has a high spatial resolution of approximately 2 to 5 millimeters. Sodium Fluoride favors uptake in the axial over the appendicular skeleton as well as joints over shafts of long bones. It produces a high bone to background ratio due to its rapid blood clearance. Fluorine is directly incorporated into the bone matrix unlike Technetium phosphate agents, which adhere to bone by chemical absorption. The tracer uptake for Sodium Fluoride is twice as high as technetium agents which translates to shorter post injection uptake prior to imaging. Sodium Fluoride Patient Prep Layer: No patient preparation is needed for Sodium Fluoride bone imaging. The typical injected dose is approximately 10 millicuries. After the injection, continue to hydrate with water and/or IV saline. Imaging typically starts at 60 to 90 minutes post injection. Some of the pitfalls for sodium fluoride bone studies include: Tracer uptake can be seen in benign bone lesions. Also, tracer uptake can be seen in degenerative joint disease located in bones and joints, and, finally, it can be difficult to interpret a super scan due to small amount of renal and soft tissue activity. FDG Metabolism Layer: Fluoride 18 FDG or fludeoxyglucose, is a very commonly used radiopharmaceutical in PET imaging. It is a glucose analog made up of carbon, oxygen, hydrogen and fluorine. FDG metabolism can be affected by the state of the patient’s metabolism. There are two states of metabolism that one should be aware of: The Fed State, which means that the glycolytic pathway is active, and the body is using glucose for energy. Then there is the Fasted State, which means that the glycolytic pathway is inactive, and the body is using fatty acids for energy. If the patient is in the Fed state, you will see more FDG uptake in the myocardial and muscle tissue, because the body is using glucose for energy. If the body is in a Fasted State, these tissues will not have as much FDG uptake. Malignant Tumors are heterogeneous populations of cells. Most of these cells are not regulated in the presence or absence of insulin. Most of these cells continuously trap FDG, because of their increase use of glucose compared to non-cancerous cells. Because of this, they are easily identifiable in PET imaging. 18F FDG (Fludeoxyglucose)* Malignant Tumors: Heterogenous populations of cells Most not regulated by presence or absence of insulin Higher use of glucose compared to non-cancerous cells Easily identifiable in PET imaging Image Courtesy of – Lausanne University Hospital, Switzerland C₆H₁₁FO₅ Commonly used in PET imaging Glucose analog *See full indication and Important Safety Information at the end of this course. Please see accompanying full prescribing information at petnetsolutions.com Table with 2 columns and 2 rows Fed State Fasted State Glycolytic pathway active Using glucose for energy FDG* uptake in the myocardial and muscle tissue will be more prevalent in the Fed State. Glycolytic pathway inactive Using fatty acids for energy Patient Preparation for Sodium Fluoride* Bone Studies NO patient prep is needed. Pitfalls: Image Courtesy of the Thompson Cancer Center – Knoxville, Tennessee, USA *See full indication and Important Safety Information at the end of this course. Please see accompanying full prescribing information at petnetsolutions.com Typical injection dose: ~ 10 mCi After injection, continue to hydrate with water and/or IV saline Imaging 60-90 minutes post injection Tracer uptake in benign bone lesions Tracer uptake in DJD of bone & joints Difficult to interpret “superscan” due to diminished renal and soft tissue activity Fluorine-18 (¹⁸F)* Fluorine is created from a proton bombardment of enriched ¹⁸O water in a cyclotron: F → O + (ꞵ , v) decays back to stable ¹⁸O hydrogen analog 109.771 minute T½ *See full indication and Important Safety Information at the end of this course. Please see accompanying full prescribing information at petnetsolutions.com Sodium Fluoride (¹⁸F NaF)* Images Courtesy of Jackson W. Kiser, MD, Molecular Imaging and Therapy Consultants of Virginia - Virginia, USA *See full indication and Important Safety Information at the end of this course. Please see accompanying full prescribing information at petnetsolutions.com 1962 1972 2000 Introduced as bone imaging agent FDA approved for bone imaging FDA approved for PET bone imaging for evaluation of altered osteogenic activity Historically not used as often due to isotope cost and availability compared to 99mTc phosphate agents Specificity and sensitivity for bone scanning High spatial resolution: ~ 2-5 mm Favors uptake: Axial over appendicular skeleton Joints over shafts of long bones High bone-to-background ratio due to rapid blood clearance Tracer uptake is approximately twice as high as 99mTc phosphate agents → shorter post-injection waiting period prior to imaging Fluorine is directly incorporated into the bone matrix unlike 99mTc phosphate agents which adhere to bone by chemical absorption Patient Scheduling for PET Oncology Imaging In this section, we will discuss important topics to remember when scheduling your PET Oncology studies. Select the tab arrows to learn more about suggestions for each condition. Claustrophobia Pregnancy or Lactation Chemotherapy Radiation Therapy Diabetes Patient Scheduling for PET Oncology Imaging Base Layer: Let’s discuss some important points to remember when scheduling your PET Oncology studies. Claustrophobia Layer: Claustrophobic patients need to have special consideration. Sometimes it’s helpful if they are able to see the scanner before the exam or have it described to them prior to scheduling. They also can check with their physician to obtain some anti-anxiety medication to take before the exam. Make sure to explain the entire process to these patients and let them know the amount of time then will be in the scanner. Communication is vital for claustrophobic patients. Pregnancy or Lactation Layer: Female patients should be asked about their pregnancy status as well as menstrual status. Menstruation can be seen as increased uptake in the uterus. Also, mothers should be asked if they are breast feeding. If they are, you may see increase uptake in the breast. Also, mothers will want to pump to have enough milk supply before FDG injection. They should have enough breast milk pumped, prior to the scan, to sustain the child for 18 to 24 hours. Chemotherapy Layer: You should inquire about the patient’s chemotherapy status, prior to the scan. It is suggested that the patient wait at least one month after last treatment before a follow up scan is performed. If imaging occurs too soon, it can result in false negative results or a flare phenomenon where high bone uptake can occur. The flare phenomenon can also occur if the patient is on immunosuppressants. Sometimes imaging during chemotherapy treatments is desirable if the physician is wanting to see the effectiveness of the treatment. Radiation Therapy Layer: Generally, patients receiving radiation therapy should not be imaged immediately following the treatment. This is due to changes and inflammation. It is recommended to wait 3-6 months post radiation therapy for PET imaging. The exception is if the referring physician is only concerned about distant metastasis. They may want to evaluate this immediately following treatment. Diabetes Layer: The state of a patient’s