Related Experiment Videos
Fatality resulting from intraventricular vincristine administration
1New York City Poison Center, New York, USA.
Journal of Toxicology. Clinical Toxicology
|July 10, 1998
Summary
Inadvertent intraventricular vincristine administration led to severe neurological toxicity and death, even with prompt treatment. This case highlights the critical need for systems to prevent such medication errors in cancer therapy.
Area of Science:
- Neuro-oncology
- Pharmacology
- Patient Safety
Background:
- Intrathecal vincristine administration is associated with high fatality rates.
- This report details a case of direct intraventricular vincristine administration via an Ommaya reservoir.
- The patient had acute lymphocytic leukemia with meningeal involvement.
Observation:
- A 59-year-old woman received 2 mg of vincristine via her Ommaya reservoir instead of the intended intraventricular cytarabine.
- The error was recognized within 10 minutes.
- The patient developed progressive neurological symptoms including tremor, disorientation, nystagmus, stupor, and coma.
Findings:
- Intraventricular vincristine caused severe neurotoxicity.
- Neurological decline progressed despite immediate and aggressive medical intervention.
- The patient died 40 days after the event without regaining neurological function.
Implications:
- Accidental direct central nervous system administration of vincristine is highly toxic and potentially fatal.
- Robust safety systems are crucial to prevent medication errors involving chemotherapy administration routes.
- This case underscores the importance of double-checking drug administration protocols, especially in neuro-oncology.