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 Table of Contents  
Year : 2021  |  Volume : 6  |  Issue : 1  |  Page : 42-45

Assessment of awareness of ultrasound safety among ultrasound users in King Saudi Arabia

1 Department of Diagnostic Radiology, Faculty of Applied Medical Sciences, King Khalid University, Abha, Saudi Arabia
2 Department of Diagnostic Radiologic Technology, Faculty of Applied Medical Sciences, Taibah University, Al-Madinah, Saudi Arabia
3 Department of Radiology, College of Applied Medical Sciences, University of Hail, Hail, Saudi Arabia

Date of Submission30-Dec-2020
Date of Decision15-Feb-2021
Date of Acceptance03-Mar-2021
Date of Web Publication31-Jul-2021

Correspondence Address:
Mohamed Adam
Department of Diagnostic Radiology, Faculty of Applied Medical Sciences, King Khalid University, Abha
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/KKUJHS.KKUJHS_36_20

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Background: Ultrasound (US) is an imaging method with significant diagnostic value; it is one of the most important diagnostic tools used by a wide range of health-care professionals across many applications. Objective: Evaluate the knowledge on implementation of the safety of diagnostic ultrasound (US) and the extent of perception of users in South King Saudi Arabia (KSA) regarding safety aspects of diagnostic methods. Methodology: This cross-sectional descriptive survey was conducted in Saudi Arabia between October 2019 and September 2020. US operators used an online questionnaire in public and private Hospitals. Data were analyzed using the SPSS software program using appropriate statistical tests. Results: A total of 105 respondents of US operators completed the questionnaires. Most of them specialized in radiology (71.4%), whereas the remaining are physicians and obstetricians. A 50.5% of the US operators responded to the correct answer for US safe in the first trimester, 21.9% responded it is safe in the second trimester, and 34.3% in the third trimester. In comparison between operators about the knowledge safety issue, sonographers have a better knowledge of US safety than others (P = 0.02), whereas females have significant experience than males (P = 0.033). Qualified US operators with postgraduate studies were significantly more knowledgeable about US safety than others (P = 0.04). Conclusions: The qualification of US users has a significant impact on US safety knowledge. Practice and awareness of US safety among US operators in KSA need further training. Further efforts are made to teach and train diagnostic medical US devices to implement safety standards.

Keywords: Knowledge, myocardial infarction, operators, safety, thermal index, ultrasound

How to cite this article:
Adam M, Gameraddin M, Alelyani M, Laghbi A, Abdallah I, Alqahtani NA. Assessment of awareness of ultrasound safety among ultrasound users in King Saudi Arabia. King Khalid Univ J Health Sci 2021;6:42-5

How to cite this URL:
Adam M, Gameraddin M, Alelyani M, Laghbi A, Abdallah I, Alqahtani NA. Assessment of awareness of ultrasound safety among ultrasound users in King Saudi Arabia. King Khalid Univ J Health Sci [serial online] 2021 [cited 2022 Jun 27];6:42-5. Available from: https://www.kkujhs.org/text.asp?2021/6/1/42/322883

  Introduction Top

Ultrasound (US) is an imaging method with significant diagnostic value; it is one of the most important diagnostic tools used by a wide range of health-care professionals across many applications. US has many benefits compared to the other imaging modalities as it is safe, cheap, and accurate such as fluoroscopy, positron emission tomography, computerized tomography, and magnetic resonance imaging. The US is the tool of choice in obstetrics firstly as it is a safe, suitable, and less consuming time (quick) diagnostic procedure. The technical development of US machines using Doppler is associated with potential risks for a client, especially in the first trimester.[1],[2]

To date, there is no evidence that the diagnostic US causes harm in humans, nor the technical development of US machines using Doppler is associated with potential risks for a client, especially in the obstetrics first trimester.[1],[2] The diagnostic US is pivotal and considered a safe imaging modality.[3] However, recent research has not yet defined the US's bioeffects on humans. Thus, most of the US users thought to depend on this fact.[4]However, some US operators thought that US should be used with high caution. Since the US is a form of energy, there is a possibility for effects in living tissues (bioeffects). Realizing the biological effects should be considered despite the invisible biological effects.[5] However, the present information indicates that the advantage gained from the exercise of diagnostic US incorrect ways exceeds any potential risks due to the increasing range of US studies being performed. US testing has become part of routine care for almost all pregnant women. Continuous power with full technical development is accompanied by potential risk when increased Doppler US use.[6],[7]

There is a possibility of realizing the biological effects listed set apart, in outlook. However, current information indicates that the advantage gained from the exercise of diagnostic US incorrect ways exceeds any potential risks. Many things raise the potential for biological effects, including (1) US testing has become part of routine care for almost all pregnant women, regardless of potential problems or not; (2) Increase the number of US tests during pregnancy; (3) potential impacts accompany continuous power full technical development; (4) examining by nonspecialists who do not recognize the potential risks and how to reduce them; and (5) Some researchers and doctors expose pregnant women to the US for long periods. Thus, the study aims to assess US safety knowledge during examination among users in Aseer province hospitals and private centers (King Saudi Arabia [KSA]).

