Inadvertent intrathecal administration of vincristine: Time to finally abolish the syringe

Gilbar, Peter J

doi:10.1177/1078155219880600

Cited by 3 publications

References 16 publications

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Inadvertent intrathecal administration of daunomycin resulting in fatality: Case report and therapeutic considerations

et al. 2021

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Background Daunomycin is a chemotherapeutic agent of the anthracycline family that is administered intravenously, most commonly in combination therapy. The authors report the first known adult case of inadvertently administered daunomycin directly into the human central nervous system and the neurologic manifestations and therapeutic interventions that followed. Clinical description A 53-year-old male presenting to the hospital for his second cycle of consolidation therapy for acute promyelocytic leukemia t(15;17) was accidentally administered 93 mg of intrathecal (IT) daunomycin. Within several hours of injection, the patient subsequently developed bilateral lower extremity pain, ascending paresthesias, headache, and left cranial nerve (CN) III palsy. Immediately following these neurologic sequalae, a subarachnoid lumbar drain was placed at the L4-5 interspace for the initial irrigation and drainage of cerebrospinal fluid (CSF). By hospital day 2, the patient's mental status significantly declined requiring an external ventricular drain (EVD) for hydrocephalus. Despite therapeutic interventions, the patient developed an ascending radiculomyeloencephalopathy with deterioration in clinical status. Eighteen days after the inadvertent injection of IT daunomycin, the patient became comatose and lost all cranial nerve function. Conclusions Accidental IT injection of daunomycin is a neurosurgical emergency and warrants prompt intervention. Symptoms can mimic other medical conditions, making it imperative an accurate diagnosis is made so that appropriate therapies are implemented. At this time, therapies include rapid removal of the chemotherapeutic agent from the IT compartment by aspiration and irrigation; however, it is unclear if neuroprotective agents may provide added benefit.

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Inadvertent intrathecal administration of daunomycin resulting in fatality: Case report and therapeutic considerations

et al. 2021

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Introduction to Medication Safety in Anesthesia and the Perioperative Period

2021

Medication Safety During Anesthesia and the Perioperative Period

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Many of us are familiar with the accidental deaths that have been reported when vincristine, intended for I.V. use, was inadvertently administered intrathecally. A recently published article in Hospital Pharmacy, by Trissel and Cohen 1 , suggests a strategy for minimizing the risk for recurrence of such an error. The article confirms the stability of vincristine when diluted to 25mL with normal saline, and suggests that the larger volume of diluted vincristine is less likely to result in a 'mix-up' in route of administration. The use of additional auxiliary warning labels when dispensing vincristine continues to be recommended.An editorial by Neil Davis 2 , in the same issue of Hospital Pharmacy, mentions that the MD Anderson Cancer Center in the U.S. has been preparing vincristine doses with 25mL normal saline in minibags for more than 20 years. The decision to dispense vincristine in minibags was made to prevent inadvertent intrathecal administration. Now that stability data is available, and published, this dispensing practice can be adopted by other facilities.Berwick 3 , and many others, have suggested that the ideal system safeguard against accidental intrathecal administration of I.V. drugs, is to have unique and non-interchangeable connections. This is described as a "forced function design" safety improvement. Until such time as there are separate drug administration systems for I.V. versus intrathecal administration, the preparation of vincristine in minibags, instead of syringes, is a medication safety practice recommendation to be considered by all facilities preparing chemotherapy.

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Vincristine must NEVER be prepared or administered in a syringe

Gilbar

2020

Leukemia & Lymphoma

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Inadvertent intrathecal administration of vincristine: Time to finally abolish the syringe

Cited by 3 publications

References 16 publications

Inadvertent intrathecal administration of daunomycin resulting in fatality: Case report and therapeutic considerations

Inadvertent intrathecal administration of daunomycin resulting in fatality: Case report and therapeutic considerations

Introduction to Medication Safety in Anesthesia and the Perioperative Period

Vincristine must NEVER be prepared or administered in a syringe

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