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Anesthesia Drug Shortages

Shortages of sedatives, analgesics, and anesthetic agents happen with uncomfortable frequency and the COVID-19 pandemic is putting great pressure on supplies of drugs that, in some cases, were already in and out of availability. Providing safe and humane anesthetic care in such times requires flexibility on the part of the provider.


The following post is a summary of ideas put together by a group of veterinary anesthetists for how to deal with shortages of drugs that specifically may be affected by the current healthcare crisis. Many of these strategies will apply to future shortage situations as well - which, unfortunately, almost certainly will occur.


ANESTHESIA & PERIOPERATIVE DRUG SHORTAGES associated with COVID-19


Nancy Brock DVM DACVAA

Rachael Carpenter DVM

Kris Kruse-Elliot DVM PhD DACVAA

Lydia Love DVM DACVAA

Heidi Shafford DVM PhD DACVAA


Check FDA website for updated info on drug shortages: https://www.accessdata.fda.gov/scripts/drugshortages/


❖ Anesthesia & perioperative drugs that may be in short supply


This is how I look when I think about anesthesia drug shortages, especially when it comes to analgesics for our patients.

  • Fentanyl, hydromorphone, morphine

  • Midazolam, diazepam

  • Propofol (but maybe not Propofol-28?)

  • Dexmedetomidine (possibly due to raw material shortage)

  • Ketamine (veterinary-labeled products may be ok)

  • Dopamine, dobutamine, norepinephrine, epinephrine, phenylephrine, vasopressin

  • Corticosteroids (injectable)

  • Neuromuscular blocking agents

  • Albuterol, theophylline, other bronchodilators

  • Furosemide

  • IV fluids

  • Antibiotics


The major issues for veterinary anesthetists will likely be adequate pain management, induction drug choices, and management of blood pressure. Here are some strategies for adjusting to these drug shortages while maintaining patient comfort and safety.


❖ Consider oral sedation/analgesia at home

  • Benefits: reduced patient anxiety & decreased anesthetic requirements - ability to avoid full mu opioid agonists for sedation, less inhalant-induced hypotension

  • Gabapentin, trazodone, oral-transmucosal acepromazine


Resources



❖ Decrease use of full mu agonist opioids

  • Avoid using full mu opioids for sedation / premedication

  • Reserve current stock of full mu agonist opioids for control of moderate-to-severe pain

  • Consider other pharmaceuticals for sedation: acepromazine, dexmedetomidine, medetomidine, butorphanol

  • Be ready to substitute one full mu agonist opioid for another

  • It is legal to obtain compounded drugs for hospital use from a 503b pharmacy during a shortage situation

  • Reserve fentanyl for high risk patients with significant acute pain

  • Reduce fentanyl infusion rate & draw up smaller quantities to reduce waste

  • Consider micro-dose ketamine boluses or infusion

  • Use butorphanol if no/mild pain anticipated or main goal is sedation or premedication

  • Buprenorphine may be adequate for moderate pain and, if combined with other analgesics, may be adequate for severe pain in some patients.

  • Pain score your patients frequently!


❖ Specific strategies for preserving opioids, especially pure mu agonists

Need sedation - use butorphanol (0.2-0.4 mg/kg IM or IV). Can be part of your premedication protocol, preserves pure mu agonist for intra-op and overlap is not an issue since premed of butorphanol unlikely to last significantly into the surgical period.

Buprenorphine - reasonably good analgesic but not very sedating. IV administration requires 30 min+ to be effective. More about buprenorphine here: https://www.mynavas.org/post/7-things-to-know-about-buprenorphine