Accidental Intrathecal Administration of Vincristine in Pediatric Patients

Abstract

Vincristine has been in clinical use for over 50 years and is indicated in the treatment of a wide range of adult and pediatric malignancies, most commonly in combination therapy. Dose-limiting toxicities of vincristine arise primarily in the peripheral nervous system with central nervous system toxicity generally not observed with intravenous therapy due to poor penetration of the blood brain barrier. Unintentional administration of vincristine directly into the cerebrospinal fluid (CSF) produces profound neurotoxicity. Since the first report in 1968 there have been numerous other cases with 31 (18 in children) of these published in the literature with 25 (15 in children) resulting in death. Many other cases are believed to have occurred but have not been officially reported. Fatalities appeared due to a progressive ascending myeloencephalopathy. Early recognition and immediate treatment with CSF drainage and intrathecal exchange appears to be the only intervention that has improved patient survival. Guidelines for the prevention of this horrific medication error have been proposed. All errors involving the administration of a vinca alkaloid into the CSF over the past 45 years have occurred when the drug has been prepared in a syringe. The most effective method currently available for preventing this tragic and invariably fatal event from ever happening is to abolish the syringe as a method of vincrisine administration. This method must be replaced by administration via a small-volume intravenous bag for all patients. Concerns regarding an increased risk of extravasation with the use of mini-bags, particularly in the pediatric population, are unfounded and should not be a deterrent to implementing this strategy. The consequences of inadvertent intrathecal administration of vincristine are overwhelming. The optimum strategy for managing this problem is by developing effective methods of prevention and incorporating these proposals into pediatric oncology centers internationally.