The last year and a half has seen more significant drug shortages than the last 30 years, says Meena Desai, MD, managing partner for Nova Anesthesia Professionals. The shortages have affected anesthesia and chemotherapy drugs most severely, creating problems for ambulatory surgery centers that rely on certain anesthetics to put patients to sleep and wake them up safely. Dr. Desai discusses seven ways drug shortages are affecting surgery centers — and offers some best practices for what anesthesiologists and ASCs can do in response.
1. Many drugs in short supply do not have viable substitutes. While some scarce drugs can be replaced with generic alternatives or a combination of drugs, Dr. Desai says certain drugs simply do not have substitutes. For example, surgery center anesthesiologists commonly use Atropine as a pre-medication for anesthesia in order to decrease bronchial and salivary secretions and emergently to prevent and counteract bradycardia associated with surgery.
Atropine is currently listed on the FDA shortage list, causing problems for surgery centers since there really is no viable alternative. "There are several drugs on the list for which there are no substitutes — or bad substitutes," Dr. Desai says. If surgery centers are left without a crucial drug, they may have to cancel or reschedule cases until they can find a new supplier.
2. Multi-dose vials may be needed in the absence of single-use vials. When one manufacturer announces a drug shortage, the demand for other manufacturers increases, Dr. Desai says. If the remaining manufacturers cannot or will not produce enough of the drug to handle the shortage, drugs are rationed in ways that endanger patient safety or profitability.
For example, a surgery center that was purchasing a drug in a single-dose vial to prevent contamination may no longer have access to single-dose vials. If the surgery center purchases multi-dose vials instead, they must now throw away and waste the remaining drug if all of it is not used with a single patient. "You have to take what you get, and you're still supposed to follow all the infection protocols," she says.
3. Medication errors are more likely. Dr. Desai says different distributors produce vials of different sizes and colors. When your operating room staff members is used to using a certain size and color of vial for a particular drug, they may reach for that vial without thinking about it or reading the label. When you suddenly have to switch drugs because of a shortage, medication errors are more likely. "When you multiply the increased likelihood for error with the number of drugs this is happening too, it makes errors much more likely," Dr. Desai says.
Make sure staff members are aware of drug changes before surgery takes place. Hold meetings to discuss any medication changes and point out drugs that look similar or different than the ones they have replaced.
4. Patient side effects will likely differ. Side effects differ from drug to drug, and patients who have visited your surgery center before will probably notice if you switch them to a completely different drug for anesthesia. Dr. Desai says during the propofol shortage, surgery centers were forced to replace propofol with Brevital. "The use of Brevital had different limitations because the wakeup profile was different and the patient was left feeling [groggier]," she says. "Patients did not feel street-ready, even though they were stable for discharge. The nausea profile also increased with the use of the substitute."
Dr. Desai says Labetalol, a drug commonly used to control blood pressure and heart rate, is currently in short supply. "It was the perfect drug because it was the right dosing with fewer side effects, and we could monitor it easily and everybody knew what to do with it," she says. Now that Labetalol is scarce, providers have to combine two drugs — one to control heart rate and another to control blood pressure. The two drugs have different half-lives and different onset rates, which changes the rapidity and reliability at which the drug works.
5. Multiple suppliers will be necessary to tackle shortages. Dr. Desai recommends surgery centers keep multiple suppliers on hand in case of shortages. "That means some of them will be higher-costing, so you may not be able to just use your buying group," she says. She recommends setting up contracts with suppliers ahead of time, since contracts may take some time to get into place. Setting up relationships with alternate suppliers now can be very helpful if your main supplier announces a drug shortage in a key area.
6. Surgery centers must maintain higher par levels. While she does not recommend surgery centers "hoard" scarce drugs, Dr. Desai says surgery centers should maintain higher par levels. In some cases, surgery centers may have to stop using a particular drug as they normally would because of its scarcity.
For example, she says lidocaine cannot be purchased easily anymore. Surgery centers often use lidocaine to decrease irritation and burning at the injection site during a propofol injection to help prevent the patient from experiencing stinging or burning. If lidocaine is in short supply, the surgery center may have to stop using lidocaine to prevent stinging and burning and reserve it for more crucial uses, such as the treatment of arrhythmia and the use of the drug in ACLS algorithms.
7. Anesthesiologists must decide how to substitute for scarce drugs. Surgery centers should assign an anesthesiologist to head decisions about drug shortages and determine how substitutions can be made, Dr. Desai says. "These aren't the kinds of things you want to discover after the problem has already happened and the drug is not available to you at all," she says. "The rescue is so much harder." She says the lead anesthesiologist should keep up with the FDA list of current drug shortages and use that information to plan ahead.
