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"Just Bag it!" Vinca Alkaloid infusion by Mini Bag is a must!

  • 1.  "Just Bag it!" Vinca Alkaloid infusion by Mini Bag is a must!

    Posted 05-23-2019 20:22
    I have seen many discussions started on this forum related to Vinca Alkaloid drugs being administered by Mini-bag versus IV push.  The NCCN "just bag it!" campaign (Just Bag It!) is something I hold near and dear to my conscience.  I feel we all learn best through examples and reasoning versus just being told "that just how we do it."  I know for most of you this is old news and your institutions have long ago implemented this change.  There is still a small amount of Oncology Nurses who are unaware of the importance of this practice and institutions where Mini-Bag change has yet to be implemented.

    Administering by mini bag is not because of just 1 or 2 patients, or because it is easier on the vein or many other statements I have read on this forum.  But rather in support of an estimated 120 patients worldwide (44 in the United States) who received accidental administration of a Vinca Alkaloid agent intrathecally.  When accidental administration into the spine occurs "it is invariably fatal, attacking the nerves, causing severe pain, spasms, and creeping paralysis before the patient loses consciousness and dies" (Balen, 2004).

    The first reported incident occurred in the United States in 1968 and unfortunately CONTINUES to happen even as recently as 2011.  I feel that every Oncology Nurse should not only be aware of the importance of the "just bag it!" campaign but must advocate for implementation if their institution has not.  In addition, preceptors need to provide the importance of this practice going beyond "this is just how we do it."  Of course it is a very RARE occurrence, especially outpatient, but I can think of many scenarios that have already and/or have the potential of crossing over into the ambulatory setting.

    Some reported cases include:
    • (1985)  21 yo (Lillian Cedeno of Albany, New York) receives her Vincristine dose (ordered to be given IV route) into her spine is immediately paralyzed and later dies.
    • (1990)  15 yo (Donna Horn of Northamptonshire, England) with Leukemia, Vincristine injected into her spine.  Paralyzed from neck down.  Died 8 year later from complications related to her paralysis.
    • (1990s) 59-yo woman with ALL received Vincristine through her Ommaya reservoir, died 40 days later.
    • (1990s) 5 yo little girl with ALL received Vincristine intrathecally and died 7 days later.
    • (1990s) 57 yo man with Lymphoblastic Lymphoma received Vincristine intrathecally and died 4 weeks later.
    • (late 1990s) 3 yo little boy with ALL received Vincristine accidentally intrathecally.  Died 6 days later.
    • (2001) 19 yo (Wayne Jowett of Nottingham, England) died within a month after receiving his dose of Vincristine intrathecally
    • (2005) 21 yo (Christopher Robin Wibeto of California, USA) died 3 days after Vincristine, which was intended for another patient, was injection into his spine.
    • (2007) 32 yo man received Vincristine via intrathecally route realized immediately and received aggressive CSF aspiration and irrigation for 6 days saving his life but leaving him paralyzed at T-9 and below.
    • (2008) 25-year-old woman with non-Hodgkin's lymphoma was adminstered Vindesine intrathecally and died when her provider confused the IV syringe of Vindesine with the syringe of methylprednisolone intended for intrathecal administration.
    • (2010) a young woman received a dose of Vincristine through an Ommaya reservoir.
    • (2010) a 33-year-old man with ALL in complete remission received his maintenance dose of IV push Vincristine via a lumbar puncture and died.
    • (2011) 38-year-old woman with lymphoma (in a US hospital) received her IV push Vincristine intrathecally and dies.
    • (2011) a 63-year-old man with lymphoma from Thailand received IV push Vincristine intrathecally and dies.

    "A medical error leading to avoidable death is always distressing, but when the death is that of a patient whose disease should have been, and probably was, curable, this feeling is intensified" (Campbell, 2001)


    Ali Jackson RN BSN OCN

  • 2.  RE: "Just Bag it!" Vinca Alkaloid infusion by Mini Bag is a must!

