Document Detail

Intrathecal vincristine: 3 fatal cases and a review of the literature.
MedLine Citation:
PMID:  19801949     Owner:  NLM     Status:  MEDLINE    
We report 3 cases of accidental intrathecal vincristine administration. All 3 patients died between 8 and 18 days after the incident because of decerebration. In the literature, we found 41 cases of accidental intrathecal injection of vincristine. These reports represent only a fraction of the existing problem. New in our report is the fact that the first 2 cases were attributed to viral infection, only after the detection of high levels of vincristine in the cerebrospinal fluid was the real cause of death ascertained. The third case occurred during the implementation of rules by the Dutch Childhood Oncology Group on how to handle intrathecal triple therapy; and despite sequential safety measures, the accident still occurred. In the Netherlands no more accidents of this nature have occurred in children after the introduction of a quadruple syringe system 8 years ago. In our opinion the best fail-safe solution would be the development of a unique connection that is incompatible with a standard Luer syringe.
Bernadette Hennipman; Esther de Vries; Jos P M Bökkerink; Lynn M Ball; Anjo J P Veerman
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Publication Detail:
Type:  Case Reports; Journal Article; Review    
Journal Detail:
Title:  Journal of pediatric hematology/oncology     Volume:  31     ISSN:  1536-3678     ISO Abbreviation:  J. Pediatr. Hematol. Oncol.     Publication Date:  2009 Nov 
Date Detail:
Created Date:  2009-11-06     Completed Date:  2009-12-08     Revised Date:  2011-10-06    
Medline Journal Info:
Nlm Unique ID:  9505928     Medline TA:  J Pediatr Hematol Oncol     Country:  United States    
Other Details:
Languages:  eng     Pagination:  816-9     Citation Subset:  IM    
Department of Paediatric Oncology/Haematology, Vrije Universiteit Medical Centre, Amsterdam, The Netherlands.
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MeSH Terms
Antineoplastic Agents, Phytogenic / administration & dosage,  adverse effects*
Child, Preschool
Fatal Outcome
Injections, Spinal / adverse effects*
Vincristine / administration & dosage,  adverse effects*
Reg. No./Substance:
0/Antineoplastic Agents, Phytogenic; 57-22-7/Vincristine
Comment In:
J Pediatr Hematol Oncol. 2010 May;32(4):336-7   [PMID:  20445422 ]
J Pediatr Hematol Oncol. 2010 Mar;32(2):167   [PMID:  20147847 ]

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

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