Emergency Management of an - HPS Chaptershpschapters.org/northcarolina/fall2016/Christine Krieman...

All Rights Reserved, Duke Medicine 2007

Emergency Management

of an 131I-MIBG Patient

in Medical ICU

Greg Egan and Christine Krieman

Duke University / Duke Health

OESO-Radiation Safety Division


• An acronym for “meta-iodo-benzylguanidine”

• Is a radioactive drug (which are also called

“radiopharmaceuticals”)

• Is a form of “systemic” radiation therapy, as opposed to

external beam therapy or brachytherapy

• Is used to treat tumors arising from the embryonic

neural crest

What is 131I-Metaiodobenzylguanidine (MIBG)?


“Neuroendocrine” Tumors That Can be

Treated With MIBG

• Carcinoid Tumors

• Pheochromocytoma

• Neuroblastoma (mainly children)

• Medullary Thyroid Carcinoma

131I-Metaiodobenzylguanidine (MIBG) therapy


Epinephrine (Adrenaline)

C C C

MIBG

Biochemical precursors of epinephrine are

preferentially concentrated by “neuroendocrine” tumors.

MIBG vs. Epinephrine


131I-Metaiodobenzylguanidine (MIBG) therapy

NC HPS, Fall 2016

A beta particle hits the DNA in the nucleus of a

replicating tumor cell,

causing the cell to die during mitosis.

-

DNA


NC HPS, Fall 2016

• Patient is injected with 504 mCi 131I-MIBG IV

• Exposure rate at 1m from patient immediately after infusion: 65 mR/hr

9/30/15

2:30 PM

504 mCi

administered

131I-MIBG therapy: Timeline


NC HPS, Fall 2016

• Code Blue is called for apparent respiratory arrest

• Hospital Code Blue team responds (23 people)

• Three Duke RSD HPs present (two are new to Duke)

• Patient is stabilized and required to be moved to Medical Intensive Care

Unit (MICU)

• Floor nurses cleaned up infusion room after patient is transferred to

MICU

9/30/15

3:00 PM

1st Code

Blue called

9/30/15

2:30 PM

504 mCi

administered



NC HPS, Fall 2016

• Code Blue Team – 23 individuals

• Estimated personnel exposures calculated from:

• Stay times ranged from 5 – 55 minutes

• Two distances from patient used for each responder’s dose

• Occupancy factor applied at each distance

• Exposures ranged from 4 – 131 mrem

9/30/15

3:00 PM

1st Code

Blue called

9/30/15

2:30 PM

504 mCi

administered



NC HPS, Fall 2016

• Patient transferred to MICU

• Corner room identified to house patient; adjacent room was evacuated

• RSD escorted patient and provided training to medical team:

• PPE required

• Time, Distance and Shielding, ALARA

• Issued dosimeters to key nursing staff

• Staff time in / time out log created

• Restrictions posted on patient’s door

• RSD contact information posted on patient’s door

9/30/15

3:00 PM

1st Code

Blue called

9/30/15

6:00 PM

Transferred

to MICU

9/30/15

2:30 PM

504 mCi

administered



NC HPS, Fall 2016

131I-MIBG Patient

Restroom

Sofa

Workstation

Workstation

Trash

Vacated

patient room

9/30/15

3:00 PM

1st Code

Blue called

9/30/15

6:00 PM

Transferred

to MICU

9/30/15

2:30 PM

504 mCi

administered

Patient room in MICU



• Family Visitation

• Attending Nuclear Medicine physician requested limited visits for

patient’s spouse and one adult family member

• RSD provided stay time for two locations in the patient’s room

(sofa and bedside)

• RSD present during all in-room visits with patient to ensure proper

PPE was worn, monitored time, and ALARA instructions were

followed

9/30/15

3:00 PM

1st Code

Blue called

9/30/15

6:00 PM

Transferred

to MICU

9/30/15

2:30 PM

504 mCi

administered



NC HPS, Fall 2016


• Second cardiopulmonary arrest; Code Blue called

• Patient was intubated and central venous access was obtained

• Impaired renal function developed; in-room continuous

hemodialysis begun

• Intensive nursing care was given throughout the evening

9/30/15

3:00 PM

1st Code

Blue called

9/30/15

6:00 PM

Transferred

to MICU

9/30/15

7:30 PM

2nd Code

Blue called

9/30/15

2:30 PM

504 mCi

administered


NC HPS, Fall 2016


• Patient was taken to Radiology for CT scan

• RSD HPs accompanied patient to Radiology and remained

present during scan

• CT indicated perforated bowel

• Patient’s family requested comfort measures only

9/30/15

3:00 PM

1st Code

Blue called

9/30/15

6:00 PM

Transferred

to MICU

9/30/15

7:30 PM

2nd Code

Blue called

10/1/15

4:00 PM

CT scan in

Radiology

9/30/15

2:30 PM

504 mCi

administered


NC HPS, Fall 2016

9/30/15

3:00 PM

1st Code

Blue called

9/30/15

6:00 PM

Transferred

to MICU

9/30/15

7:30 PM

2nd Code

Blue called

10/1/15

4:00 PM

CT scan in

Radiology

10/4/15

8:00 PM

Patient

dies

• Patient died on October 4, 2015 at 8:00 PM

• The funeral home retrieved the body the following morning

• Information for funeral home personnel about bodies

containing radioactive materials was reviewed with the staff

and provided to the driver

• No subsequent contact from the funeral home

9/30/15

2:30 PM

504 mCi

administered



Summary and Conclusions

• Life-threatening illness in a hospitalized MIBG patient is a rare

occurrence

• Creativity and flexibility are required in managing unexpected

events as they occur • Some aspects of patient care just don’t have “SOPs”!

• Radiation exposures to code team, nursing staff and family

members are manageable

Emergency Management of an - HPS Chaptershpschapters.org/northcarolina/fall2016/Christine Krieman...

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