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Journal of Clinical Oncology, Vol 22, No 5 (March 1), 2004: pp. 965-966 © 2004 American Society of Clinical Oncology. DOI: 10.1200/JCO.2004.99.138
In Reply:Peter MacCallum Cancer Centre, East Melbourne, Victoria, Australia Various strategies have been proposed to prevent inadvertent intrathecal vincristine administration. The Vincotube System described by Palmieri et al [1] has merit in that it is another step in identifying the intravenous (IV) route for vincristine administration. However, the design and application of the Vincotube System is based on the preparation and administration of vincristine in a syringe. The limitation of designing enhancements around this requirement is that the vincristine could still be administered intrathecally despite the use of the Vincotube System. This would require the practitioner to ignore the clear warnings, but unfortunately, history and human frailties have taught us that this can happen, with dire consequences. A key component of the Vincotube System is that the syringe is colored red and has all the appropriate labeling and packaging, which as the authors rightly claim, would help to prevent inadvertent intrathecal administration. However, in many of the devastating cases of intrathecal administration of vincristine, the syringe in which the drug was pre-pared was also clearly labeled and packaged, yet this was not sufficient to prevent this catastrophic event. The fundamental imperative in reducing the risk of administering vincristine intrathecally is the design of systems that result in the vincristine preparation being incompatible with the intrathecal access device. Most practitioners administering intrathecal drugs are familiar with administering these drugs via a syringe, and even those not experienced with this route would expect that small-volume syringe preparations would be suitable. Consequently, the preparation of vincristine for IV bolus administration in a small-volume IV bag, as opposed to a syringe, is the only suitable method that should considered [2]. Hence, improvements in system design should be based on improving this method of delivery. Tragically, there is a recent unpublished report of vincristine being administered intrathecally by staff in a diagnostic imaging department, further highlighting the need to make IV and intrathecal systems incompatible, as in this case, along with all others, the vincristine was prepared and administered in a syringe. The method we have implemented, and recommend, is simple and inexpensive and does not require medical staff to avail themselves to an educational video or CD-ROM before administering intrathecal chemotherapy. Chemotherapy drugs (such as methotrexate and cytarabine) intended for intrathecal administration are prepared in a syringe and labeled, packaged, and identified as such. Chemotherapy drugs (including vesicants) intended for IV bolus administration are prepared in a small-volume IV bag and administered as a short IV bolus. An increased risk of extravasation has been suggested as a reason not to adopt this approach [3]. However, we contend that this risk is minimal given that the drugs are in a diluted form, are administered under constant direct supervision, and the actual incidence of extravasation is less than one in 1,000 administrations. As a result, this concern is not warranted in light of the risks of intrathecal vincristine administration. We acknowledge, along with others (including the designers of the Vincotube System), that approaches to the preparation of vincristine are only one component in the design of processes to reduce the incidence of vincristine being given intrathecally [1,3,4]. Focus must continue on the appropriate training and credentialing of practitioners involved in any of the steps from prescribing, preparing, dispensing, and administering chemotherapy. Improvements in the design of preparation must result in the IV preparation being physically incompatible with intrathecal administration equipment. We commend Palmieri et al in their efforts—the system they propose has benefits over the preparation of vincristine in proprietary syringes; however, for the reasons detailed above, we contend that preparation must be in small-volume IV bags. Authors' Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest. REFERENCES 1. Palmieri C, Barron N, Vigsushin DM: The Vincotube System: A design solution to prevent the accidental administration of intrathecal vinca alkaloids. J Clin Oncol 22:10.1200/JCO.2004.99.127
2. Stefanou A, Dooley M: Simple method to eliminate the risk of inadvertent intrathecal vincristine administration. J Clin Oncol 21:2044, 2003 3. Womer RB, Bickert B: In reply. J Clin Oncol 21:2044, 2003
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
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Copyright © 2004 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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