blood sugar can affect the quality of a scan. You should find out if a patient is diabetic before scheduling the study. Diabetes is characterized by disordered metabolism, especially hyperglycemia, typically due to decreased circulating insulin levels. FDG uptake can be impaired due to diabetic hyperglycemia. The patient’s blood sugar levels should be under control using diet or medication. The non-diabetic normal fasting range should be 70 – 99 milligrams per deciliter. A diabetic range is normally 125 or higher. Type 1 diabetic patients can, ideally, be scheduled for imaging in the early morning so overnight fasting can be utilized. Patients that are treated with insulin can take their injections and begin their PET scan two hours later because of the quick absorption of insulin. The peak action of insulin is within 1 to 3 hours after administration. Type 2 diabetic patients can be scanned in the afternoon. These patients can wake, eat and take their oral medications in the morning. Then they can start their fast for 4 hours. The blood sugar should be checked on diabetic patients before injection and the ideal serum glucose level is 70 to 120 mg/deciliter. Diabetes Diabetes is characterized by disordered metabolism, typically due to decreased circulating insulin levels. FDG* uptake can be impaired due to diabetic hyperglycemia Patient’s blood sugar levels should be under control by diet or medication Non-diabetic normal fasting range: 70-99 mg/dL Diabetic range: >125 mg/dL Type 1 Diabetes: Schedule in the A.M. PET study can be started 2 hours after administration of insulin Type 2 Diabetes: Schedule in the P.M. Patients can eat and take medications in A.M. Fast for 4 hours Ideal serum glucose level for diabetic patients is 70-120 mg/dL. *See full indication and Important Safety Information at the end of this course. Please see accompanying full prescribing information at petnetsolutions.com Radiation Therapy Suggestions: Not recommended immediately following treatment Inflammation Wait 3-6 months Exception: Immediate imaging can be performed if the referring physician is only concerned about distant metastasis Image Courtesy of Siemens Healthineers Example of inflammatory aortic FDG uptake Chemotherapy Suggestions: Wait at least 1 month after last treatment before follow up scan Imaging too soon can result in: False negative imaging results Flare phenomenon (high bone uptake) – can also be observed with patients on immunosuppressants Exception: Documentation of effectiveness of chemotherapy treatment Images Courtesy of Dana Farber Cancer Institute - Boston, MA, USA Metastatic gastro intestinal stromal tumor – good response to Gleevec therapy seen on serial FDG PET Tumor non responsive to Gleevec therapy – progressively increasing metastatic burden Pregnancy or Lactation Ask about: Pregnancy status Menstrual status menstruation may show increased uptake in uterus Lactation increased uptake in breasts have mothers pump before injection should have enough breast milk pumped to sustain child for 18 to 24 hours Image Courtesy of Siemens Healthineers Claustrophobia Suggestions: Anti-anxiety medications Explain the entire process of the procedure including amount of time to be spent in the scanner Communication is vital for claustrophobic patients See the scanner prior to scan or provide a detailed description of the scanner PET Oncology Patient Instructions In this section, we will be discussing some important patient preparation instructions for oncology studies. Select the numbered steps below to learn more about the instructions to prepare a patient for oncology studies. 1 1 1 2 2 2 3 3 3 4 4 4 PET Oncology Patient Instructions Base Layer: Next, we will be discussing some important patient preparation instructions for oncology studies. Fasting Layer: For PET oncology studies with FDG, the patient should be in a fasting state. It is typically recommended that the patient be fasting 6 to 12 hours prior to the scan, and the minimum fasting time should be no shorter than 4 hours. Water and daily medications should be taken. Fasting reduces circulating insulin levels and glucose levels, which reduces uptake to the myocardium and muscle tissues. Inpatients will typically have their physician discontinue any IV lactose or dextrose infusions during the fasting period. For diabetics it is typically recommended to refrain from taking insulin or other diabetic medications for at least 2 hours prior to exam, with their physicians consent. Caffeine and Nicotine Layer: Caffeine and Nicotine should be discontinued for several hours prior to the appointment. This is to reduce myocardial glucose uptake. Hydration Layer: It is recommended that patients be well hydrated prior to their PET exam. It is suggested that patients drink at least 48 ounces of water the day before the exam and another 24 ounces the day of the exam. Being well hydrated facilitates better FDG uptake, increases FDG clearance from non-target tissues, and lowers the radiation dosage to the patient. It also helps reduce tracer concentration artifacts. Exercise Layer: Patients undergoing a PET scan should refrain from exercise and strenuous physical activity 24 hours prior to the scan. Doing this will limit muscle uptake of FDG. After activity, muscles will use the glucose to replace the glycogen stores. Athletes must refrain from training up to 72 hours prior to scan. Exercise 4 Limits muscle uptake of FDG*: Post activity, muscles use glucose to replace glycogen stores Refrain from exercise and strenuous activity 24 hours prior to scan Athletes should refrain from training up to 72 hours prior to exam Image Courtesy of Siemens Healthineers *See full indication and Important Safety Information at the end of this course. Please see accompanying full prescribing information at petnetsolutions.com Hydration 3 Patients should be well hydrated prior to exam. 48 oz. of water the day before 24 oz. of water the day of Hydration: Facilitates better FDG* uptake Increases FDG* clearance from non-target tissues Lowers radiation dose to the patient Reduces tracer concentration artifacts *See full indication and Important Safety Information at the end of this course. Please see accompanying full prescribing information at petnetsolutions.com Discontinue several hours prior to appointment Reduces myocardial glucose uptake Caffeine and Nicotine 2 Image Courtesy of Siemens Healthineers Fasting Recommended fasting time: 6-12 hours (minimum of 4 hours) Water and daily medications can be taken Fasting reduces circulation levels of insulin and glucose Reduces uptake in myocardium and muscle tissues 1 Inpatients: Discontinue IV lactose or dextrose infusions during fasting period Diabetics: Refrain from taking insulin or other diabetic medications for at least 2 hours prior to exam (with physician consent) Image Courtesy of Siemens Healthineers PET Oncology Patient Preparation In this section, we will discuss patient preparation for PET Oncology studies. Select the numbered steps below to learn more about how to prepare a patient for oncology studies. 