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1. Many drugs in short supply do not have viable substitutes. While some scarce drugs can be replaced with generic alternatives or a combination of drugs, Dr. Desai says certain drugs simply do not have substitutes. For example, surgery center anesthesiologists commonly use Atropine as a pre-medication for anesthesia in order to decrease bronchial and salivary secretions and emergently to prevent and counteract bradycardia associated with surgery.
Atropine is currently listed on the FDA shortage list, causing problems for surgery centers since there really is no viable alternative. "There are several drugs on the list for which there are no substitutes — or bad substitutes," Dr. Desai says. If surgery centers are left without a crucial drug, they may have to cancel or reschedule cases until they can find a new supplier.
2. Multi-dose vials may be needed in the absence of single-use vials. When one manufacturer announces a drug shortage, the demand for other manufacturers increases, Dr. Desai says. If the remaining manufacturers cannot or will not produce enough of the drug to handle the shortage, drugs are rationed in ways that endanger patient safety or profitability.
For example, a surgery center that was purchasing a drug in a single-dose vial to prevent contamination may no longer have access to single-dose vials. If the surgery center purchases multi-dose vials instead, they must now throw away and waste the remaining drug if all of it is not used with a single patient. "You have to take what you get, and you're still supposed to follow all the infection protocols," she says.
3. Medication errors are more likely. Dr. Desai says different distributors produce vials of different sizes and colors. When your operating room staff members is used to using a certain size and color of vial for a particular drug, they may reach for that vial without thinking about it or reading the label. When you suddenly have to switch drugs because of a shortage, medication errors are more likely. "When you multiply the increased likelihood for error with the number of drugs this is happening too, it makes errors much more likely," Dr. Desai says.
Make sure staff members are aware of drug changes before surgery takes place. Hold meetings to discuss any medication changes and point out drugs that look similar or different than the ones they have replaced.
4. Patient side effects will likely differ. Side effects differ from drug to drug, and patients who have visited your surgery center before will probably notice if you switch them to a completely different drug for anesthesia. Dr. Desai says during the propofol shortage, surgery centers were forced to replace propofol with Brevital. "The use of Brevital had different limitations because the wakeup profile was different and the patient was left feeling [groggier]," she says. "Patients did not feel street-ready, even though they were stable for discharge. The nausea profile also increased with the use of the substitute."
Dr. Desai says Labetalol, a drug commonly used to control blood pressure and heart rate, is currently in short supply. "It was the perfect drug because it was the right dosing with fewer side effects, and we could monitor it easily and everybody knew what to do with it," she says. Now that Labetalol is scarce, providers have to combine two drugs — one to control heart rate and another to control blood pressure. The two drugs have different half-lives and different onset rates, which changes the rapidity and reliability at which the drug works.
5. Multiple suppliers will be necessary to tackle shortages. Dr. Desai recommends surgery centers keep multiple suppliers on hand in case of shortages. "That means some of them will be higher-costing, so you may not be able to just use your buying group," she says. She recommends setting up contracts with suppliers ahead of time, since contracts may take some time to get into place. Setting up relationships with alternate suppliers now can be very helpful if your main supplier announces a drug shortage in a key area.
6. Surgery centers must maintain higher par levels. While she does not recommend surgery centers "hoard" scarce drugs, Dr. Desai says surgery centers should maintain higher par levels. In some cases, surgery centers may have to stop using a particular drug as they normally would because of its scarcity.
For example, she says lidocaine cannot be purchased easily anymore. Surgery centers often use lidocaine to decrease irritation and burning at the injection site during a propofol injection to help prevent the patient from experiencing stinging or burning. If lidocaine is in short supply, the surgery center may have to stop using lidocaine to prevent stinging and burning and reserve it for more crucial uses, such as the treatment of arrhythmia and the use of the drug in ACLS algorithms.
7. Anesthesiologists must decide how to substitute for scarce drugs. Surgery centers should assign an anesthesiologist to head decisions about drug shortages and determine how substitutions can be made, Dr. Desai says. "These aren't the kinds of things you want to discover after the problem has already happened and the drug is not available to you at all," she says. "The rescue is so much harder." She says the lead anesthesiologist should keep up with the FDA list of current drug shortages and use that information to plan ahead.
Related Articles on Anesthesia:
Ultrasound for Regional Anesthesia Does Not Improve Pain Outcomes
Anesthesiologists Recommend Dim Green Light for Overly Dark Operating Rooms