Inadvertent intrathecal administration of vincristine: Has anything changed?

Abstract

In 2004, an editorial was published in this journal entitled ‘Inadvertent intrathecal administration of vincristine: are we fulfilling our roles as oncology pharmacists?’. The last sentence in the article provides an ominous warning. ‘Unless we, as oncology pharmacists, work together to ensure vincristine can only be given intravenously it is only a matter of time until another tragic fatality occurs’. Eight years later it is again time to ask the question. Are we fulfilling our roles as oncology pharmacists? Has anything changed? It was with great sadness that I recently read case reports of yet two other fatal errors involving the administration of vincristine via the intrathecal route. Since a review of literature case reports was published in 2007, a number of other incidents have taken place. While details of most of these cases are sketchy, both human and system failures have occurred to make these errors possible. However, a common theme has emerged: all the doses of vinca alkaloid have been prepared in a syringe. In Hong Kong, a young female leukemic patient was erroneously given intrathecal vincristine in addition to cytarabine through a spinal needle. The vincristine was prepared in a syringe (2mg in 2mL) by the pharmacy department. The error was not noticed for 3 days and the patient died 22 days after the original incident. In Argentina, a 33-year-old man with acute lymphocytic leukemia in complete remission was prescribed vincristine maintenance therapy. Vincristine was accidentally given via lumbar puncture and the mistake not noticed until the following day. The patient died 20 days later. In Germany, a youngman with Burkitt’s lymphoma was administered intrathecal vincristine instead of methotrexate. After the instillation of 1mg of vincristine the error was detected. Prompt treatment prevented a fatality but the patient was left with sensorimotor dysfunction. In France, three cases of accidental vincristine administration were reported. While these cases occurred between 1998 and 2000 they have not been previously published. All cases involved administration via a syringe and all ended in death. In the USA, a 36-year-old female with Burkitt’s lymphoma was accidentally given vincristine intrathecally. Despite treatment she died 10 days later. In Thailand, vincristine was administered intrathecally to a 63-year-old man with diffuse large B cell lymphoma instead of hydrocortisone. The mistake was noticed within 30 minutes, but despite CSF irrigation the patient died on day 12. In France, a young female patient with non-Hodgkin’s lymphoma was erroneously given vindesine intrathecally instead of via the intended intravenous route. The physician who accidentally administered the drug described confusion between two syringes, one containing corticosteroid and the other containing vindesine. The patient survived for 6 weeks. To my knowledge, every error involving the administration of a vinca alkaloid into the spinal fluid over the past 40 years has occurred when the drug was prepared in a syringe. Why do we persist with this method of administration? Why do invariably young, potentially curable patients continue to die? The most effective method currently available for preventing this tragic and invariably fatal accident from ever occurring is to eliminate the syringe as a method for the administration of vincristine or other vinca alkaloids. This method must be replaced by administration via a small-volume intravenous bag. This strategy works on the premise that it would be virtually impossible to administer vincristine in this form to a patient through a spinal needle and also has the advantage of prompting staff to realize that something is obviously wrong if this is even attempted. Although this is the safest and most effective way of eliminating accidental spinal administration of vinca alkaloids, this approach was criticized as potentially increasing the risk of extravasation injury. To allay these concerns, a retrospective study was conducted in Australian hospitals to determine the incidence of vinca alkaloid extravasation following administration via