1 1 1 2 2 2 3 3 3 4 4 4 5 5 5 6 6 6 PET Oncology Patient Preparation Base Layer: Now we will discuss the steps to take in preparing a patient for PET oncology studies. Scanner Quality Control Layer: First thing you should do before injecting any patient is to make sure your scanner is in working order. Make sure you do your daily PET/CT QC before you inject anyone. Patient Interview Questions Layer: There are several questions that you should ask your patient prior to their scan. The first one that should be asked if the patient has had any recent biopsies or surgeries. Also, ask if the patient has had any recent imaging procedures performed. Have they had any oral contrast recently? Inquire about recent general medical history such as coughing, bronchitis or pneumonia. Have they been through any radiation or chemotherapy, and what was the date of their last regimen. Lastly, observe the patient and note any medical issues that you see. Evaluation of Patient Size Layer: Make sure you evaluate the patient’s size. This means you should weigh the patient. Most of the newer Biograph scanners have a table weight limit of 500 lbs, so make sure you are not exceeding the recommended limits of the table. Also, most of the newer Biograph scanners have 70 and 78 centimeter bores. Make sure your patient is able to fit into the bore of your scanner. Lastly, having an accurate weight will help with the accuracy of the SUV measurements. FDG Injections Layer: Prior to FDG injection, make sure you know the patient’s blood glucose level. If the serum glucose level is high, at 150 to 200 milligrams per deciliter, it is typically recommended to reschedule the patient until the blood glucose level is under better control. You also should always inject with an IV or butterfly needle and follow with a 20 to 30 milliliter saline flush to reduce venous retention. Most imaging facilities use a dose of 5 to 10 millicuries for an adult patient. After the injection, assay the syringe and IV to record the residual dose. Make sure the dose is entered in the patient protocol on the scanner. Uptake Period Layer: During the uptake period after injection, make sure to keep the patient warm and comfortable. Keep the patient quiet and calm to minimize uptake into the muscles. Holding books, playing video games, or walking around during uptake can increase the uptake in the muscles that are used during that task. Sometimes diuretics are recommended to be administered during the uptake period. These are helpful in evaluating pelvic lymph node activity or hypermetabolic lesions in the bladder wall associated with some genitourinary carcinomas. The typical uptake period is 60 to 90 minutes post injection, but they may vary based on indication. Prior to Imaging Layer: After the uptake phase, make sure you have the patient empty their bladder. For head and neck malignancies, have the patient swallow water or rinse mouth to minimize salivary radioactivity in the area of interest. Make sure the patient is positioned comfortably on the scanner to reduce incidences of motion artifacts. Finally, have the patient change into a gown or paper pants to ensure that no metal artifacts are introduced into the scan. Empty bladder Prior to Imaging 6 Head and neck malignancies: Swallow water Rinse mouth Patient is positioned comfortably on the scanner table to reduce incidences of motion and artifacts Image Courtesy of Siemens Healthineers - Erlangen, Germany Patient is asked to change into gown or paper pants to ensure no metal artifacts introduced into the scan Uptake Period Keep patient warm and comfortable 5 Keep patient calm and quiet to minimize muscle uptake No reading, playing video games or walking around Diuretics are sometimes recommended Helpful for evaluating pelvic lymph node activity Hypermetabolic lesions in bladder wall Depending on the indication, the typical uptake period is 60-90 minutes Image Courtesy of Siemens Healthineers FDG* Injections 4 Prior to injection: If patient’s BGL > 150-200 mg/dL, reschedule the patient Injection: Inject using IV or butterfly needle Follow with 20-30 mL saline flush Typical adult FDG* dose: 5-10 mCi After injection: Assay the syringe and IV for residual dose Make sure to enter the dose in the patient protocol *See full indication and Important Safety Information at the end of this course. Please see accompanying full prescribing information at petnetsolutions.com Evaluation of Patient Size 3 Weigh the patient: Most newer Biograph scanners have a table weight limit of 500 lbs DO NOT exceed the recommended table weight limits Make sure the patients girth does not exceed the bore size. Biograph Bore Sizes: Biograph™ Horizon = 70 cm Biograph™ mCT/Vision = 78 cm Accurate weight = Accurate SUV measurements Patient Interview Questions 2 Remember to Ask: Any recent biopsies or surgeries? Any recent imaging procedures performed? Any oral contrast recently? General medical history? (coughing, bronchitis, pneumonia) Any Radiation and/or Chemotherapy? If so, date of last regimen Observe the patient and take note of any medical issues that can be seen. Scanner Quality Control Make sure the scanner is in working order prior to injecting patients. 1 Good QC: Bad QC: Images Courtesy of Siemens Healthineers PET Cardiology Imaging and Tracers In this section, we will discuss the steps of patient preparation for PET Cardiology studies and common radiopharmaceuticals. Image Courtesy of Centre Hospitalier Universitaire Vaudois (CHUV) – Lausanne, Switzerland PET Cardiology Imaging and Tracers In this next section, we will discuss the steps of patient preparation for PET Cardiology studies and common radiopharmaceuticals. PET Cardiac Radiopharmaceuticals We are going to start this section off with the typical radiopharmaceuticals used in PET Cardiology Imaging. PET Myocardial Perfusion Isotopes: Ammonia Rubidium Chloride PET Myocardial Visibility Isotopes: FDG* Select the tab arrows to learn more about each radiopharmaceutical used in cardiology imaging. Ammonia Rubidium Chloride FDG* *See full indication and Important Safety Information at the end of this course. Please see accompanying full prescribing information at petnetsolutions.com PET Cardiac Radiopharmaceuticals Base Layer: We are going to start this section off with the typical radiopharmaceuticals used in PET Cardiology Imaging. Ammonia Layer: Ammonia is one of the isotopes that is commonly used in PET myocardial perfusion imaging. It is a cyclotron produced radiopharmaceutical with a half life of 10 minutes and relatively low energy of 1.19 mega electron volts. The advantages of using Ammonia is that it exhibits rapid blood clearance. Also, you can perform exercise testing using this isotope. It is administered as a bolus injection and has a relatively high uptake and retention, of about 83%. It can also be used for quantification for coronary blood flow reserve. Some of the disadvantages of using ammonia for cardiac perfusion imaging is that it’s cyclotron produced, therefor you would need to have a radiopharmacy nearby. Since it does have a longer half-life, you can experience decreased throughput when comparing it to rubidium imaging. It has a high initial cost as well. In smokers, you can have marked lung uptake. Sometimes you can have a low uptake in the lateral or posterolateral wall in some normal patients. Some patients can also experience excess lung and liver uptake. Rubidium Chloride Layer: Another popular PET isotope used in cardiac imaging is Rubidium Chloride. It is generator produced, has a half-life of 75 seconds and an energy of 3.35 MeV. Some of the advantages of Rubidium Chloride