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Effects of an Inadvertent Dose of Cytarabine in a Child with Fanconi’s Anemia

Reducing Medication Errors

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Abstract

We report the case of a 7-year-old boy with Fanconi’s anemia, who underwent a bone marrow transplant using an unrelated donor, and who received an inadvertent dose of cytarabine (cytosine arabinoside). The cytarabine was given by mistake 6 months following transplant. This caused excessive toxicity to many systems, including the pulmonary and renal systems. The patient recovered from the episode, but this article further highlights the acute adverse effects of cytarabine. Furthermore, it is the first report of excessive toxicity to cytarabine in a child with Fanconi’s anemia. The article also highlights the problems of medication administration errors, particularly in those exquisitely sensitive to the effects of toxic drugs.

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References

  1. Barrett AJ, Brigden WD, Hobbs JR, et al. Successful bone marrow transplant for Fanconi’s anaemia. BMJ 1977; I: 420–2

    Article  Google Scholar 

  2. Gluckman E, Berger R, Dutreix J. Bone marrow transplantation for Fanconi anemia. Semin Hematol 1984; 21: 20–6

    PubMed  CAS  Google Scholar 

  3. Hows JM, Yin JL, Marsh J, et al. Histocompatible unrelated volunteer donors compared with HLA nonidentical family donors in marrow transplantation for aplastic anemia and leukemia. Blood 1986; 68: 1322–8

    PubMed  CAS  Google Scholar 

  4. Hows JM, Chappie M, Marsh JC, et al. Bone marrow transplantation for Fanconi’ s anaemia: the Hammersmith experience 1977–1989. Bone Marrow Transplant 1989; 4: 629–34

    PubMed  CAS  Google Scholar 

  5. Gluckman E. Allogeneic bone marrow transplant in Fanconi anemia. Bone Marrow Transplant 1996; 18: 140–4

    PubMed  Google Scholar 

  6. Dokal IS, Roberts IA. Bone marrow transplantation for Fanconi’s anemia: conditioning with reduced doses of cyclophosphamide without radiation [letter]. Br J Haematol 1996; 94: 423

    PubMed  CAS  Google Scholar 

  7. Liu JM, Buchwald M, Walsh CE, et al. Fanconi anemia and novel strategies for therapy. Blood 1994; 84: 3995–4007

    PubMed  CAS  Google Scholar 

  8. Gluckman E. Radiosensitivity in Fanconi anemia: application to the conditioning for bone marrow transplantation. Radiother Oncol 1990; 18: 88–93

    Article  PubMed  Google Scholar 

  9. Andersson BS, Cogan BM, Keating MJ, et al. Subacute pulmonary failure complicating therapy with high-dose Ara-C in acute leukemia. Cancer 1985; 56: 2181–4

    Article  PubMed  CAS  Google Scholar 

  10. Trigg ME, Finlay JL, Bozdech M, et al. Fatal cardiac toxicity in BMT in patients receiving cytosine arabinoside, cyclophosphamide and TBI. Cancer 1987; 59: 43–7

    Article  Google Scholar 

  11. Haupt HM, Hutchins GM, Moore GW. Ara-C lung: noncardiogenic pulmonary edema complicating cytosine arabinoside therapy of leukemia. Am J Med 1981; 70: 256–61

    Article  PubMed  CAS  Google Scholar 

  12. Davies L, Dolgin S, Kattan M. Morbidity and mortality of open lung biopsy in children. Pediatrics 1997; 99(5): 660–4

    Article  PubMed  CAS  Google Scholar 

  13. Vogler WR, Winton EF, Heffner LT, et al. Ophthalmological and other toxicities related to cytosine arabinoside and total body irradiation as preparative regimen for bone marrow transplantation. Bone Marrow Transplant 1990; 6: 405–9