  Methodology Top

A prospective, analytical, descriptive study dealt with US safety assessment in KSA. An online questionnaire was designed to include all the intended variables to satisfy the study. The designed questionnaire was sent to the participants (US operators) by their e-mails and other social media such as WhatsApp. They have completed filling the questionnaire from October 2019 to September 2020. A total of 105 US operators had responded to the questions. The intended questions emphasized issues of US safety.

The participants were asked to examine their knowledge on the following: (1) applying thermal index (TI) and mechanical index in US safety, (2) US safety during first, second, and third trimesters.

Statistical analysis

The data were analyzed using statistical packages for social sciences (SPSS) Version 23.0 (IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp.). A Chi-square test was used to find an association between the independent and dependent variables. Descriptive statistics were used to describe the qualitative variables as frequency and percentage. P < 0.05 is considered to be statistically significant.

  Results Top

One hundred and five out of 131 US operators completed the questionnaires with an 80% response rate; most of them specialized in radiology (71.4%), and the remaining (28.6%) are physicians, obstetricians, and nurses. The male-to-female ratio was 1:1.1. Sonographers represented 65.7% and radiologists were 23.8% [Table 1]. They performed approximately 26 cases per day (8000 cases/year). Regarding US Safety, 58.1% of the participants responded well familiar with myocardial infarction (MI), whereas 68.6% were familiar with TI. Regarding MI, females demonstrated significantly good familiarity with MI than males (P = 0.033). Simultaneously, there were no significant differences between males and females regarding their knowledge of TI (P = 0.65), as shown in [Figure 1] and [Figure 2], respectively. The participant's opinions toward US safety during pregnancy revealed that 53 (50.5%) responded the US should be used only for medical reasons in the first trimester. In comparison, 49 (46.7%) showed it is safe but should be used only when medically indicated. In the third trimester, 49 (46.7%) of the participants responded that the US is safe but should be used mainly when medically indicated [Table 2].
Table 1: Characteristics of the study participants

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Figure 1: Association of gender with familiarity with the term myocardial infarction

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Figure 2: Association of gender with familiarity with the term thermal index

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Table 2: Personal opinions regarding the safety of ultrasound

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Gender and current professions were significant factors affecting knowledge of MI among the participants, P = 0.033 and. 039, respectively. Qualification of the participants has a significant impact on the TI effect (P = 0.04) and does not affect MI knowledge (-value = 0193). In contrast, the participants' specialty had no significant impact on understanding MI and TI, P = 0.315 and 0.358, respectively [Table 3]. Sonographers demonstrated good ability on MI rather than TI compared to nonsonographers (P = 0.02). A total of 33 out of 105 responded they did not know how to manipulate TI and MI during a particular examination. A twenty out of 33 (60%) of sonographers answered that they did not know how to deal with TI and MI during a specific examination [Table 4]. Therefore, there was a significant association of the participants' current profession with US safety knowledge during the examination (P = 0.006), as shown in [Table 4].
Table 3: Factors affecting knowledge of mechanical index and thermal index among the participants

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Table 4: Association of current profession of the participants with knowledge of ultrasound safety during the examination

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  Discussion Top

There is a concern regarding US users' knowledge of safety issues. In this study, the response rate was 80%, and most of the responders specialized in radiology (71.4%); they were the US's significant users. There is a continuous trend in the growth of US diagnostic devices' output parameters in the past three decades. Therefore, it is essential to discuss safety since all the diagnostic procedures are based on physical power interactions with biological tissues and associated risks.

The present study revealed that most participants showed that Doppler US should be used only for medical reasons in the first and second trimesters. Their response reflects that they were aware of the Doppler safety in pregnancy. Recent technical development has focused on raising image goodness and Doppler conduct, which has been responsible for the safe. It was reported that Doppler US was a noninvasive means of detecting fetal abnormalities and has revolutionized the management of pregnancies.[8] The issue is that the probe produces heat (hyperthermia), which should be avoided, especially during the uterus's scanning. Another study conducted by Alreshidi et al., who studied imaging modalities and risks, reported that medical students have limited knowledge of the risks of radiation and safety measures.[9]

In this study, gender and current profession significantly impact the knowledge of US safety (P < 0.05). It was observed that females were more knowledgeable than males. They were more familiar with MI than males. It was observed that sonographers were significantly knowledgeable compared to the other professions. On the other hand, there was a significant difference in TI knowledge among the participants (P < 0.05).

The participants' qualification has a significant impact on knowledge of TI compared to MI. This difference is attributed to increasing knowledge in higher studies such as Master's and Ph. D. Sheiner et al. reported a significant number of familiar with US safety issues.[10] These findings indicate variation in knowledge among participants regarding the displayed MI and TI on the sonographic screen during scanning. In contrast, Wasickanin et al. reported that 70% of US obstetric providers did not realize output display standard functions of the equipment.[11] The variation of knowledge of these parameters indicates that the implementation of safety in the US still needs training among the operators.

