Journal of pediatric hematology/oncology
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J. Pediatr. Hematol. Oncol. · Nov 2009
Review Case ReportsIntrathecal vincristine: 3 fatal cases and a review of the literature.
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. ⋯ 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.