The incidence of extravasation of vinca alkaloids supplied in syringes or mini-bags

Secondary Central Nervous System Lymphoma: Updates in Treatment and Prophylaxis Strategies

OPINION STATEMENT

Referring to any central nervous system (CNS) involvement with preceding or concurrent systemic disease, secondary CNS lymphoma (SCNSL) lacks a clear standard of care and historically carries a very poor prognosis. Aggressive histologies predominate, most notably diffuse large B cell lymphoma (DLBCL), with higher relative frequency in Burkitt lymphoma but lower absolute incidence. Therapeutic strategies commonly feature intensive CNS-penetrant chemotherapy, including methotrexate, cytarabine, and others. Combination regimens, novel targeted agents, and cellular therapy considerations are reviewed, noting that patients with SCNSL are often excluded from clinical trials and dedicated SCNSL studies are historically limited. Given these challenges, there has been renewed attention on CNS prophylaxis as well as strategies for early CNS detection. Prophylaxis is standard of care in Burkitt lymphoma, whereas its role in DLBCL and related histologies is increasingly unclear.

Inadvertent intrathecal administration of daunomycin resulting in fatality: Case report and therapeutic considerations

Background

Daunomycin is a chemotherapeutic agent of the anthracycline family that is administered intravenously, most commonly in combination therapy. The authors report the first known adult case of inadvertently administered daunomycin directly into the human central nervous system and the neurologic manifestations and therapeutic interventions that followed.

Clinical description

A 53-year-old male presenting to the hospital for his second cycle of consolidation therapy for acute promyelocytic leukemia t(15;17) was accidentally administered 93 mg of intrathecal (IT) daunomycin. Within several hours of injection, the patient subsequently developed bilateral lower extremity pain, ascending paresthesias, headache, and left cranial nerve (CN) III palsy. Immediately following these neurologic sequalae, a subarachnoid lumbar drain was placed at the L4-5 interspace for the initial irrigation and drainage of cerebrospinal fluid (CSF). By hospital day 2, the patient's mental status significantly declined requiring an external ventricular drain (EVD) for hydrocephalus. Despite therapeutic interventions, the patient developed an ascending radiculomyeloencephalopathy with deterioration in clinical status. Eighteen days after the inadvertent injection of IT daunomycin, the patient became comatose and lost all cranial nerve function.

Conclusions

Accidental IT injection of daunomycin is a neurosurgical emergency and warrants prompt intervention. Symptoms can mimic other medical conditions, making it imperative an accurate diagnosis is made so that appropriate therapies are implemented. At this time, therapies include rapid removal of the chemotherapeutic agent from the IT compartment by aspiration and irrigation; however, it is unclear if neuroprotective agents may provide added benefit.

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The inadvertent intrathecal injection of daunomycin is fatal.

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Accurate diagnosis is difficult as symptoms often mimic other conditions.

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Cerebral spinal fluid lavage and continuous drainage should be initiated.

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Neuroprotective agents may be considered for salvage therapy.

Safe vincristine use in Switzerland: Still a long way to go?

Background

Different international organizations recommend safety measures for the use of vincristine to prevent wrong route administrations. A central recommendation is to use infusion bags instead of syringes to prevent confusion with intrathecal chemotherapy. This study aimed to investigate the implementation of safety measures for vincristine and intrathecal chemotherapies in Switzerland.

Method

We conducted a written survey among hospital pharmacies of all general care and pediatric hospitals in Switzerland (n = 102). A responsible person of each hospital pharmacy was invited by email to participate in the online survey in May 2018.

Results

Of 66 responding hospitals (response rate 65%), 27 have a hospital pharmacy preparing parenteral chemotherapy. All of these hospitals prepared vincristine in 2017, while 21 also prepared intrathecal chemotherapy. Of these 21, 16 hospitals prepared vincristine as syringes, with small volume syringes being the most widely distributed dosage form. A switch from syringes to infusion bags was discussed in seven hospitals, and discussions led to plans for switch in two. The most prevalent safety measures were labeling for vincristine and special delivery for intrathecal drugs. Of hospitals preparing both vincristine syringes and intrathecal chemotherapy, four reported to have no safety measures implemented neither for vincristine nor for intrathecal chemotherapy.

Conclusion

International recommendations are not widely implemented in Swiss hospitals. Syringes are still in use and other safety measures are sparsely disseminated. Thus, Swiss vincristine patients are still at an increased risk for wrong route application. Recommendations have to be further disseminated and implementation could be enhanced.

Intrathecal chemotherapy: potential for medication error

BACKGROUND

The central nervous system is a unique sanctuary site for malignant disease. To ensure optimal disease control, intrathecal (IT) chemotherapy is commonly given in conjunction with standard chemotherapy protocols, thus providing the opportunity for medication errors.