    Posted 05-24-2019 09:22
    Thank you so much for this thread!  Just had this discussion yesterday. Several RN's could not understand why we can't push or use a pump to administer Vincristine.  I was NOT aware of the "Just Bag It" campaign.   I printed it out and will bring it to our next RN meeting.  As you said it is always best to know why we do something as opposed to just saying that's just how we do it!  Thank you again!!

    Donna Lucin RN OCN
    Wisconsin Rapids WI

  • 3.  RE: "Just Bag it!" Vinca Alkaloid infusion by Mini Bag is a must!

    Posted 05-24-2019 09:58
    I am writing to ask for clarification. In my institution we do use a pump for the administration of vincristine which comes in a mini bag but is always administered through a port. My understanding is it should not be administered via pump if being administered peripherally. Is this correct?

    Theresa Stross RN
    Unionville CT

  • 4.  RE: "Just Bag it!" Vinca Alkaloid infusion by Mini Bag is a must!

    Posted 05-24-2019 17:53
    Hi Theresa-

    ONS supports infusion of mini-bag Vinca Alkaloids via infusion pump only if through a central line.   If peripheral access Mini-Bag must be infused by gravity Piggy-back while nurse stays with the patient.

    However, I personally infuse mini-bags by gravity IV piggy back and stay with the patient regardless of access but that's just me as I'm concerned about the patient standing up and somehow causing a port needle dislodgment.

    My goal of my post is to encourage other nurses to advocate for Mini Bag implementation if their facility is still using syringes.

    Mini-bags across the board is the only way to make accidental Intrathecal administration a "Never Event."

    Maybe it's just more personal for me as I watched my husband receive tx for Hodgkins when our first was 18 months old.  Trying my best to be the wife and not the ONC nurse I had to speak up when I witnessed a drug error during his first cycle. Of course the error was nothing compared to any "Never Events." And maybe it's a strange but every time I administer a mini bag Vinca Alkaloid I do so in respect of the lives lost.

    I believe every single oncology nurse needs to be aware as they are often the ones handing over the syringe to the doctor.  This error even happened after a safety effort implementation of diluting Vincristine into larger 20 ml syringes!

    I'm hoping to empower others to Advocate and to understand why we do this.  And please share to oncology nurses alike.

    Thank you for your time!

    Ali Jackson RN BSN OCN

  • 5.  RE: "Just Bag it!" Vinca Alkaloid infusion by Mini Bag is a must!

    Posted 06-01-2019 09:04
    Theresa - Has anyone clarified this question?  I am so curious to know what other facilities do.  The debate at our facility is - doesn't the pump offer a more even drip count on administration (as opposed to gravity) and therefore should we not use a pump all the time...?  Thanks for your input!  Donna

    Donna Lucin RN OCN
    Wisconsin Rapids WI

  • 6.  RE: "Just Bag it!" Vinca Alkaloid infusion by Mini Bag is a must!

    Posted 06-01-2019 15:45

    Hi Donna
    I had one response from a nurse who said that ONS only recommends using a pump if Vincristine is administered via a central line. If given peripherally it must be administered by gravity. That makes sense. Thanks for the email! 

    Sent from my iPhone

  • 7.  RE: "Just Bag it!" Vinca Alkaloid infusion by Mini Bag is a must!

    Posted 06-02-2019 09:07
    When administering vincristine, its imperative the RN assures the IV access has a good blood return & there is no resistance when flushing the port or PIV-avoiding extravasation is of utmost importance. If you use a pump to administer vincristine to a patient with a PIV, the pump cannot detect resistant pressures from a misaligned or dislodged IV and will continue to infuse the vincristine and cause extravasation. Administering vincristine via gravity to a patient with a PIV, allows you to watch the rate of the drip and see whether there is resistance (slowing or stopping of drip). If you observe slowing or stopping of the drip, you would then clamp the line and check for blood return. If there is blood return, you can then feel for yourself if there is resistance in the IV by gently flushing it. If all checks out you can resume the drip. If there is no blood return, a new IV must be started and the patient must  be assessed for extravasation at the original IV site.