Fatal consequences of a simple mistake: how can a patient be saved from inadvertent intrathecal vincristine?

摘要

Since its introduction in 1963, vincristine sulfate, commonly known as vincristine, has been widely used as a chemotherapeutic agent for a variety of malignancies including lymphoma, leukemia, rhabdomyosarcoma, neuroblastoma, and Wilms tumor. Vincristine is administered intravenously as bolus often in combination with other multidrug chemotherapy regimen. Despite its long-term extensive use and the Food and Drug Administration recommended box label warning, there have been a number of cases in which vincristine was inadvertently administered intrathecaliy. If administered intrathecally, vincristine causes severe and irreversible central nervous system toxicity and motor dysfunction followed by progressive ascending radiculomyeloen-cephalopathy, coma and death [1]. The error generally occurs when vincristine is confused with therapeutic agents normally administered intrathecally, such as methotrexate or cytarbine. Intrathecal administration of vincristine was first described to cause a fatal ascending myeloencephalopathy in humans in 1968 in the United States [2]. Since then, over 16 cases in the United States and over 60 cases worldwide have been reported in the literature [3]. However, the true incidence of inadvertent intrathecal vincristine administration is not known. Some of these incidents, particularly lethal events, prompt publication and others reported to organizations such as the Institute for Safe Medication Practices. Inadvertent intrathecal vincristine administration also occasionally has received media attention.