OBJECTIVE

A systematic review of the current literature on medication errors associated with the administration of IT chemotherapy was conducted.

METHODS

English-language literature published from January 1960 through June 2013 was accessed. Case reports, clinical studies, and review articles pertaining to IT medication errors were included in the review. References of all relevant articles were searched for additional citations.

RESULTS

Twenty-two cases of accidental IT overdoses have been reported with methotrexate and 1 with cytarabine. There have been numerous cases of antineoplastic agents intended for administration by the parenteral route being inadvertently given intrathecally. Vincristine has been implicated 31 times (25 deaths), as well as vindesine, asparaginase, bortezomib, daunorubicin, and dactinomycin. This has led to profound toxicity and, commonly, death. Unfortunately, many cases go unrecognized or unreported.

CONCLUSIONS

The best method for eliminating the risk of IT medication errors is to develop effective methods of prevention and incorporate them into oncology and hematology practice internationally. Strategies include abolishing the syringe as a method of vinca alkaloid administration and substituting small-volume intravenous bags, and developing novel methods for intraspinal drug administration.

IMPLICATIONS FOR PRACTICE

The nursing profession is in a unique position to influence change and lead the way in establishing preventative strategies into current practice.

Lack of vincristine infiltrates in patients with retinoblastoma receiving chemotherapy by peripheral intravenous lines

The delivery route of chemotherapy for intraocular retinoblastoma has become controversial. One objection to systemic delivery is the need for central venous access. We cross-referenced a hospital vascular access database with our tumor registry to determine the incidence of chemotherapy infiltrates. Sixty-five patients received 270 cycles of chemotherapy via peripheral intravenous access. Vincristine infiltration was 0% (95% confidence interval [CI] 0-0.16%) while that of non-vesicant chemotherapy was 0.7% (95%CI 0.1-2.6%). Giving chemotherapy via peripheral access to patients with retinoblastoma is safe. It can decrease therapy costs and prevent central line associated blood stream infections.

Introduction of vincristine mini-bags and an assessment of the subsequent risk of extravasation

INTRODUCTION

Numerous international organisations have advocated the preparation of vincristine in small volume intravenous bags in order to eliminate inadvertent intrathecal administration. However, the risk of extravasation is a significant deterrent, and adoption of this practice has been variable and only hesitantly accepted in the clinical setting.

PURPOSE

We carried out a study with the aims of establishing the incidence of reported extravasation of vincristine administration to paediatric and adult patients in mini-bags; here we describe motivating factors and barriers faced by clinical staff. The secondary aim was to support the need for change and implementation of the international recommendations.

METHODS

Chemotherapy-certified nurses completed a survey spanning August 2009 to August 2011, to ascertain the incidence of extravasation associated with the administration of vincristine in mini-bags.

RESULTS

This period captured 421 occasions of vincristine administration in 25-ml or 50-ml mini-bags (in 0.9% sodium chloride). The median age of patients was 13 years (range 2.5 months to 99 years). Vincristine was administered through peripheral lines (26.4%), portacath (52.0%), PICC line (15.9%) and Hickman line (5.7%). The majority of infusions were over at least 10 minutes (50.1%). There were no cases of extravasation reported.

CONCLUSIONS

The administration of vincristine in small volume intravenous bags was safe, practical, and feasible in all patient groups. The successful implementation of the international recommendations for vincristine administration in mini-bags to eliminate potential inadvertent intrathecal administration was dependent on stakeholder buy-in.

Medication safety and the administration of intravenous vincristine: International survey of oncology pharmacists

Purpose

The risk of medication errors with vincristine administration is well documented. Our objective was to ascertain how vincristine is administered worldwide and determine what strategies for preventing the accidental intrathecal administration of vincristine are in place.

Methods

A survey, comprising 28 questions, was distributed to 363 International Society of Oncology Pharmacy Practitioners members from 42 countries via email. Questions were asked on methods of vincristine administration, intrathecal drug administration and strategies used to prevent medication errors. A reminder was sent and the survey was available on the International Society of Oncology Pharmacy Practitioners website. Only one survey per institution was requested.

Results

In all, 62 responses from 15 countries were received, with the majority from Australia. Vincristine was dispensed in mini-bags in 77.4% of centres, though some also used syringes. Syringes were used in 31.1% of centres, with half these doses prepared undiluted. Administration took 5 to 15 minutes in most centres (78.8%). The most common reasons for still using syringes were perceived risk of extravasation and faster infusion time. Despite numerous vincristine administrations, extravasation was very rare. Other recommended strategies for error prevention were in use in the majority of centres.

Conclusion

Comparisons with three previous surveys are difficult as the majority of respondents in those studies were from the USA. A number of areas appear to have improved, particularly the preparation of vincristine in mini-bags, but they are far from perfect. Deaths continue to occur following accidental intrathecal administration of vincristine. International Society of Oncology Pharmacy Practitioner members are urged to lead the way in incorporating strategies for prevention into institutions worldwide.

