Preventing intrathecal administration of vincristine

To the Editor: The national media recently highlighted the tragic consequences of the inadvertent spinal administration of the antineoplastic drug vincristine. The 7.30 Report (ABC Television) detailed the case of a young man erroneously administered vincristine intrathecally instead of, as intended, intravenously, resulting in progressive neurotoxicity, paralysis and death.1

Since the first report in 1968 of unintentional intrathecal administration of vincristine,2 many, invariably fatal, cases have been described. These have involved a combination of human and system errors affecting the medical, nursing and pharmacy professions.

On behalf of the Society of Hospital Pharmacists of Australia, we recommend the following strategies to reduce the opportunity for error:

• Only specifically trained and designated oncology staff should prepare, dispense and administer cytotoxic medication.

• Intrathecal chemotherapy should only be administered during normal working hours, and in an area where no other cytotoxic drugs are given or stored.

• Medical staff must use a formal checking procedure, involving an oncology-trained nurse, to ensure the right drug is given at the right dose, by the right route, to the right patient.

• Intrathecal drugs must be packaged separately and clearly labelled both on the syringe and outer container “For intrathecal use”.

• Specifically designated containers should be used for transportation of intrathecal drugs from the pharmacy and for storage on the ward.

• Intrathecal doses should be delivered separately and preferably administered after drugs to be given by other routes have been supplied to the ward and administered.

• Vincristine should be prepared in a small-volume intravenous bag rather than a syringe.3 For adults, prepare vincristine in an intravenous bag in 50 mL of sodium chloride 0.9% and administer it as a short intravenous bolus over 5–10 minutes. Smaller volumes and a slower administration rate are suggested for children. While this method has been criticised as potentially increasing the risk of extravasation injury, this has not been reported as a problem.

• Vincristine should be clearly labelled both on the intravenous bag and outer container “For intravenous use only — fatal if given by other routes”. Negative labels, such as “Not for intrathecal use”, must never be used.

Many hospitals currently use syringes for vincristine and increase the diluent volume in the syringe as a deterrent to intrathecal administration; however, fatalities have occurred after the administration of vincristine supplied in 10 mL4 and 20 mL5 syringes. The safest method of eliminating the potential for spinal instillation of vincristine remains the abolition of the syringe as a means of administration.