is that it’s a potassium analog, which will give it identical kinetics to the SPECT imaging agent Thallium Chloride. Since it is generator produced, you can have it onsite more easily. Strontium 82 is the parent and you elute the generator with saline. Rubidium Chloride is lower cost than ammonia, and due to its short half-life, you can have high throughput capacity. This is also helpful if you need a repeat scan. Lastly, there is low technologist exposure with Rubidium Chloride. Some of the disadvantages of using Rubidium include having to administer the isotope as a long infusion. There are high monthly costs associated with Rubidium. Also, it’s a higher energy isotope, which causes lower resolution and more scatter from a 700 keV gamma third particle. This accounts for 10 – 15% of the total activity. Rubidium has a lower uptake retention than ammonia, which is approximately 59%. The image quality of Rubidium is affected by BMI, pulmonary hypertension, and left ventricular hypertrophy due to blood pool activity. You can only perform pharmacologic stress testing because of the short half-life. Also, the image quality declines over the generator life, due to lower specific activity. FDG Layer: For PET Cardiac Viability imaging, you have FDG. This is the only isotope used for this kind of imaging, because the glucose is what is being utilized by the cardiac metabolism. FDG is cyclotron produced with a half-life of 110 minutes. Its energy is .6335 mega electron volts. The advantages of using FDG for cardiac PET imaging include its sufficient half life for remote transport, as well as it can be produced locally with a cyclotron. Also, FDG is widely accepted for clinical oncology, cardiology, and neurology applications. Finally, it allows for quantification of uptake to aid in diagnosis and monitoring. The disadvantages of using FDG include requiring strict patient preparation to ensure accurate results, its uptake period can affect distribution, as well as diabetic patients can be difficult to manage. ¹⁸F FDG* Cyclotron produced T½: 110 minutes Energy: 0.6335 MeV Images Courtesy of Charit é University Hospital - Berlin, Germany Advantages: Sufficient T½ for remote transport Can be produced locally with a cyclotron Widely accepted for clinical oncology, cardiology and neurology applications Allows for quantification of uptake (SUV) to aid in diagnosis/monitoring Disadvantages: Requires strict patient prep to ensure accurate results Uptake period can affect distribution Diabetic patients can be difficult to manage FDG PET for follow-up of apical MI. *See full indication and Important Safety Information at the end of this course. Please see accompanying full prescribing information at petnetsolutions.com ⁸²Rb (Rubidium Chloride) Generator produced T½: 75 seconds Energy: 3.35 MeV Advantages: K analog Generator produced Lower cost than NH Short T½ → high throughput capacity Repeat scans quicker Low technologist exposure Disadvantages: Administered as a long infusion, no bolus Higher monthly costs Higher energy → lower resolution, and more scatter from 700 keV gamma 3rd particle (10-15% of total activity) Lower uptake and retention than NH3 Image quality affected by: BMI, Pulmonary HTN, and LVH Can only perform pharmacologic stress testing Image quality declines over generator life Image Courtesy of Manchester Royal Infirmary - Manchester, England ¹³NH₃ Ammonia* Cyclotron produced T½: 10 minutes Energy: 1.19 MeV Advantages: Exhibits rapid blood clearance Can perform exercise testing Bolus injection Relatively high uptake retention (~83%) Quantification (CBR) Disadvantages: Cyclotron Produced Longer T½ → decreased throughput when compared to ⁸²Rb High initial cost Marked lung uptake in smokers Low uptake in lateral/posterolateral wall in some normals Excess lung and liver uptake in some patients Image Courtesy of Jackson W. Kiser, MD, Molecular Imaging and Therapy Consultants of Virginia - Virginia, USA *See full indication and Important Safety Information at the end of this course. Please see accompanying full prescribing information at petnetsolutions.com Patient Scheduling: PET Myocardial Perfusion Imaging Best candidates for PET MPI: Women Breast implants Bariatric patients Chest wall deformity Inconclusive SPECT study Image Courtesy of Siemens Healthineers Patient Scheduling: PET Myocardial Perfusion Imaging In the next couple of slides we will discuss important considerations for scheduling a patient for a PET cardiac study. Which patients are the best candidates for PET myocardial perfusion imaging? Women are good candidates because of breast tissue attenuation. Also, people with breast implants because of the same reason. These types of patients can show artifacts on the images. Bariatric patients are good candidates because of the better count statistics you get with PET imaging. Patients with a chest wall deformity are better off with PET cardiac scan. Lastly, patients with an inconclusive SPECT study would benefit from a PET scan evaluation. Patient Scheduling: PET MPI vs SPECT MPI Potentially higher specificity Easier to diagnose 3 vessel disease Always has attenuation correction Non invasive way to calculate MBF and CBF reserve Better spatial resolution Increased count statistics PET/CT scanner not available Likelihood of CAD is low (PET normal) Likelihood of significant CAD high Angioplasty is almost certain Crucial to correlate exercise symptoms with simultaneous imaging PET/CT Imaging: SPECT Imaging: Patient Scheduling: PET MPI vs SPECT MPI To start off, why would you do a PET myocardial perfusion scan over a SPECT myocardial perfusion scan? PET imaging usually has higher specificity than SPECT scans. It is also easier to diagnose 3 vessel disease with PET imaging. If you have a SPECT only scanner, you will not have attenuation correction. PET/CT scanners always have attenuation correction. PET imaging is a non-invasive way to calculate myocardial blood flow and cardiac blood flow reserve. PET usually has better spatial resolution and you can get increased count statistics with PET imaging. Some of the reasons that a SPECT study is ordered instead of a PET study include: if a PET/CT scanner is not available, if the likelihood of CAD is so low, the PET/CT is likely to be normal, or if the likelihood of significant CAD is so high, angioplasty is almost certain. Lastly, if it’s crucial to correlate exercise symptoms with simultaneous imaging. Patient Scheduling: PET Myocardial Viability Imaging Why PET Myocardial Viability Scanning? Permanent damage vs. Viable heart muscle tissue Determines myocardial viability using FDG* (form of glucose): Heart has to demonstrate ability to metabolize glucose Permanent damage No glucose metabolism No benefit from revascularization 35% of bypass or angioplasty patients do not show improvement in cardiac function No Permanent Damage Heart able to metabolize glucose Possible benefit from revascularization Glucose loading is time consuming and can cause scheduling delays. Image Courtesy of Jackson W. Kiser, MD, Molecular Imaging and Therapy Consultants of Virginia - Virginia, USA *See full indication and Important Safety Information at the end of this course. Please see accompanying full prescribing information at petnetsolutions.com Patient Scheduling: PET Myocardial Viability Imaging A key issue for patients who have