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
Fentanyl, hydromorphone, morphine
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
Neuromuscular blocking agents
Albuterol, theophylline, other bronchodilators
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
This NAVAS blog post: https://www.mynavas.org/post/oral-sedatives-and-anxiolytics-for-veterinary-visits
Pre-Hospital Sedation Options for Cats and Dogs https://vetanesthesiaspecialists.com/for-vets/resources/
Veterinary Anesthesia Update 3rd Edition: Available on VIN, or as a print version https://www.nancybrockvetservices.com/
❖ 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