Intrathecal Vincristine: Long-Term Survivor of Potentially Fatal Chemotherapeutic Error

Two Fatal Cases of Accidental Intrathecal Vincristine Administration: Learning from Death Events

“…There are 7 reported cases in which an intrathecal vincristine injection was mistakenly given, which then received CSF irrigation fluid plus fresh-frozen plasma following CSF aspiration to try to counter the effects of vincristine [2,6,10,11,12,13,14]. Six of the 7 survived, although all had paraparesis or tetraparesis [6,10,11,12,13,14]. There are no survival reports of patients mistakenly receiving an intrathecal vincristine injection who did not have CFS irrigation with fresh-frozen plasma.…”

Medication safety and the administration of intravenous vincristine: International survey of oncology pharmacists

“…In the only patients who survived, the mistake was discovered immediately and therapy, involving initial aspiration of vincristine, instituted without delay. 4,[7][8][9][10][11][12] In six cases aggressive cerebrospinal fluid (CSF) irrigation with fresh frozen plasma, commonly incorporating lactated Ringer's solution, followed. 4,[8][9][10][11][12] However, all survivors were left with some significant form of neurological deficit.…”

“…There have been 32 cases of vincristine inadvertently given intrathecally, rather than by the intended intravenous (IV) route, documented in the English language, medical literature. [1][2][3][4] Of these incidents, 25 have proven fatal. Unfortunately many more cases have gone unrecognized or unreported, or have only been reported through adverse event or medication safety databases, legal claims, regulatory agencies, drug companies or published via local media sources.…”

Preventing Vincristine Sulfate Medication Errors

“…She also developed a neurogenic bladder that required intermittent catheterization. Seven years later, she remained in remission but did not regain motor function of her legs and continued to have a neurogenic bladder (Iqbal, Abdullah, Tuner, & Al-Sudairy, 2002). The researchers could not determine whether this patient's survival occurred as a result of undergoing immediate CSF fluid exchange or if she survived because, unlike other patients who received a full dose of IV vincristine intrathecally, she received about half of the vincristine dose.…”

“…A disturbing trend in the literature regarding inadvertent intrathecal vincristine administration is the use of "intrathecal vincristine" without the word "inadvertent." Titles of journal articles, such as "Intrathecal Vincristine: Fatal Myeloencephalopathy Despite Cerebrospinal Fluid Perfusion" (Alcaraz et al, 2002) or "Intrathecal Vincristine: Long-Term Survivor of Potentially Fatal Chemotherapeutic Error" (Iqbal et al, 2002), in some ways make it sound as if intrathecal vincristine is an accepted treatment. To avoid confusion, clinicians and authors should consistently refer to this type of medication error as "inadvertent intrathecal vincristine administration," "accidental intrathecal vincristine administration," or "erroneous intrathecal vincristine administration."…”