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Standard Operating Procedure (SOP): CBCT with NewTom 5XL Series - Veterinary Use

Important Note on Naming: The NewTom 5XL is the original medical/dental platform from Cefla/NewTom. The veterinary-optimized successor is the NewTom 5G XL VET. Both share the same gantry architecture, lying-down patient positioning, and NNT/Neowise software stack. This SOP covers both, with series-specific parameters noted where they differ.

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SECTION 1: Purpose and Scope

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SECTION 2: Equipment Overview - Series Comparison

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SECTION 3: Personnel Requirements

1. A licensed veterinarian or credentialed veterinary radiologist must authorize every scan and review all images.
2. The radiographer/operator must have completed NewTom device training and hold current radiation safety certification.
3. Minimum two trained personnel required during scanning of anesthetized patients.
4. All personnel must exit the room or stand behind a shielded barrier during exposure.

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SECTION 4: Pre-Scan Preparation

4.1 Machine Warm-Up and Daily QC

1. Power on the unit at least 15 minutes before first scan of the day.
2. Perform the daily calibration/flat-field correction through NNT/Neowise software (Settings > QC > Daily Calibration). This corrects for detector drift.
3. Verify laser alignment lights are functional and accurately centred on the table.
4. Check that the emergency stop button is accessible and functional.
5. Confirm the patient table moves freely through its full range of motion.
6. Log all QC results in the maintenance register.

4.2 Patient Registration in Software

1. Open NNT Workstation or Neowise software.
2. Create a new patient record: enter species, breed, age, sex, body weight, and referring veterinarian.
3. Select the appropriate study type (Dental/Oral, Head/Skull, Extremities, Spine, Thorax, Abdomen, etc.).
4. Assign a unique patient ID consistent with the clinic's PACS/record system.

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SECTION 5: Anesthesia and Patient Safety

CBCT of veterinary patients always requires general anesthesia or deep sedation to prevent motion artifacts. This is the single most important factor for image quality.

5.1 Pre-Anesthetic Assessment

• Full physical examination, minimum database (CBC, biochemistry panel).
• Confirm the patient is fasted per standard protocols (minimum 8 hours for dogs/cats; species-specific for exotics).
• Establish IV access before entering the imaging room.

5.2 Anesthetic Protocol (General Guidance)

Specific drug dosages must be confirmed by the attending veterinary anesthesiologist and are outside the scope of this SOP.

5.3 Monitoring During Scan

• Pulse oximetry, capnography, and ECG should be used throughout.
• A dedicated anesthetist monitors the patient; the radiographer operates the console.
• All monitoring cables must be routed so they do not cross the X-ray field.
• Have emergency resuscitation equipment immediately available outside the room.

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SECTION 6: Patient Positioning - Series-Wise

6.1 Head / Skull / Dental Studies (Most Common Veterinary Indication)

• Sternal: Place the animal in sternal recumbency with the head extended and resting on the table insert or foam positioning aid. Secure the head using tape or Velcro straps over the occiput. The nose should be parallel to the table surface.
• Dorsal: For mandibular studies, dorsal recumbency with the mandible positioned uppermost may improve access. Support the neck with foam wedges.
• Cranio-caudal: For nasal passages and frontal sinuses, position the head with the nose pointing toward the gantry.
• Use the alignment lasers to centre the region of interest (ROI) within the FOV.
• Endotracheal tube (ETT) should be secured away from the dental region; use gauze padding to prevent tube artifact overlying teeth.

6.2 Spinal Column Studies

• The spine should be as straight as possible and parallel to the long axis of the table.
• Use foam pads and wedges under the sternum and abdomen to minimise spinal sag.
• For cervical spine: extend the head slightly; align C1-C7 within the selected FOV.
• For thoracolumbar spine (disc disease): align the suspected region to the centre of the FOV using laser guides.
• Secure all limbs away from the scan field to prevent scatter artifact.