Treatment of skin injury due to vinorelbine extravasation using bFGF and rhGM-CSF: an experimental study in a murine model

BACKGROUND AND OBJECTIVE

A murine model of skin injury from vinorelbine extravasation was established to evaluate the treatment efficacy of basic fibroblast growth factor (bFGF) and recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF).

MATERIALS AND METHOD

Experimental models were divided into bFGF, rhGM-CSF, and control (saline) groups, with 40 mice in each group. Edema and ulceration were measured on Days 1, 3, 5, 7, 10, 14, and 18 after the onset of extravasation; injuries were examined pathomorphologically in three mice/group/time point.

RESULTS

Edema reached maximum size on Day 3 in the bFGF and rhGM-CSF groups and Day 5 in the control group. The difference between the two experimental groups was not significant; differences between the control group and the experimental groups were statistically significant at all time points. Edema and ulceration began to improve on Day 10 in the bFGF and rhGM-CSF groups and Day 18 in the control group. Healing duration was 14-18 days in the experimental groups, with a (not significantly) shorter duration in the bFGF group. Healing was completed by Day 27.5 in the control group. Pathomorphological evaluation showed regular re-epithelization and newly formed granulation tissue in the bFGF and rhGM-CSF groups on Day 13. In the control group, wounds were partially healed, edema and shallow ulcers existed, and epithelization was fragile and disorganized on Day 18.

CONCLUSIONS

bFGF and rhGM-CSF are useful for the treatment of skin injury due to vinorelbine extravasation, but bFGF may be slightly more effective in decreasing time and improving quality of healing.

Accidental intrathecal administration of vincristine

We describe a case of accidental intrathecal administration of vincristine in a 33-year-old man with clinical diagnosis of acute lymphocytic leukemia. The patient died 20 days after receiving the drug. Clinically, the patient developed acute ascending paralysis with motor and sensory dysfunctions, and respiratory failure. Neuropathological investigation revealed lesions in spinal cord, roots, and cerebellum characterized by rarefaction of the neuropil, axonal, and myelin degeneration, accompanied by macrophagic infiltration.

Securing the circuit of intrathecally administered cancer drugs: example of a collective approach

The treatment of leptomeningeal metastasis is based on protocols linking systemic chemotherapies and intrathecal injections of antineoplastic agents. Since the late 1960s, cases of accidental intrathecal injections of vinca-alkaloids, which have almost always proved fatal, have been documented. The most concerned countries, supported by the WHO, have published numerous recommendations aimed at reducing this type of risk. The aim of our work was to improve safety procedures for the intrathecal administration of antineoplastic drugs in an oncology hospital: the Centre Oscar Lambret, Lille, France. To this end, we compiled and analyzed a total of eight international recommendations. Our method was to meet the requirements of the AFSSAPS (French agency for the safety of health products), then to adopt recommended procedures in other countries, where appropriate.

We considered the whole drugs circuit from prescription to administration. Improvements basically focused on the computerization of prescription, the dilution in mini-bags of vinca-alkaloids, and the additional labeling of intrathecally administered preparations as well as those with some vinca-alkaloids. This multidisciplinary approach to improve our practices complements the precautions taken by healthcare teams.

Oncology medication safety: A 3D status report 2008

Background. The safe use of medications is a major concern in oncology practice. Three organizations collaborated on a survey to determine if practitioners had implemented current recommended safe practices for IV vincristine administration, general oncology safe practices, and safe practices for oral chemotherapy.

Methods. A survey was distributed to members of the Hematology Oncology Pharmacy Association (HOPA) and the International Society of Pharmacy Practitioners (ISOPP) using Survey Monkey TM. The Institute of Safe Medication Practices (ISMP) also solicited readers of its Medication Safety Alert! ® to respond to the survey. A comparison to results from a survey conducted by ISMP in 2006 on safe practices for IV vincristine was also conducted.

Results. The majority of respondents were aware of the WHO recommendations for IV vincristine, although the rate of implementation of the guidelines ranged from 24.1 to 53.6%. When compared to the ISMP 2006 survey there was a 25.8—37.4% improvement in following many of the safe practice guidelines. Administering IV vincristine via a minibag showed the lowest rate of adoption (less than 40%). Of the 35 survey items on general chemotherapy safety strategies, 80% of respondents had implemented at least 21 items in the survey. Overall 32.4% of respondents did not consider oral chemotherapy as requiring the same safety concerns as parenteral therapy.

Conclusions. The results of this survey will provide a new baseline for the adoption rate of safe medication practice recommendations related to oncology. Further work on addressing barriers in adopting identified safe practice recommendations needs to be conducted.