been diagnosed with coronary artery disease is to determine whether there has been permanent damage to the heart muscle, or myocardium, due to reduced supply of nutrients. This means looking at areas of the heart that are not functioning properly and determining whether the tissue is still alive or viable. PET/CT imaging using the radiopharmaceutical FDG, is utilized by physicians to determine myocardial viability and whether the heart can recover if blood supply is restored by revascularization. Myocardial viability imaging utilizes FDG, a form of glucose, which helps the physician determine if areas of the heart tissue demonstrate the ability to metabolize glucose. If the heart muscle has been damaged permanently, it will not show any glucose metabolism, and the patient will not benefit from revascularization or by having blood supply re-established. Such a patient would need medical therapy or a heart transplant. About 35% of coronary artery disease patients who receive bypass surgery or angioplasty to revascularize the heart do not show improvement in cardiac function because the affected tissue is permanently damaged and not reversible. PET Cardiac Imaging Patient Instructions Instructions: NPO for 4-6 hours No caffeine for 24 hours No nicotine for 6 hours No beta blockers No calcium channel blockers No theophylline derivatives for 48 hours PET Cardiac Imaging Patient Instructions Instructions for PET cardiac imaging are similar to the instructions given for SPECT patients. The patient should be NPO for 4 to 6 hours with no consumption of caffeine for 24 hours and nicotine for 6 hours. The patient should also be off any beta blocker and calcium channel blocker medications. Lastly, the patient should not be given any theophylline derivatives for 48 hours prior to the scan. PET Cardiac Imaging Patient Preparation In the next couple of slides we will discuss patient preparation suggestions for PET myocardial perfusion imaging (MPI) and PET myocardial viability imaging. PET Cardiac Imaging Patient Preparation Now let’s discuss some of the patient preparation suggestions for PET cardiac imaging. PET Myocardial Perfusion Imaging Patient Preparation Get a full patient cardiac history: Symptoms Cardiac Events NPO for 6 Hours No caffeine or nicotine Can affect pharmacological stress medication and should be discontinued 24 hours prior to exam Smoking can affect CBF reserve and should be discontinued 6 hours prior to exam Note medications that can affect pharmacological stress agents: Nitroglycerine compounds Theophylline Beta blockers Calcium channel blockers Stop breast feeding before injection of tracer 13NH3 Ammonia* → wait 5 hours before resuming 82Rb Rubidium Chloride → can resume when patient returns home *See full indication and Important Safety Information at the end of this course. Please see accompanying full prescribing information at petnetsolutions.com PET Myocardial Perfusion Imaging Patient Preparation When a patient arrives to the department for PET cardiac imaging, a cardiac history should be obtained. This should include the symptoms that are being experienced, and any history of cardiac events. The patient should have fasted for 6 hours before the procedure. Caffeine can counteract pharmacological stress medications, so the patient should be off caffeine for 24 hours. Smoking can affect coronary flow reserve, and the patient should not have smoked for 6 hours prior to examination. Medications should also be noted. Some of the medications that can affect the pharmacological stress agents include nitroglycerine compounds, theophylline, beta blockers and calcium channel blockers. Breast feeding should be stopped before the injection of the tracer. If ammonia is used, the mother can resume breast feeding 5 hours post injection. If the mother is given Rubidium, she can resume feeding when she returns home. PET Myocardial Viability Imaging Patient Preparation Cardiac Metabolism Facts: Perfusion, contractility and metabolism are closely interrelated Fasting state heart will metabolize fatty acids Glucose-loaded state heart will metabolize sugar Ischemia Low perfusion Myocardial cells shift from fatty acid to glucose metabolism Select the numbered steps below to learn more about preparing a patient for a myocardial viability study. 1 1 1 2 2 2 3 3 3 4 4 4 PET Myocardial Viability Imaging Patient Preparation Base Layer: Another type of cardiac study that is performed in PET imaging is the myocardial viability study. Before we discuss this study, let’s first discuss some facts of cardiac metabolism. Perfusion, contractility and metabolism in the heart are closely inter-related. When the heart is in a fasting state, it will metabolize fatty acids. When it’s in a glucose-loaded state, it will metabolize sugar. During ischemia, when perfusion is low, the myocardial cell will shift from fatty acid metabolism to glucose metabolism. Cardiac History Layer: When the patient arrives at the facility for a cardiac viability study, you should get a full patient history. Ask about any symptoms and cardiac events. You should also get a list of the medications that the patient is taking. Diabetic Layer: Next, determine if the patient is diabetic. If so, check to see if medications are taken to control blood glucose levels. The type and dosage of hypoglycemic medications may play a role in the decision of how to manage serum glucose levels during the procedure. Oral Glucose Protocol Layer: For PET myocardial viability studies with FDG, the heart has to be using glucose. To accomplish this, you have to glucose load the patient. To start the procedure, make sure the patient has fasted 5 to 12 hours prior to the exam. Next, check the blood glucose level of the patient. If the BGL is less than 250 milligrams per deciliter, administer oral glucose dose of 25 to 100 grams. If the BGL is greater than 250 milligrams per deciliter, no glucose loading is necessary. Administer insulin, according to the chart that shows the guidelines for blood glucose maintenance after oral glucose administration. After insulin administration, administer 5 – 15 millicurie of FDG, if the blood glucose level is less than 150 milligrams per deciliter. IV Glucose Protocol Layer: Shown is an example of a IV glucose loading protocol. The patient should be fasting for 6 to 12 hours prior to the procedure. If the fasting blood glucose level is less than 125 grams per deciliter, administer 50% dextrose in water intravenously. 