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Simple Method to Eliminate the Risk of Inadvertent Intrathecal Vincristine Administration

Peter MacCallum Cancer Centre, Victoria, Australia

To the Editor: There are many reports of incidents of inadvertent intrathecal administration of vincristine, the earliest dating back to 1978 and the most recent in 2002.^1–3 One of the many outcomes described by Womer et al⁴ of their systems for inpatient chemotherapy administration was a set of rules for minimizing the risk of intrathecal vincristine administration. The consequence of intrathecal vincristine administration is devastating, and as these authors and others have highlighted, it has occurred at many institutions throughout the world.

The strategy described by Womer et al⁴ to minimize this risk is not sufficient, as complete elimination is warranted and possible. The preparation of vincristine for intravenous bolus administration in a small-volume intravenous bag, as opposed to a syringe, is the only method of completely eradicating the risk of this drug accidentally being given intrathecally. This method of preparation is a practice that has been adopted not only at our institution, but also at the majority of hospitals in Australia. All published reports of intrathecal vincristine administration have been associated with preparation of the drug in a syringe.

In adults, vincristine is prepared in a small-volume intravenous bag containing 50 mL of sodium chloride 0.9%. This is administered as a short intravenous bolus for 5 to 10 minutes. For pediatric patients, the same approach is used but with a smaller volume of fluid in the infusion bag and a slower rate of administration.

We believe that this method of diluting vincristine for intravenous bolus-dosing into a small-volume intravenous bag, rather than in a syringe, is a simple method of eradicating the risk of catastrophic inadvertent intrathecal administration of vincristine.

REFERENCES

1. Shepherd DA, Steuber CP, Starling KA, et al: Accidental intrathecal administration of vincristine. Med Pediatr Oncol 5:85–88, 1978[Medline]

2. Alcaraz A, Rey C, Concha A, et al: Intrathecal vincristine: Fatal myeloencephalopathy despite cerebrospinal fluid perfusion. J Toxicol Clin Toxicol 40:557–561, 2002[CrossRef][Medline]

3. Dyer C: Doctors suspended after injecting wrong drug into spine. BMJ 322:257–258, 2001[Free Full Text]

4. Womer RB, Tracy E, Soo-Hoo W, et al: Multidisciplinary systems approach to chemotherapy safety: Rebuilding processes and holding the gains. J Clin Oncol 20:4705–4712, 2002[Abstract/Free Full Text]

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