Information Notice 1994-37, Misadministration Caused by a Bent Interstitial Needle During Brachytherapy Procedure

Misadministration Caused by a Bent Interstitial Needle During Brachytherapy Procedure
	ML031060537
Person / Time
Site:	Beaver Valley, Millstone, Hatch, Monticello, Calvert Cliffs, Dresden, Davis Besse, Peach Bottom, Browns Ferry, Salem, Oconee, Mcguire, Nine Mile Point, Palisades, Palo Verde, Perry, Indian Point, Fermi, Kewaunee, Catawba, Harris, Wolf Creek, Saint Lucie, Point Beach, Oyster Creek, Watts Bar, Hope Creek, Grand Gulf, Cooper, Sequoyah, Byron, Pilgrim, Arkansas Nuclear, Three Mile Island, Braidwood, Susquehanna, Summer, Prairie Island, Columbia, Seabrook, Brunswick, Surry, Limerick, North Anna, Turkey Point, River Bend, Vermont Yankee, Crystal River, Haddam Neck, Ginna, Diablo Canyon, Callaway, Vogtle, Waterford, Duane Arnold, Farley, Robinson, Clinton, South Texas, San Onofre, Cook, Comanche Peak, Yankee Rowe, Maine Yankee, Quad Cities, Humboldt Bay, La Crosse, Big Rock Point, Rancho Seco, Zion, Midland, Bellefonte, Fort Calhoun, FitzPatrick, McGuire, LaSalle, Fort Saint Vrain, Shoreham, Satsop, Trojan, Atlantic Nuclear Power Plant
Issue date:	05/27/1994
From:	Paperiello C; NRC/NMSS/IMNS
To:	;
References
	-nr IN-94-037, NUDOCS 9405230065
	Download: ML031060537 (5)
	v • d • e

UNITED STATES

NUCLEAR REGULATORY COMMISSION

OFFICE OF NUCLEAR MATERIAL SAFETY AND SAFEGUARDS

WASHINGTON, D.C. 20555 May 27, 1994 NRC INFORMATION NOTICE 94-37: MISADMINISTRATION CAUSED BY A BENT INTERSTITIAL

NEEDLE DURING BRACHYTHERAPY PROCEDURE

Addressees

All U.S. Nuclear Regulatory Commission Medical Licensees authorized to use

brachytherapy sources in high-, medium-, and pulsed-dose-rate remote

afterloaders.

Purpose

NRC is issuing this information notice to alert NRC licensees of an incident

involving an interstitial needle bent inside the patient's body during a high- dose-rate procedure with an Omnitron 2000 brachytherapy system. The bend in

the Omnitron interstitial needle, through which the radioactive source

travels, prevented the source from retracting beyond the point of the bend.

This resulted in the actual radiation dose received by the patient exceeding

the prescribed dose by approximately 75 percent. It is expected that

recipients will review this information for applicability to their facilities

and consider actions, as appropriate. However, suggestions contained in this

information notice are not new NRC requirements; therefore, no specific

actions nor written response is required.

Description of Circumstances

On January 13, 1994, at the end of an interstitial lung treatment, the source

wire containing a 144.3 gigabecquerel (3.9 curie) iridium-192 source failed to

retract to the shielded storage position. Members of the medical staff

followed appropriate emergency procedures and removed the needle from the

patient. Licensee personnel noted a kink in the interstitial needle after

removal. Once outside the patient's body, the source retracted into the

shielded position. As a result of the stuck source, the dose to the last

treatment position was 17.32 gray (Gy) (1732 rads) versus the prescribed dose

of 10 Gy (1000 rads). In addition, an area just below the last treatment

location received a dose of approximately 14 Gy (1400 rads) versus the 8 Gy

(800 rads) intended in the prescribed treatment plan.

The kink in the needle occurred at a location where the interstitial needle

extended beyond a biopsy needle to facilitate the insertion. Under this

configuration, the biopsy needle acted as a sleeve covering approximately 75 percent of the interstitial needle. The licensee's preliminary conclusion was

that the kink at the interface between the interstitial and biopsy needles was

caused by a sudden movement of the patient near the end of the treatment. The

licensee reached this conclusion on the basis that X-rays taken just before

the treatment revealed no unusual conditions and the treatment was uneventful

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IN 94-37 May 27, 1994 until the patient's sudden movement. When the biopsy and interstitial needles

were withdrawn from the patient, the kink in the interstitial needle was

relieved somewhat, allowing the source to return to the storage position.

Early during the needle insertion process, it had been difficult to insert a

different Omnitron needle through the patient's rib cage to the treatment

site. As a result, licensee physicians opted to use a biopsy needle, through

which the interstitial needle was placed in the desired location. Believing

that the shielding provided by the biopsy needle would interfere with the

delivery of the radiation dose, a physician retracted the biopsy needle to

just outside the treatment site.

