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Accidental intraventricular vincristine administration: an avoidable iatrogenic death
1Department of Forensic Medicine, Institute of Science and Forensic Medicine, Singapore, Republic of Singapore.
Medicine, Science, and the Law
|July 1, 1996
Summary
Accidental intraventricular vincristine administration in acute lymphoblastic leukemia led to fatal encephalomyelitis. This case highlights the severe neurotoxicity of vincristine when delivered directly into the central nervous system.
Area of Science:
- Neuro-oncology
- Chemotherapy administration
- Neuropathology
Background:
- Acute lymphoblastic leukemia (ALL) requires intensive chemotherapy.
- Vincristine is a standard chemotherapeutic agent.
- Intraventricular chemotherapy is used for CNS-directed treatment.
Observation:
- A patient with ALL received accidental intraventricular vincristine.
- The patient developed progressive ascending paralysis and coma.
- Supportive care and CNS washout were administered.
Findings:
- Autopsy revealed florid encephalomyelitis.
- The neuropathology indicated brain death.
- Intraventricular vincristine was identified as the likely cause.
Implications:
- Vincristine is highly neurotoxic when administered intraventricularly.
- Strict protocols are essential to prevent medication errors in chemotherapy.
- This case underscores the critical importance of accurate drug delivery routes.