20 milligrams of hydrocortisone should be added to the 50% dextrose in water to minimize the rather severe pain that can occur at the injection site with 50% dextrose in water. If the fasting blood glucose level is between 125 and 225 milligrams per deciliter, give 12 grams of 50% dextrose in water intravenously. If the fasting blood glucose level is greater than 225 milligrams per deciliter, administer insulin using this formula: 50 subtracted from the blood glucose level, divided by 25. After 30 to 60 minutes, if the blood glucose level is less than 150 milligrams per deciliter, give 5 to 15 millicuries of FDG intravenously. If the blood glucose level is greater than 150 milligrams per deciliter, give more regular insulin until blood glucose level is less than 150 milligrams per deciliter before giving FDG. Giving FDG when blood glucose level is 150 to 200 milligrams per deciliter can result in a poor quality study. Uptake time for the isotope is 45 to 60 minutes. IV Glucose Loading Protocol 4 Patient should be fasting 6 to 12 hours prior to the procedure Check blood glucose level (BGL) Fasting BGL is < 125 mg/dl → administer 125 g D-50-W: Add 20 mg Hydrocortisone to D-50-W to minimize pain at injection site Fasting BGL is between 125-225 mg/dl → administer 12g D-50-W Fasting BGL is > 225 mg/dl → administer insulin using the following formula: (BGL-50)/25 After 30-60 minutes, if BGL is < 150 mg/dl → administer 5-15 mCi FDG* intravenously After 30-60 minutes, if BGL is > 150 mg/dl → administer more regular insulin until BGL is < 150 mg/dl before administering FDG* Uptake time is 45 to 60 minutes *See full indication and Important Safety Information at the end of this course. Please see accompanying full prescribing information at petnetsolutions.com Oral Glucose Loading Protocol 3 Patient should be fasting for 6-12 hours Check blood glucose level (BGL) If BGL is < 250 mg/dl → administer oral glucose of 25-100 g If BGL is > 250 mg/dl → no glucose loading necessary Proceed with insulin administration (see chart) Administer 5-15 mCi of FDG* if BGL is < 150 mg/dl Guidelines for Blood Glucose Maintenance After Oral Glucose Administration: Data Courtesy of ASNC Practice Points 2011 *See full indication and Important Safety Information at the end of this course. Please see accompanying full prescribing information at petnetsolutions.com If the patient is diabetic: Check medications being taken to control BGL Type and dosage may play role in decision on how the manage BGL during the procedure Determine if Patient is Diabetic 2 Cardiac History Documentation Get a full patient cardiac history: Symptoms Cardiac events List of medications 1 PET Neurology Patient Preparation Finally, in this section, we will discuss patient preparation for PET neurology studies. Select the numbered steps below to learn more about how to prepare a patient for neurology studies. 1 1 1 2 2 2 3 3 3 4 4 4 5 5 5 PET Neurology Patient Preparation Base Layer: Finally, in the following section, we will discuss patient preparation for PET neurology studies. FDG Brains Layer: Typically, PET brain scanning using FDG is done with normal fasting plasma glucose, which is usually achieved by fasting for 6 hours before examination. The dose of FDG intravenous injection is usually between 5 and 10 millicuries. The patient should be resting during the uptake period with their eyes closed, ears unplugged, not doing any physical activity for 20 to 60 minutes. Because of the dependence of cerebral blood flow and cerebral metabolic rate of glucose on neuronal activity, the conditions during examination are crucial for interpretation of results. The state of consciousness, sensory influences, anxiety, and sedative drugs can affect the global levels of FDG distribution. Effects of Sleep Layer: In sleep, depending on the sleep cycle, the overall uptake of activity in the brain is affected. For example: during slow wave sleep there is a global decrease in cerebral blood flow. Sometimes, the level of anxiety during REM dreams is reported to increase the global cerebral metabolic rate of glucose. Sleep should be avoided during the uptake period if at all possible. Uptake Period Layer: Clinical FDG brain studies are usually performed with the patients in a resting state. This means no specific sensory stimulation. These patients should not be engaged in a behavioral or physical task. These patients need a quiet uptake area that allows for no sensory stimulation. In many departments, patients are asked to close their eyes before the start of the examination and to keep them closed throughout the procedure. It’s important to make patients familiar with their surroundings prior to the examination to avoid any unnecessary anxiety and restlessness. Despite all the preparation, it’s just not possible to control the patient’s mental functions. Sedative Drugs Layer: There is a global reduction of the cerebral metabolic rate of glucose and cerebral blood flow when patients are on sedative drugs. Some of these include propofol, sevoflurane, isoflurane and halothane. Only ketamine and related anesthetics may increase metabolic activity. The sedative effects of benzodiazepines are often most pronounced in the thalamus and the occipital cortex. Opioids, such as morphine and buprenorphine can reduce the cerebral metabolic rate. Non-Sedative Drugs Layer: Non-sedative drugs, such as acetazolamide and adenosine, can influence the cerebral blood flow and the cerebral metabolic rate. Some will increase these in certain areas in the brain. Non-Sedative Drugs Non-sedative drugs: Acetazolamide Adenosine Can influence cerebral blood flow and cerebral metabolic rate → some will increase these in certain areas of the brain. 5 Sedative Drugs 4 Sedative drugs that cause global reduction in CMRglc and CBF: Propofol Sevoflurane Isoflurane Halothane Sedative drugs that increase in CMRglc and CBF: Ketamine Related anesthetics Benzodiazepine Effects: Most pronounced in the thalamus and occipital cortex Opioids that reduce CMRglc: Morphine Buprenorphine Uptake Period – Resting State 3 FDG* Brain studies usually performed with patient in resting state: No specific sensory stimulation No engagement in a behavioral or physical task Quiet uptake area needed Recommend eyes closed throughout procedure and make patients familiar with surroundings prior to exam to avoid anxiety and restlessness. *See full indication and Important Safety Information at the end of this course. Please see accompanying full prescribing information at petnetsolutions.com Overall uptake is affected, depending on sleep cycle. Slow wave sleep: Global decrease in CBF Anxiety during REM phase: Increases CMRglc Avoid sleep during uptake periods. Effects of Sleep on Brain Glucose Uptake 2 Patient Preparation for FDG* Brains PET brain scanning using FDG*: Normal fasting plasma glucose Fasting for 6 hours Dose = 5-10 mCi 1 Uptake: Patient should be resting Eyes closed Ears unplugged No physical activity Time = 20-60 minutes Conditions that can affect global levels of FDG* distribution: State of consciousness Sensory influences Anxiety Sedative Drugs *See full indication and Important Safety Information at the end of this course. Please see accompanying full prescribing information at petnetsolutions.com List the steps of preparing patients for PET neurology imaging List the steps of preparing patients for PET cardiology imaging List the steps of preparing patients for PET oncology imaging Course Review Congratulations. You have completed the Patient Preparation for PET Imaging course. Select the objectives listed below to review the material before proceeding to the final assessment. 