Discussion

Needles and other accessories to high-dose-rate remote afterloading therapy

may be subjected to unusual mechanical stresses during patient treatment.

Each patient setup should be carefully evaluated to avoid or minimize the

potential for deformation of needles and other guides. In particular, reducing thickness or withdrawing another device in order to preserve dose

rate may not be in the best interests of safety. In most instances, any

reduction in dose rate may be compensated by a modest increase in treatment

time. If the use of extremely thin materials cannot be avoided, licensees

should ensure that their operating and emergency procedures are adequate to

prevent and mitigate the consequences of mechanical deformations in the path

of the source wire. In such circumstances, surgical intervention may be

required and should be included in emergency plans as required in NRC

Bulletin 93-01.

This information notice requires no specific action nor written response. If

you have questions about the information in this notice, please contact the

technical contact listed below or the appropriate regional office.

I^,Carl J. Paperiello, Director

Division of Industrial and

Medical Nuclear Safety

Office of Nuclear Material Safety

and Safeguards

Technical contacts: Hector Bermudez, RII

(404) 331-7880

James Smith, NMSS

(301) 415-7904 Attachments:

1. List of Recently Issued NMSS Information Notices

2. List of Recently Issued NRC Information Notices

Attachment 1 IN 94-37 May 27, 1994 LIST OF RECENTLY ISSUED

NMSS INFORMATION NOTICES

Information Date of

Notice No. Subject Issuance Issued to

94-35 NIOSH Respirator User 05/16/94 All holders of OLs or CPs

Notices, "Inadvertent for nuclear power reactors, Separation of the Mask- and all licensed fuel

Mounted Regulator (MMR) facilities.

from the Facepiece on the

Mine Safety Appliances (MSA)

Company MMR Self-Contained

Breathing Apparatus (SCBA)

and Status Update"

94-23 Guidance to Hazardous, 03/25/94 All NRC licensees.

Radioactive and Mixed

Waste Generators on the

Elements of A Waste

Minimization Program

94-21 Regulatory Requirements 03/18/94 All fuel cycle and materials

when No Operations are licensees.

being Performed

94-17 Strontium-90 Eye Appli- 03/11/94 All U.S. Nuclear Regulatory

cators: Submission of Commission Medical Use

Quality Management Plan Licensees.

(QMP), Calibration, and

Use

94-16 Recent Incidents Resulting 03/03/94 All U.S. Nuclear Regulatory

in Offsite Contamination Commission material and fuel

cycle licensees.

94-15 Radiation Exposures during 03/02/94 All U.S. Nuclear Regulatory

an Event Involving a Fixed Commission licensees author- Nuclear Gauge ized to possess, use, manu- facture, or distribute

industrial nuclear gauges.

Attachment 2 IN 94-37 May 27, 1994 LIST OF RECENTLY ISSUED

NRC INFORMATION NOTICES

Information Date of

Notice No. Subject Issuance Issued to

94-36 Undetected Accumulation 05/24/94 All holders of OLs or CPs

of Gas in Reactor for nuclear power reactors.

Coolant System

91-81, Switchyard Problems that 05/19/94 All holders of OLs or CPs

Supp. 1 Contribute to Loss of for nuclear power reactors.

Offsite Power

94-35 NIOSH Respirator User 05/16/94 All holders of OLs or CPs

Notices, "Inadvertent for nuclear power reactors, Separation of the Mask- and all licensed fuel

Mounted Regulator (MMR) facilities.

from the Facepiece on the

Mine Safety Appliances (MSA)

Company MMR Self-Contained

Breathing Apparatus (SCBA)

and Status Update"

94-Z4 Thermo-Lag 330-660 05/13/94 All holders of OLs or CPs

Flexi-Blanket Ampacity for nuclear power reactors.

Derating Concerns

94-33 Capacitor Failures in 05/09/94 All holders of OLs or CPs

Westinghouse Eagle 21 for nuclear power reactors.

Plant Protection Systems

93-53, Effect of Hurricane 04/29/94 All holders of OLs or CPs

Supp. 1 Andrew on Turkey Point for nuclear power reactors.

Nuclear Generating

Station and Lessons Learned

94-32 Revised Seismic Hazard 04/29/94 All holders of OLs or CPs

Estimates for nuclear power reactors.

94-31 Potential Failure of 04/14/94 All holders of OLs or CPs

Wilco, Lexan-Type HN-4-L for nuclear power reactors.

Fire Hose Nozzles

90-68, Stress Corrosion Cracking 04/14/94 All holders of 01 or CPs

Supp. 1 of Reactor Coolant Pump for pressurized water

Bolts reactors.

OL = Operating License

CP = Construction Permit

___ IN 94-37

_ May 27, 1994 until the patient's sudden movement. When the biopsy and interstitial needles