Safety of inadvertent administration of overdose of intrathecal Cytarabine in a pediatric patient. (October 2015)

• Record Type: Journal Article
• Authors: Omar, Suha Al; Amayiri, Nisreen; Madanat, Faris
• Is Part Of: Journal of oncology pharmacy practice. Volume 21:Number 5(2015)
• Page Start: 384
• Page End: 387
• Publication Date: 2015-10
• Subjects: Intrathecal Cytarabine -- medication error -- overdose -- pediatric; Cancer -- Chemotherapy -- Periodicals; Clinical pharmacology -- Periodicals; 616.994061
• DOI: 10.1177/1078155214534104
• Languages: English
• ISSNs: 1078-1552

Abstract

Purpose: To describe a medication error of intrathecal Cytarabine overdose that was managed conservatively with no apparent toxicities. Summary: An 11-year-old girl was diagnosed with bone marrow relapsed precursor B-cell acute lymphoblastic leukemia. According to her chemotherapy protocol, she was started on triple intrathecal chemotherapy consisting of Methotrexate, Cytarabine and Hydrocortisone on day 1 of the protocol. After the intrathecal therapy being administered to the patient, the pharmacist who checked the medication realized that the wrong formulation of Cytarabine was used to prepare the intrathecal therapy; this error resulted in five times overdose of Cytarabine. The patient was then managed conservatively without cerebrospinal fluid exchange. Our patient remained clinically and neurologically stable without apparent toxicities and was discharged safely from hospital. Conclusion: Supportive care without the need for invasive procedures such as cerebrospinal fluid exchange may be adequate for managing intrathecal Cytarabine overdose.