1 1 1 2 2 2 3 3 3 Course Review List the steps of preparing patients for PET neurology imaging Patient preparation prior to neurology scan: Brain scanning using FDG* is done with normal fasting plasma glucose → fast for 6 hours FDG* dose: 5-10 mCi Uptake period: 20-60 minutes Patient should be in a resting/relaxed state No physical activity Avoid sleep Sedative drugs: Global reduction in CMRglc and CBF → Propofol, Sevoflurane, Isoflurane, Halothane Increase in CMRglc and CBF → Ketamine, related anesthetics Benzodiazepine → most pronounced in the thalamus and occipital cortex Opioids (Morphine and Buprenorphine) → reduces CMRglc Non-sedative drugs: Some will increase in certain areas of the brain → acetazolamide, adenosine *See full indication and Important Safety Information at the end of this course. Please see accompanying full prescribing information at petnet.com List the steps of preparing patients for PET cardiology imaging PET Cardiac Radiopharmaceuticals: Ammonia Rubidium Chloride FDG* Instructions for patients: NPO for 4 – 6 hours No caffeine for 24 hours No nicotine for 6 hours No beta blockers No calcium channel blockers No theophylline derivatives for 48 hours Scheduling a patient for cardiac scan: Advantages of PET MPI v. SPECT MPI Patients best for PET MPI: women, breast implants, bariatric patients, chest wall deformity, inconclusive SPECT study Myocardial Viability Imaging → determining permanent damage vs. viable heart muscle tissue MPI Patient Preparation: Cardiac history documentation NPO for 6 hours No caffeine or nicotine Stop medications that can affect pharmacological stress agents Stop breast feeding prior to injection of tracer Myocardial Viability Imaging Patient Preparation: Cardiac History documentation Determine if patient is diabetic Glucose load the patient Oral glucose loading protocol IV glucose loading protocol *See full indication and Important Safety Information at the end of this course. Please see accompanying full prescribing information at petnet.com List the steps of preparing patients for PET oncology imaging Important considerations when scheduling patients for PET imaging: Claustrophobia Pregnancy or Lactation Chemotherapy Radiation Therapy Diabetes Instructions for patients: Recommending fasting time 6-12 hours prior to scan Discontinue caffeine and nicotine several hours prior to scan Should be well hydrated Refrain from exercise 24 hours prior to scan Common Tracers: Fluorine Sodium Fluoride FDG* Patient preparation steps: Ensure scanner is working Ask patient interview questions Evaluate the patient size Know the patients blood glucose level prior to FDG* injection Keep the patient warm and comfortable during uptake period Have the patient empty their bladder Position the patient comfortably *See full indication and Important Safety Information at the end of this course. Please see accompanying full prescribing information at petnet.com Fludeoxyglucose 18F (FDG) Injection for Intravenous Use Indications and usage Fludeoxyglucose 18 F injection is indicated for positron emission tomography (PET) imaging in ​the following settings: ​ Oncology: For assessment of abnormal glucose metabolism to assist in the evaluation of malignancy in patients with known or suspected abnormalities found by other testing modalities, or in patients with an existing diagnosis of cancer.​ Cardiology: For the identification of left ventricular myocardium with residual glucose metabolism and reversible loss of systolic function in patients with coronary artery disease and left ventricular dysfunction, when used together with myocardial perfusion imaging.​ Neurology: For the identification of regions of abnormal glucose metabolism associated with foci of epileptic seizures. Important safety information​ Radiation Risk: Radiation-emitting products, including Fludeoxyglucose F 18 Injection, may increase the risk for cancer, especially in pediatric patients. Use the smallest dose necessary for imaging and ensure safe handling to protect the patient and health care worker. Blood Glucose Abnormalities: In the oncology and neurology setting, suboptimal imaging may occur in patients with inadequately regulated blood glucose levels. In these patients, consider medical therapy and laboratory testing to ensure at least two days of normoglycemia prior to Fludeoxyglucose F 18 Injection administration. Adverse Reactions: Hypersensitivity reactions with pruritus, edema, and rash have been reported. Have emergency resuscitation equipment and personnel immediately available. Dosage forms and strengths Multiple-dose 30 mL and 50 mL glass vial containing 0.74 to 7.40 GBq/mL (20 to 200 mCi/mL) Fludeoxyglucose F 18 Injection and 4.5 mg of sodium chloride with 0.1 to 0.5% w/w ethanol as a stabilizer (approximately 15 to 50 mL volume) for intravenous administration. Fludeoxyglucose F 18 Injection is manufactured and distributed by PETNET Solutions, Inc., 810 Innovation Drive, Knoxville, TN 39732 These highlights do not include all the information needed to use Fludeoxyglucose F 18 Injection safely and effectively. See full prescribing information for Fludeoxyglucose F 18 Injection, available at petnetsolutions.com. Fludeoxyglucose Indications and Important Safety Information Sodium Fluoride 18F Injection for Intravenous Use Indications and usage Sodium Fluoride F 18 Injection (18F NaF) is a radioactive diagnostic agent for positron emission tomography (PET) indicated for imaging bone to define areas of altered osteogenic activity. Important safety information​ Allergic Reactions: As with any injectable drug, allergic reactions and anaphylaxis may occur. Emergency resuscitation equipment and personnel should be immediately available. Cancer Risk: Sodium Fluoride F 18 Injection may increase the risk of cancer. Use the smallest dose necessary for imaging and ensure safe handling to protect the patient and health care worker. Adverse Reactions: No adverse reactions have been reported based on a review of the published literature, publicly available reference sources, and adverse drug reaction reporting systems. The completeness of the sources is not known. Dosage forms and strengths Multiple-dose vial containing 370–7,400 MBq/mL (10–200 mCi/mL) of no-carrier-added sodium fluoride F 18 at EOS reference time in aqueous 0.9% sodium chloride solution. Sodium Fluoride F 18 Injection is a clear, colorless, sterile, pyrogen-free and preservative-free solution for intravenous administration. Sodium Fluoride F 18 Injection is manufactured and distributed by: PETNET Solutions, Inc. 810 Innovation Drive Knoxville, TN 39732 These highlights do not include all the information needed to use Sodium Fluoride F 18 Injection safely and effectively. See full prescribing information for Sodium Fluoride F 18 Injection, available at petnetsolutions.com Sodium Fluoride Indications and Important Safety Information Ammonia N 13 Injection for Intravenous Use Indications and usage Ammonia N 13 Injection (13NH3) is a radioactive diagnostic agent for positron emission tomography (PET) indicated for diagnostic PET imaging of the myocardium under rest or pharmacologic stress conditions to evaluate myocardial perfusion in patients with suspected or existing coronary artery disease. Important safety information​ Cancer Risk: Ammonia N 13 Injection may increase the risk of cancer. Use the smallest dose necessary for imaging and ensure safe handling to protect the patient and the health care worker. Adverse Reactions: No adverse reactions have been reported for Ammonia N 13 Injection based on a review of the published literature, publicly available reference sources, and adverse drug reaction reporting systems. The completeness of the sources is not known. Dosage forms and strengths Glass vial (30 mL) containing 0.138-1.387 GBq (3.75-37.5 mCi/mL) of Ammonia N 13 Injection in aqueous 0.9 % sodium chloride solution (the total volume in the vial will vary) for intravenous