    PubMed  CAS  Google Scholar 

  14. Kumar M, Saleh A, Rao PV, et al. Toxicity associated with high-dose cytosine arabinoside and total body irradiation as conditioning for allogeneic bone marrow transplantation. Bone Marrow Transplant 1997; 19: 1061–4

    Article  PubMed  CAS  Google Scholar 

  15. Orser B. Reducing medication errors. Can Med Assoc J 2000; 162(8): 1150–1

    CAS  Google Scholar 

  16. Hennessy S. Potentially remediable features of the medication-use environment in the United States. Am J Health Syst Pharm 2000; 57(6): 543–8

    PubMed  CAS  Google Scholar 

  17. Barker KN, Allan EL. Understanding and preventing drug misadventures: research on drug-use-system errors. Am J Health Syst Pharm 1995; 52(4): 400–3

    PubMed  CAS  Google Scholar 

  18. Cohen MR. Understanding and preventing drug misadventures: drug product characteristics that foster drug-use-system errors. Am J Health Syst Pharm 1995; 52(4): 395–9

    PubMed  CAS  Google Scholar 

  19. Crane VS. New perspectives on preventing medication errors and adverse drug events. Am J Health Syst Pharm 2000; 57(7): 690–7

    PubMed  CAS  Google Scholar 

  20. Gobis LJ. Medication errors: learn from your colleagues’ mistakes. RN 1995; 58(12): 59–63

    PubMed  CAS  Google Scholar 

  21. Pepper GA. Understanding and preventing drug misadventures: errors in drug administration by nurses. Am J Health Syst Pharm 1995; 52(4): 390–5

    PubMed  CAS  Google Scholar 

  22. Trinkle R, Wu JK. Errors involving pediatric patients receiving chemotherapy: a literature review. Med Pediatr Oncol 1996; 26(5): 344–51

    Article  PubMed  CAS  Google Scholar 

  23. Schulmeister L. Chemotherapy medication errors: descriptions, severity, and contributing factors. Oncol Nurs Forum 1999; 26(6): 1033–42

    PubMed  CAS  Google Scholar 

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Acknowledgements

The authors acknowledge that they have no conflicts of interest.

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Authors and Affiliations

  1. Division of Blood & Bone Marrow Transplantation, Department of Pediatrics, A.I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, Delaware, 19803, USA

    Michael E. Trigg

  2. Department of Anesthesia and Critical Care, A.I. duPont Hospital for Children, Wilmington, Delaware, USA

    Vinay Nadkarni

  3. Division of Pulmonology, A.I. duPont Hospital for Children, Wilmington, Delaware, USA

    Aaron Chidekel

  4. Division of Nephrology, A.I. duPont Hospital for Children, Wilmington, Delaware, USA

    Charles McKay

  5. Division of Hematology/Oncology, A.I. duPont Hospital for Children, Wilmington, Delaware, USA

    Rita Meek, Gregory Griffin, Maureen Edelson & Anne Reilly

  6. Pharmacy Department, A.I. duPont Hospital for Children, Wilmington, Delaware, USA

    Joseph Peoples & Stuart Levine

  7. Department of Pathology, A.I. duPont Hospital for Children, Wilmington, Delaware, USA

    Frederick Meier

Authors
  1. Michael E. Trigg
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  2. Vinay Nadkarni
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  3. Aaron Chidekel
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  4. Charles McKay
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  5. Rita Meek
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  6. Gregory Griffin
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  7. Maureen Edelson
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  8. Anne Reilly
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  9. Joseph Peoples
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  10. Stuart Levine
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  11. Frederick Meier
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Corresponding author

Correspondence to Michael E. Trigg.

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Trigg, M.E., Nadkarni, V., Chidekel, A. et al. Effects of an Inadvertent Dose of Cytarabine in a Child with Fanconi’s Anemia. Pediatr-Drugs 4, 205–208 (2002). https://doi.org/10.2165/00128072-200204030-00007

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  • DOI: https://doi.org/10.2165/00128072-200204030-00007

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