There was debate regarding US safety; to date, no biological effects were detected at diagnostic levels in laboratory studies for a human. In contrast, several investigators have reported that the US can cause unfavorable health effects on mice.[12],[13] Other reviews said that there were still concerns about the diagnostic US's overall safety and its potential correlation to increased risk of autism spectrum disorders.[14],[15],[16],[17] In general, the significant effects are not well understood on humans.

Overall, most participants know about US safety and parameters to reduce bioeffects in practice.

There were various drawbacks to the study, which does not alter the significance of the findings. First of all, the sample size was not large enough. Second, the questions were not answered entirely. Some participants did not fully consider the importance of the study topic to justify the time spent answering the questionnaire; others did not respond as they were unable due to a high routine overload work. These limitations have not affected the overall significance of the study.

  Conclusions Top

Gender, qualification of US users have a significant impact on US safety knowledge. Sonographers showed adequate knowledge about US safety compared to nonsonographers. More significant efforts are well needed to increase participants' understanding of the bio-effects of diagnostic US. Further research is required to fill the knowledge gap between practices and US safety.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Barnett SB, Ter Haar GR, Ziskin MC, Rott HD, Duck FA, Maeda K. International recommendations and guidelines for the safe use of diagnostic ultrasound in medicine. Ultrasound Med Biol 2000;26:355-66.  Back to cited text no. 1
ter Haar G. The new British Medical Ultrasound Society Guidelines for the safe use of diagnostic ultrasound equipment. Ultrasound 2010;18:50-1. Doi.org/10.1258/ult. 2010.100007.  Back to cited text no. 2
European Society of Radiology (ESR). Position statement and best practice recommendations on the imaging use of ultrasound from the European Society of Radiology ultrasound subcommittee. Insights Imaging 2020;11:115.  Back to cited text no. 3
Shankar H, Pagel PS. Potential adverse ultrasound-related biological effects: A critical review. Anesthesiology 2011;115:1109-24.  Back to cited text no. 4
Abramowicz JS, Barnett SB, Duck FA, Edmonds PD, Hynynen KH, Ziskin MC. Fetal thermal effects of diagnostic ultrasound. J Ultrasound Med 2008;27:541-59.  Back to cited text no. 5
Ter Haar G. Ultrasonic imaging: Safety considerations. Interface Focus 2011;1:686-97.  Back to cited text no. 6
Nelson TR, Fowlkes JB, Abramowicz JS, Church CC. Ultrasound biosafety considerations for the practicing sonographer and sonologist. J Ultrasound Med 2009;28:139-50.  Back to cited text no. 7
Kennedy AM, Woodward PJ. A radiologist's guide to the performance and interpretation of obstetric doppler US. Radiographics 2019;39:893-910.  Back to cited text no. 8
Alreshidi MN, Alshubrmi D, Alreshidi F, Soliman K, Alrashidi I. Knowledge about imaging modalities, risks, and protection in radiology among medical students at the University of Hail. Avicenna J Med 2020;10:15-21.  Back to cited text no. 9
  [Full text]  
Sheiner E, Shoham-Vardi I, Abramowicz JS. What do clinical users know regarding safety of ultrasound during pregnancy? J Ultrasound Med 2007;26:319-25.  Back to cited text no. 10
Wasickanin M, Lentscher J, Foglia L, Colburn Z, Estrada S. Biosafety of sonography: Survey of current knowledge and practice patterns in obstetrics providers. J Ultrasound Med 2020;39:1743-51.  Back to cited text no. 11
Sinharay S, Tu TW, Kovacs ZI, Schreiber-Stainthorp W, Sundby M, Zhang X, et al. In vivo imaging of sterile microglial activation in rat brain after disrupting the blood-brain barrier with pulsed focused ultrasound: [18F] DPA-714 PET study. J Neuroinflammation 2019;16:155.  Back to cited text no. 12
Bobola MS, Chen L, Ezeokeke CK, Olmstead TA, Nguyen C, Sahota A, et al. Transcranial focused ultrasound, pulsed at 40 Hz, activates microglia acutely and reduces Aβ load chronically, as demonstrated in vivo. Brain Stimul 2020;13:1014-23.  Back to cited text no. 13
Abramowicz JS. Ultrasound and autism: Association, link, or coincidence? J Ultrasound Med 2012;31:1261-9.  Back to cited text no. 14
ter Haar GR, Abramowicz JS, Akiyama I, Evans DH, Ziskin MC, Maršál K. Do we need to restrict the use of Doppler ultrasound in the first trimester of pregnancy? Ultrasound Med Biol 2013;39:374-80.  Back to cited text no. 15
Williams EL, Casanova MF. Potential teratogenic effects of ultrasound on corticogenesis: Implications for autism. Med Hypotheses 2010;75:53-8.  Back to cited text no. 16
Williams EL, Casanova MF. Reassessment of teratogenic risk from antenatal ultrasound. Transl Neurosci 2013;4:81-7.  Back to cited text no. 17


  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4]


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