6.3 Limb / Extremity Studies

• Place the animal in lateral recumbency for hindlimb studies.
• The affected limb should be positioned uppermost and extended toward the gantry.
• Use foam blocks and sandbags to isolate the limb from the body.
• For distal extremities (carpus, tarsus, digits): place the limb through the gantry bore while the body remains on the table outside.
• Minimize overlap of contralateral limb by using a foam spacer between limbs.

6.4 Nasal Cavity / Skull Base Studies

• Extend the head to open the pharyngeal airway and align the nasal planum perpendicular to the X-ray beam.
• Centre lasers on the nasal bridge for nasal tumour or rhinitis studies.
• Use the largest appropriate FOV (17x19 cm or 21x19 cm) to capture the full nasal passage and sinuses.

6.5 Thorax / Abdomen (5G XL VET - Extended FOV Capability)

• Only feasible on the 5G XL VET series with FOV up to 21x19 cm; the original 5XL may have insufficient coverage for large-breed thoracic scanning.
• Breath-hold is not possible in veterinary patients - minimize scan time by selecting ECO Scan protocol (5G XL VET) or lowest-adequate scan time on 5XL.
• Respiratory motion artifact is a significant limitation; manage by ensuring adequate anesthetic depth.

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SECTION 7: FOV and Protocol Selection - Series-Wise

7.1 FOV Selection Guide

7.2 Scan Protocol Selection

7.3 Voxel Size Selection

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SECTION 8: Scanning Procedure - Step by Step

1. Confirm patient is under stable anesthesia before transferring to the scanner table.
2. Transfer patient to the motorized table with all IV lines, ETT, and monitoring leads secured.
3. Position the patient per Section 6 for the relevant anatomical region.
4. Adjust the table height and position using the console or PC controls.
5. Use the alignment lasers to centre the ROI within the planned FOV.
6. At the NNT/Neowise console: select patient, confirm FOV, protocol (SafeBeam recommended), and voxel size.
7. Perform a Scout/Preview scan (digital scout radiograph) to confirm positioning. Adjust if required.
8. Ensure all personnel have exited the room or are behind shielding. Confirm room warning light is active.
9. Initiate the CBCT acquisition from the protected console.
10. Monitor the patient via in-room camera throughout the scan.
11. On scan completion, re-enter the room promptly. Confirm patient is stable.
12. Transfer patient to recovery monitoring immediately.

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SECTION 9: Image Reconstruction and Quality Check

1. Reconstruction initiates automatically post-scan in NNT/Neowise (typically 1-3 minutes).
2. Review the scout and the reconstructed volume for:
   • Motion artifact (streaking / blurring) - if severe, rescan if clinically justified
   • Positioning adequacy (ROI fully within FOV)
   • Ring artifacts (indicates detector issue - log and report to service engineer)
   • Metallic artifact from implants or ETT connectors
3. Apply appropriate reconstruction filter (standard, sharp, or smooth) for the tissue type.
4. Export to DICOM for PACS archiving. Export 3D volume or MPR series as clinically required.

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SECTION 10: Radiation Safety and Dose Records

• All scans must be recorded with: patient ID, species, body weight, FOV used, kV, mA, scan time, and dose area product (DAP) if recorded by the unit.
• NewTom 5G XL VET delivers radiation dose up to 10x lower than conventional CT for equivalent coverage.
• Apply the ALARA principle at all times: use the smallest FOV that covers the ROI, use SafeBeam or ECO Scan where diagnostically adequate.
• No gonadal shielding is possible or practical in anesthetized veterinary patients; minimize exposure through FOV restriction.

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SECTION 11: Post-Scan Patient Care

1. Return the patient to the anesthetic recovery area immediately after the scan.
2. Monitor oxygen saturation and temperature until extubation and full recovery.
3. Record scan completion time and anesthetic duration in the medical record.
4. The attending veterinarian or radiologist should review and report images within the agreed service timeframe.

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SECTION 12: Troubleshooting

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SECTION 13: Cleaning and Infection Control

1. After each patient, wipe down the table surface and head support with disinfectant wipes compatible with carbon fibre surfaces (check NewTom equipment manual for approved products).
2. Use disposable drapes over the table for barrier protection.
3. Clean any bodily fluid contamination immediately per clinic infection control policy.
4. The gantry bore and fixed surfaces should be wiped between patients.

