Extravasation During a Therapeutic Dose
A 58-year-old man with metastatic prostate cancer is receiving a therapeutic dose of Lu-177 PSMA. A 22-gauge IV in the right antecubital fossa was placed and flushed with saline; blood return was confirmed. During slow injection, the patient reports burning at the site, and the technologist notes swelling and mild redness around the cannula. Roughly 40% of the planned activity has been delivered. The patient is hemodynamically stable and has no shortness of breath. The department has an extravasation kit and a written procedure. The referring oncologist is in clinic and reachable by phone.
1. What immediate actions should the technologist take, and what should be documented?
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The technologist should stop the injection immediately. Do not flush the line or attempt to "push through" the resistance. Leave the cannula in place initially unless the department procedure directs removal, so that the physician can decide whether aspiration or specific management is needed. Notify the supervising physician and the radiation safety officer immediately, and activate the extravasation procedure.
Apply the measures specified in the departmental extravasation protocol (which may include cold or warm compresses depending on the agent, elevation, and marking the site); the technologist must follow the written procedure and physician direction rather than improvising. Assess the site: size, color, tenderness, capillary refill, and distal pulses, and mark the borders for later comparison. Monitor the patient. Estimate and record the activity delivered versus extravasated (approximately 60% remaining, with a measured estimate from the residual in the vial/tubing if possible). Document the time, site, gauge, agent, estimated activity, symptoms, interventions, and notifications. The physician should discuss the event with the patient and arrange follow-up. Report the event through the facility's incident/radiation safety reporting system.
2. How should the remaining activity and the patient's therapy plan be handled after the extravasation?
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The remaining activity should not be injected at the same site. The physician, with the radiation safety officer, should decide whether a new IV can be placed at a different site and whether the remaining dose should be completed, deferred, or adjusted, considering the estimated extravasated activity and the prescribed total. The technologist should not make that decision independently.
The patient should be informed of what happened, what was done, and what to watch for (increasing pain, swelling, blistering, skin changes) and whom to call. Follow-up of the site should be arranged, and the event and its management documented in the record. The estimated extravasated activity should be included in the radiation safety report, since it affects the patient's actual administered activity and dosimetry. If the therapy is completed via a new site, the total administered activity should be documented accurately, distinguishing intended versus actual delivery.