administration. Ammonia N 13 Injection is manufactured and distributed by: PETNET Solutions, Inc. 810 Innovation Drive Knoxville, TN 39732 These highlights do not include all the information needed to use Ammonia N 13 Injection safely and effectively. See full prescribing information for Ammonia N 13 Injection, available at petnetsolutions.com Ammonia Indications and Important Safety Information Please note that the learning material is for training purposes only! All images not cited were obtained from the Siemens Digital Asset Pool. For the proper use of the software or hardware, please always use the Operator Manual or Instructions for Use (hereinafter collectively “Operator Manual”) issued by Siemens Healthineers. This material is to be used as training material only and shall by no means substitute the Operator Manual. Any material used in this training will not be updated on a regular basis and does not necessarily reflect the latest version of the software and hardware available at the time of the training. The Operator's Manual shall be used as your main reference, in particular for relevant safety information like warnings and cautions. Note: Some functions shown in this material are optional and might not be part of your system. Certain products, product related claims or functionalities (hereinafter collectively “Functionality”) may not (yet) be commercially available in your country. Due to regulatory requirements, the future availability of said Functionalities in any specific country is not guaranteed. Please contact your local Siemens Healthineers sales representative for the most current information. The reproduction, transmission or distribution of this training or its contents is not permitted without express written authority. Offenders will be liable for damages. All names and data of patients, parameters and configuration dependent designations are fictional and examples only. All rights, including rights created by patent grant or registration of a utility model or design, are reserved. Copyright © Siemens Healthcare GmbH 2021 Siemens Healthineers Headquarters\Siemens Healthcare GmbH\Henkestr. 127\ 91052 Erlangen, Germany\Telephone: +49 9131 84-0\siemens-healthineers.com Disclaimer Disclaimer Assessment This assessment will test your retention of the presented content. A passing score of 80% or higher is required to complete the course and earn your certificate. You may repeat the assessment as many times as needed. Start Assessment Introduced as a bone imaging agent in 1962 Improved sensitivity and specificity of bone scanning Favors uptake in appendicular skeleton and shafts of long bones over axial skeleton & joints Better tracer than 99mTc agents, translating to shorter uptake time periods Which of the following is NOT correct about Na18F bone imaging? Question 1 of 10 Select the best answer. Multiple Choice Question Incorrect Incorrect Incorrect Correct Myocardial tissue in fed state uses glucose for energy Myocardial tissue in fasted state uses glucose for energy Myocardial tissue in fasted state uses fatty acids for energy Muscle tissue continuously absorbs glucose at low levels in the absence of insulin Which of the following is NOT correct concerning FDG metabolism? Question 2 of 10 Select the best answer. Multiple Choice Question Incorrect Incorrect Incorrect Correct One week or more post chemotherapy Two weeks or more post chemotherapy One month or more post chemotherapy During chemotherapy if evaluating treatment effectiveness When is a good time to perform PET imaging on a chemotherapy patient? Question 3 of 10 Select the best answer. Multiple Choice Question Incorrect Incorrect Incorrect Correct Minimum 4 hours NPO (typically better 6-12 hours) No caffeine or nicotine for several hours prior No insulin or diabetic meds at least 2 hours prior No strenuous physical exercise for 6 hours prior Which of the following is NOT proper patient instruction for oncologic FDG PET imaging? Question 4 of 10 Select the best answer. Multiple Choice Question Correct Incorrect Incorrect Correct 82Rb Rubidium Chloride 18F FDG 99mTc Sestamibi 201Tl Thallous Chloride Which of the following is a PET perfusion imaging radiopharmaceutical? Question 5 of 10 Select the best answer. Multiple Choice Question Correct Incorrect Incorrect Correct 5-10 minutes 45-60 minutes 60-90 minutes 6-12 hours What is the uptake time for IV Glucose loading? Question 6 of 10 Select the best answer. Multiple Choice Question Correct Incorrect Incorrect Correct Propofol Ketamine Morphine Adenosine Which of the following is a non-sedative drug for Neurology Imaging? Question 7 of 10 Select the best answer. Multiple Choice Question Correct Incorrect Incorrect Correct Better spatial resolution You can correlate exercise symptoms with simultaneous imaging It is a non-invasive way to calculate MBF and CBF reserve Easier to diagnose 3 vessel disease Which of the following is an advantage of ordering SPECT Imaging over PET Imaging for MPI? Question 8 of 10 Select the best answer. Multiple Choice Question Correct Incorrect Incorrect Correct Exhibits rapid blood clearance Bolus injection Relatively high uptake retention Short half-life Which of the following is NOT an advantage of using Ammonia for Cardiac PET Imaging? Question 9 of 10 Select the best answer. Multiple Choice Question Correct Incorrect Incorrect Correct No theophylline derivatives for 24 hours No beta blockers NPO for 4-6 hours No calcium channel blockers Which of the following is NOT proper patient instruction for PET myocardial perfusion imaging? Question 10 of 10 Select the best answer. Multiple Choice Question Correct Incorrect Incorrect Correct Review Review Retry Assessment Results %Results.ScorePercent%% %Results.PassPercent%% Continue YOUR SCORE: PASSING SCORE: Assessment Results You did not pass the course. Take time to review the assessment then select Retry to continue. Congratulations. You passed the course. Exit To access your Certificate of Completion, select the Launch button drop down on the course overview page. You can also access the certificate from your PEPconnect transcript. You have completed the Patient Preparation for PET Imaging Online Training. Completion HOOD05162003131877 | Effective Date: 12-Feb-2021 Fludeoxyglucose F 18 Full Prescribing Information Sodium Fluoride F 18 Injection Full Prescribing Information Ammonia N 13 Injection Full Prescribing Information 1 Untitled Scene 1.1 Welcome 1.2 PET Oncology Imaging 1.3 Common Oncology Tracers 1.4 Patient Scheduling for PET Oncology Imaging 1.5 PET Oncology Patient Instructions 1.6 PET Oncology Patient Preparation 1.7 PET Cardiology Imaging and Tracers 1.8 PET Cardiac Radiopharmaceuticals 1.9 Patient Scheduling: PET Myocardial Perfusion Imaging 1.10 Patient Scheduling: PET MPI vs SPECT MPI 1.11 Patient Scheduling: PET Myocardial Viability Imaging 1.12 PET Cardiac Imaging Patient Instructions 1.13 PET Cardiac Imaging Patient Preparation 1.14 PET Myocardial Perfusion Imaging Patient Preparation 1.15 PET Myocardial Viability Imaging Patient Preparation 1.16 PET Neurology Patient Preparation 1.17 Course Review 1.18 Fludeoxyglucose Indications and Important Safety Information 1.19 Sodium Fluoride Indications and Important Safety Information 1.20 Ammonia Indications and Important Safety Information 1.21 Disclaimer 1.22 Assessment 1.34 Completion