Adapting to Drug Shortages

[944S]

So as with the numerous and beyond ridiculous drug shortages what are some alternative induction/mac regimens you are using or will use?
Because propofol in our area is severely restricted creativity has been a necessity. Here are some things I have been doing depending on length of surgery and other factors.

For nml inductions.

1. My favorite has been an extra dose of versed upon arrival in room then 2 fentanyl with nitrous/sevo inhalation induction. Works great in the correct patient.

2. If looks like it is needed an extra dose of versed with fentanyl then <1mg/kg Ketamine and mask the rest of the way down.

3. Versed/fentanyl/Etomidate. Least favorite

4. Versed/fentanyl/Brevital

Rapid Sequence inductions.

1. Versed/fentanyl/Etomidate / Roc

2. extra versed with Ketamine 1mg/kg and Rocc

3. Brevital with Rocc.

Succ is substituted for the Rocc if needed.


MAC's.

They have been pushing Lusedra at our site but it has NOT been a favorite due to perineal burning and less predictability. It was suggested by a rep to give 1/2 cc in holding to prime receptors as a way of preventing the burning. I tried that only one time and the patient tried to climb out of the bed. We had not left holding yet!! This also happened to many of my colleagues when they tried it and therefore I don't know anyone using this tech. Heavy dosing of versed prior to Lusedra use seems to be the only reliable method.

This has left us with the following options for MAC.

Versed /Fentanyl

Versed/Lusedra

Although I used it all the time in school nobody has used precedex at our clinical site. I tried to use some recently but was unable to get it or it would also be a great option

We have reserved the majority of remaining supplies of propofol for GI. They were not happy with Lusedra and we have to keep them happy.

Would love to hear any other favorites you might have.

[MmacFN]

well..

If I am being honest we have yet to see a shortage of anything except pre-filled lidocaine syringes.... For a very short period there was talk of a succs issue but it never happened, never seen a prop. issue...

If i had to do long Macs i'd use ketamine and versed with morphine

If I had to do short Macs id use ketamine, versed and fent (if needed) with MS for post op pain if there was to be any.

That is my backup plan anyway. Ive never seen Lusedra so id have to factor that in after i played with it a little.

[SuperSleeper]

We went a long time without using prop last year. Ended up using brevital all the time. Got used to it pretty quickly and it works great as a subsitute (obviously for appropriate cases...). We used roc all the time when we had a vec shortage...or tracrium if needed. Problem with roc is that dang redosing bs (i don't redose with it). Used roc quite a bit for RSIs...not at the exclusion of sux, just per MDA preference mostly. We used precedex a lot and started using remi in cases just in this last year.

I guess I was lucky in my program in terms of learning flexibility with the drugs. We never really knew what we were going to use for sure until shortly before the case and the MDA could always come in and change it up (often did). Also had the benefit of young and old-school MDAs. One, in particular (shout out to Shepherd!!!) is AWESOME at "Hey! Let's try this and see how it goes!"

[armygas]

LET ME SAY THIS.....

As the drug shortages occur, business WILL NOT STOP and the "standard of care" will also evolve...(yes even with sux)

Preach all ya want, but reality is reality.

[jwk]

well..

If I am being honest we have yet to see a shortage of anything except pre-filled lidocaine syringes.... For a very short period there was talk of a succs issue but it never happened, never seen a prop. issue...

If i had to do long Macs i'd use ketamine and versed with morphine

If I had to do short Macs id use ketamine, versed and fent (if needed) with MS for post op pain if there was to be any.

That is my backup plan anyway. Ive never seen Lusedra so id have to factor that in after i played with it a little.

We've been lucky as well - we haven't really been "without" yet, although we've had days where all we had was 50cc propofols. It's a shame to waste all that drug, but it does indeed get tossed after drawing out the usual 20cc.

We actually took the pentothal out of our CS rooms a few months ago when it was in short supply. It's now in the pyxis only - but nobody's missed it.

I used ketamine and versed for a short MAC case a couple months ago. This old lady was totally whacked out from 40mg of ketamine despite getting 5mg of versed. I've never had anyone react that poorly to ketamine before.

[ethernaut]

i've been fortunate to not see a propofol shortage. however, it seems our diprivan is being replaced with generic. we don't have pentothal anymore, and we don't carry methohexital on formulary. we also have the fortune of choice among remifentanil and precedex if/when needed. as for the narcan shortage? well, i suppose treat autonomics with beta blockers intraoperatively, and give opioids in PACU.

[bettermj]

MACs I've used combo of Versed/Demerol with some Fent on standby.

[ethernaut]

MACs I've used combo of Versed/Demerol with some Fent on standby.

demerol? wouldn't be my first six choices or so, but eh.. to each their own.

[Anthony]

Pentathol? Bueller ? Bueller? Anyone?

[Anthony]

Also, anyone running N20 via NC? Works like a charm... just use the circuit adapter or ask your dentist how to do it