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SECTION 14: Maintenance and Service

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• NewTom 5G XL VET product specifications (Cefla s.c., 2024)
• NewTom 7G Vet technical datasheet (used for protocol benchmarking)
• Watanabe et al. (2011) CBCT and intraoral radiography in veterinary dental diagnosis - PMC
• NewTom NNT / Neowise Software User Manual (consult unit-specific version supplied with your device)

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Disclaimer: This SOP is a clinical guidance framework based on manufacturer documentation and published veterinary literature. Always supplement with the specific operator manual supplied with your unit, local radiation protection regulations, and institutional protocols. Drug protocols must be confirmed with a qualified veterinary anesthesiologist.

NewTom 5XL CBCT - Key Practical Points for Veterinary Use

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1. Anesthesia is Non-Negotiable

• Always use general anesthesia or deep sedation. Animals cannot hold still voluntarily.
• Motion = ruined scan. Anesthetic depth is the #1 quality factor.
• Have a dedicated anesthetist monitoring the patient while you operate the console.

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2. Patient Lies Down - Use This Advantage

• The recumbent table is ideal for sedated animals - no upright positioning needed.
• Use foam wedges and tape to keep the patient stable and straight.
• Route all IV lines and ETT away from the scan field to avoid metal artifacts.

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3. Always Use SafeBeam (Default Protocol)

• SafeBeam auto-adjusts dose based on patient size - less radiation for small cats, more for large dogs.
• Only switch to ECO Scan for post-op checks (lowest dose, lowest detail).
• Use Best Quality only for surgical planning (longer scan = more motion risk under anesthesia).

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4. FOV Rule - Smallest That Covers the Region

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5. Use the Laser Guides Every Time

• Before every scan, use alignment lasers to centre the region of interest.
• Always run a Scout scan first to confirm positioning before the full CBCT acquisition.
• Reposition if the ROI is off-centre - a repeat scout is far cheaper than a rescan under anesthesia.

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6. Voxel Size Matters

• Teeth / fine bone detail - use 0.075-0.1 mm (Ultra HD)
• Spine / joints / nasal - use 0.2 mm (Standard) - faster, less artifact risk
• Do not use Ultra HD for everything - it increases scan time and motion risk.

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7. Metal Artifacts - Anticipate and Minimize

• Dental implants, orthopedic plates, and ETT connectors all cause streak artifacts.
• Position metal hardware outside the FOV if possible.
• In software: apply metal artifact reduction (MAR) filter during reconstruction.

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8. After the Scan - Immediate Patient Priority

• Return the animal to recovery the moment scanning is done.
• Do not review images while the patient is still on the scanner table.
• Image reporting can wait; airway management cannot.

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9. Daily QC - 2 Minutes That Protect Every Scan

• Run the flat-field/detector calibration every morning before the first patient.
• If you skip this, ring artifacts and poor contrast will degrade all scans that day.

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10. The One Rule That Covers Everything

Smallest FOV + SafeBeam + deepest anesthesia + laser-confirmed positioning = a diagnostic scan every time.

All Pre-Requisites for CBCT with NewTom 5XL - Veterinary

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A. PERSONNEL PRE-REQUISITES

Training & Certification

• Operator must have completed NewTom device-specific training (provided by Cefla/NewTom or authorized distributor)
• Valid radiation safety/protection certification (as per local regulatory authority)
• Knowledge of basic CBCT physics - kV, mA, FOV, voxel, dose concepts
• Familiarity with NNT Workstation / Neowise software - patient registration, FOV selection, reconstruction
• Annual refresher training on radiation protection and equipment updates

Clinical Knowledge Required

• Understanding of veterinary anatomy relevant to the scan region (skull, dental, spine, limbs)
• Ability to recognize positioning errors on scout images
• Knowledge of anesthetic monitoring parameters (SpO2, ETCO2, heart rate)
• Ability to respond to anesthetic emergencies (or immediately call for help)

Minimum Team Required

• 1 operator/radiographer at the console (outside the room during exposure)
• 1 dedicated anesthetist monitoring the patient throughout
• 1 veterinarian available to authorize the scan and review images

