This case involves a 28-year-old male patient who underwent an IV infiltration at a radiology clinic prior to having imaging. In the process of having a CT scan with contrast, the contrast extravasated into the patient’s left hand. The patient noted severe swelling and pain and notified the technologist. Once the technologist was notified, the patient was sent to the emergency room. The patient was then urgently sent to the operating room where he had a fasciotomy due to compartment syndrome in the left hand with a carpal tunnel release. Following the surgery, the patient was put on a 5-pound lift, push, and pull restriction for his left hand.
Question(s) For Expert Witness
- 1. How often do you place IVs in patients prior to the performance of imaging studies?
- 2. What factors contribute to contrast extravasation?
Expert Witness Response E-135834
I’m a CT technologist with a master’s degree in health administration and a certification as a radiology administrator. IV’s are used commonly in CT to provide enhancement of infections, lesion/tumors, and highlight structures, such as arteries and veins and bleeds. Approximately 25-35% of cases require contrast injections. Contrast must also be given at specific speeds based on the enhancement required. Pulmonary emboli studies have to be injected at a high rate and contrast given and the machine engaged within 25 seconds of the start of that injection. Based on this, many variables can lead to contrast extravasation including patients habitus, injection site, etc.
Expert Witness Response E-135486
I am a registered CT technician with years of experience. How often I place IVs prior to imaging studies depends on the study being performed. There are certain exams which require the use of an IV placement. For example, you would need IV contrast to rule-out diseases such as metastatic cancer. The IV gauge or size would also depend on the type of exam that you are doing. For example, a pulmonary embolism chest CT scan usually requires a large 18 gauge catheter because a minimum of 4-5 CCs of IV dye is injected per second. These types of IV accesses are almost always placed in the antecubital (elbow region) because those veins are stronger and it doesn’t hurt the patient as much. Other CT scans, such as a head with contrast, could use a smaller IV catheter and the injection rate can be slow.
Extravasation of contrast dye does happen from time to time. But, there are a lot of missing details that would allow someone to provide you a good opinion on the case below. For example, what type of CT was it? That would determine the rate of flow and pressure that the dye was being injected at. What size of needle or catheter did the CT tech place in the patient’s hand? Why did they choose to use the hand vs. another area, such as the antecubital? Was it a needle placed by a floor nurse/ER or did the CT tech choose to start their own access (i.e., how long had that IV access already been in place)? Did the CT tech test the IV before injecting the dye? This is usually done with a 10 CC saline syringe to test the IV. If the CT exam will be performed with a high rate of injection such as a PE study, there is also an option of testing the IV using the pressure injector to make sure that the vein can handle a pressure injector. Was that completed? On some studies, such as an abdomen/pelvis with contrast, the CT technician can remain in the room and check the IV as the dye is being injected. This allows the technician to monitor the IV access. For studies such as angiography or pulmonary embolism, however, this is not possible. Lastly, was there an intercom that allowed the CT technician to hear that the patient was having issues and were they observing the patient through the window during the injection?