Potential salvage therapy for inadvertent intrathecal administration of vincristine

Michelagnoli, Maria; Bailey, Chris; Wilson, IH; Livingston, J. H.; Kinsey, Sally

doi:10.1046/j.1365-2141.1997.3693183.x

Cited by 32 publications

(21 citation statements)

References 6 publications

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“…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.…”

Section: Discussionmentioning

confidence: 99%

“…There are no survival reports of patients mistakenly receiving an intrathecal vincristine injection who did not have CFS irrigation with fresh-frozen plasma. It is believed that adding fresh frozen plasma to the CSF causes rapid binding of the vincristine to blood components and thus minimizes its neurotoxicity [6,12]. In addition to aggressive CSF dilution, administration of neuroprotective agents such as pyridoxine, folic acid, glutamic acid, and corticosteroids has been widely used to prevent further neuronal damage from vincristine [15].…”

Section: Discussionmentioning

confidence: 99%

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

2015

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We report 2 cases of accidental intrathecal vincristine administration. These injections were scheduled as intravenous injections of vincristine at the same time as other intrathecal drugs were scheduled. The mistakes were recognized immediately after administration, and a lumbar puncture was performed to lavage the cerebrospinal fluid (CSF) immediately after the incident. However, both cases developed progressive sensorimotor and radiculo-myelo-encephalopathy and the patients died 3 and 6 days after the incidents due to decerebration. A number of cases of accidental intrathecal vincristine administration have occurred in recent years in other settings, and we add our events to emphasize the need for a preventative and strictly followed protocol in oncology treatment units to prevent further unnecessary deaths.The best ‘cure' for mistakenly administered vincristine via lumbar puncture is prevention, which can be improved by strict adherence to a comprehensive guideline. Oncologic treatment centers should be aware of this guideline and evaluate their protocol for vincristine administration to prevent future incidents. Based on our past experiences, we strongly recommend ‘time-independent' procedures to prevent this type of incident.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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

2015

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“…She was a 10-year-old girl left with lower-limb paraplegia 21. Other international reports around this time came from Australia and Singapore as recorded in a chronological summary in 2005 by the Society of Hospital Pharmacists of Australia 22…”

Section: Failure Of International Translationmentioning

confidence: 99%

The quest to eliminate intrathecal vincristine errors: a 40-year journey

Noble

Donaldson²

2010

Quality and Safety in Health Care

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“…Survival has occasionally been reported following aggressive rescue therapy, but survivors have been severely handicapped. [29,30] …”

Section: Vinca Alkaloidsmentioning

confidence: 99%

Chemotherapy of Childhood Lymphoblastic Leukaemia

Lilleyman

1999

Pediatric Drugs

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It is 50 years since the first effective drug for childhood lymphoblastic leukaemia (ALL) was described. At that time the outlook for such children was certain death. Now patients have an odds-on chance of normal health and life expectancy. Although the greatest gains have been made in recent years, the classes of drug that have achieved this have all been available for over 20 years. It is their better deployment and the greater understanding of their pharmacology that have allowed both more effective protocols to be devised and long term adverse effects to be recognised and avoided. Supportive treatment has also improved in parallel. Three major problems remain: (i) how to recognise children in whom conventional therapy will fail; (ii) how to prevent failure; and (iii) how to treat it if it occurs. Therapy will fail in some children for pharmacological reasons--noncompliance or constitutional (genetic) drug resistance. For such children in vitro drug sensitivity testing and greater pharmacological vigilance may help by identifying those at risk and allowing intervention. In others, treatment will fail because of intrinsically resistant disease that either develops despite therapy or regrows from a minimal residue. Despite wider application of sophisticated immunological and genetic studies both at diagnosis or later, recognising poor-prognosis children prospectively is hampered by the lack of a biological classification system that is sufficiently sensitive and specific to categorise all patients reliably. In those where there is no doubt about high-risk status, treatment failure rates are still unacceptably high whatever therapy is given, and salvage therapy in any child who relapses is a continuing challenge.

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Potential salvage therapy for inadvertent intrathecal administration of vincristine

Cited by 32 publications

References 6 publications

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

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

The quest to eliminate intrathecal vincristine errors: a 40-year journey

Chemotherapy of Childhood Lymphoblastic Leukaemia

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