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B. MACHINE PRE-REQUISITES

Room and Installation

• Dedicated X-ray room with radiation shielding compliant with local regulations
• Warning light / audible alarm at the room entrance (active during exposure)
• Room must be locked or access-controlled during scanning
• Adequate ventilation in the room (for anesthetic gas scavenging)
• Stable power supply - UPS (uninterruptible power supply) recommended to prevent mid-scan power failure

Machine Readiness

• Machine powered on minimum 15 minutes before first scan (warm-up period)
• Daily flat-field/detector calibration completed and logged (via NNT/Neowise: Settings > QC > Daily Calibration)
• Laser alignment verified - lasers must accurately mark the isocentre of the gantry
• Emergency stop button tested and confirmed accessible
• Patient table tested for full range of motorized movement (up/down, in/out)
• No error codes or warning indicators on the console
• Confirm software is open and responsive before bringing the patient in

Software Readiness

• NNT Workstation or Neowise software fully loaded and logged in
• DICOM / PACS connectivity confirmed (test send if first scan of the day)
• Adequate storage space on the workstation (CBCT volumes are large files)
• Previous patient data closed - new patient session ready to open

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C. PATIENT PRE-REQUISITES

Clinical Assessment

• Full physical examination completed by the attending veterinarian
• Body weight recorded - required for anesthetic drug calculation and SafeBeam dose calibration
• Species, breed, age, sex documented
• Known cardiac, respiratory, or renal disease flagged to the anesthetist
• Bleeding disorders or coagulopathies noted (relevant if biopsy follows scan)
• Confirmed clinical indication for CBCT documented in the record (e.g., suspected nasal tumour, IVDD localization, dental resorption)

Pre-Anesthetic Work-Up

• Minimum database: CBC + biochemistry panel (especially in sick or geriatric patients)
• Fasting confirmed:
  • Dogs and cats: minimum 8-12 hours food, 2-4 hours water
  • Rabbits and small herbivores: do not fast (gut stasis risk) - consult specialist
  • Exotic species: follow species-specific protocols
• IV catheter placed and patent before the patient enters the imaging room
• Pre-anesthetic medications administered as prescribed with documented time

Contraindications to Check Before Scanning

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D. ANESTHESIA PRE-REQUISITES

Equipment Ready in Room

• Anesthetic machine with calibrated vaporizer and working flowmeters
• Endotracheal tubes - multiple sizes available for the species
• Laryngoscope with appropriate blade size
• Suction unit functional and within reach
• Pulse oximeter, capnography (ETCO2), ECG monitor set up and connected
• Warming device (forced air or circulating water blanket) - CBCT rooms are cold
• Emergency drug kit prepared and immediately accessible:
  • Atropine
  • Adrenaline (epinephrine)
  • Doxapram (respiratory stimulant)
  • IV fluids running or immediately available

Anesthetic Monitoring Cables

• All cables must be long enough to reach monitoring equipment outside or at the edge of the room
• No monitoring cable should cross the X-ray field of view
• Pulse oximeter probe placed on tongue or toe - secured so it will not fall off during table movement

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E. POSITIONING PRE-REQUISITES

Materials Required Before Patient is Placed

• Foam wedges and positioning pads - multiple sizes
• Velcro straps or soft tape - to secure the head and limbs
• Disposable table drapes - for infection control
• Gauze rolls - to pad and secure the ETT away from the dental region
• Radiolucent sandbags - to stabilize limbs without adding metal artifact
• Positioning aids already placed on the table before transferring the anesthetized patient

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F. DOCUMENTATION PRE-REQUISITES

• Patient ID and species
• Body weight
• Clinical indication / referral reason
• Veterinarian authorization for scan
• Anesthetic induction time
• Anesthetic agent used
• FOV and protocol selected (to be recorded post-scan)
• Operator name and radiation safety ID
• Daily QC completed and logged

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Summary Checklist - Pre-Scan Go/No-Go

If any item is marked ✗ - do not proceed. Resolve the gap before transferring the patient to the scanner.