Drug Shortages

We have shortages of atropine and fentanyl right now.... at least the sizes and concentrations that we normally stock in our ORs...

Our pharmacy has been dividing large vials into small aliquots...
Apparently 50 ml vials of fentanyl into 2 ml aliquots....

no words on midazolam shortage but I hardly use it.. I find that propofol works much better

drccw

btbam said:

Our pharmacist said we have an extreme shortage of fentanyl and versed with no supply arriving in the near future...what's a good alternative to versed, haldol? She said she can't get ativan. How are you guys dealing with these seemingly random shortages?

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Don't y'all have Valium?

Just don't use versed. I don't use it unless I'm doing a block or a mac case

Yeah, saw the fentanyl shortage. So let me ask. If I have a day with 8 knee scopes that need to be done by 2pm, I like using about 25-100mcq of fentanyl as I always have the patient breathing spontaneously with the LMA. Have you guys used morphine for LMA cases and what would be the equivalent. I like fentanyl as it is short acting in smaller doses. What about dilaudid, can that work.

Basically, on days I really need to move, I really can't be using a narcotic that prevents the patient breathing spontaneously at it slows down the or.

Ketamine is a great analgesic that doesn't depress the respiratory drive. I recently used Precedex on a sedation case it worked great too, definitely plan on using it in more sedation cases.

I think these drug shortages although a pain in the butt for those out of residency is great for residents. At my program we had an astromorph shortage so we did combined spinal epidurals on our c-section patients. if it wasn't for this shortage I wouldn't have done as many CSE's as I have.

I agree that it's a great learning tool in residency as long as you're flexible. (I had an attending tell me he once did a day only using drugs that started with the letter M. )

My hospital has been short on fentanyl, versed and rocuronium with varying propofol blackouts. Our VA was out of propofol for nearly a year... so more morphine, ketamine, intranasal clonidine.... (peds)

I'm spending a month at a private women's hospital with a huge OB service, and they're running out of pitocin! I'm not quite sure what they'll do if they exhaust the current supply.

lord_jeebus said:

I'm spending a month at a private women's hospital with a huge OB service, and they're running out of pitocin! I'm not quite sure what they'll do if they exhaust the current supply.

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That will suck for you. Limited pit means saving it for the OR for C/s, longer labor, and probably more c/s for failure to progress. Something tells me they'll find some.

I'm at a hospital I haven't been to in a while, and I'm in the room and I find out there's no toradol, zofran, etomidate. WTF? I could use droperidol (which ive never used and saw in a back closet in the workroom and IV acetaminophen, which isn't the greatest for spasmodic pain) but oh we'll. What's the incentive or dis-incentive to not have these drugs available? For the veterans out there, has there ever been shortages like this in the past?

Sure, just give dilaudid 0.5 mg up front, induce with propofol, and titrate to resp. rate.

For cases involving an endotracheal tube, I like giving about 1 mg/kg of esmolol instead of fentanyl to blunt the sympathetic response to intubation. Can use more esmolol during the case and then titrate in dilaudid at the end.

Our surgicenter is short on almost everything, but the hospital is doing OK.

cincincyreds said:

Yeah, saw the fentanyl shortage. So let me ask. If I have a day with 8 knee scopes that need to be done by 2pm, I like using about 25-100mcq of fentanyl as I always have the patient breathing spontaneously with the LMA. Have you guys used morphine for LMA cases and what would be the equivalent. I like fentanyl as it is short acting in smaller doses. What about dilaudid, can that work.

Basically, on days I really need to move, I really can't be using a narcotic that prevents the patient breathing spontaneously at it slows down the or.

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Out of reglan, zantac- So, RSI now is zofran and bicitra and pray...

btbam said:

Our pharmacist said we have an extreme shortage of fentanyl and versed with no supply arriving in the near future...what's a good alternative to versed, haldol? She said she can't get ativan. How are you guys dealing with these seemingly random shortages?

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So it is a tradition here to try to get people to disclose their true training. Not so we can berate them but more so we know how to respond and in what detail.

So I gotta ask you, are you a nurse? AA?

If this has already been addressed, I appologize but I missed it.

I have found versed to be hugely overused and overrated by virtue of drug shortages. Life is better without it and there is less chasing blood pressure due to polypharmacy. I have seen benedryl used as a poor man's versed in preop...

I did most of my training without access to Sux except in RSI cases.

I did a lot of etomidate inductions during the propofol shortage and got used to its effects.

Zofran is currently in short supply where I work, so it is saved for the PACU. I have used anzemet a few times as a result.

I love the fact that we have so many tools. I take the approach that shortages are just there to keep you on your toes and familiar with alternative approaches.

I routinely make the residents do cases without midazolam and fentanyl. A few mL of propofol in pre-op to sedate the patient for transport works perfectly. Admittedly, the duration is too short for blocks, lines, etc., so periodic redoses are often needed. With regard to the poster who wants spontaneously ventilating patients with LMAs without fentanyl, I can't recall ever making someone apneic with morphine or hydromorphone (but I've seen it with as little as 100 mcg of fentanyl).

You'd be fine to give a few mg morphine or 0.5 or so of hydromorphone with induction and titrate from there. Personally, I don't give opiates routinely during induction anyway, so if it were me, I'd induce, place LMA, and THEN start titrating the hydromorphone, since they're already spontaneously ventilating shortly after LMA placement.

We were out of propofol for awhile, as well, and used lots of etomidate (mayb-i-date, as I liked to call it) combined with sevoflurane. Seemed to work okay, albeit slowly. And since vets don't puke, we didn't have a lot of fallout. 0.2 mg/kg seemed like an underdose, most of the time, though.

Noyac said:

So I gotta ask you, are you a nurse? AA?

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BTBAM is an AA

MRW said:

BTBAM is an AA

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Thanks

We're short Zofran, sort of, just 20 mL multidose vials.

For a while all we had were 15 mg vials of Toradol.

Used a lot of methohexital during the propofol shortage. Lots and lots of patient movement, had to give muscle relaxant most of the time for LMAs.

pgg said:

We're short Zofran, sort of, just 20 mL multidose vials.

For a while all we had were 15 mg vials of Toradol.

Used a lot of methohexital during the propofol shortage. Lots and lots of patient movement, had to give muscle relaxant most of the time for LMAs.

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Why not mask with 8% sevo after IV induction for a couple minutes before placing the LMA.
Mask induction... It's not just for Peds anymore.

Op,
Tell us why you think Haldol might be a good replacement for versed.

Also, if you could get Ativan, would you use that?

What exactly are you using (being told to use) versed for?

I'm starting to keep a running tally of substitutions I've done in the past couple years with all the random shortages.

remifentanil --> sufentanil

propofol --> propofol (somehow we never ran out for real - hah!)

vecuronium --> rocuronium

rocuronium --> vecuronium

fentanyl --> whatever else is lying around

pink tape --> silk tape for ETT (I've never gone back to pink tape since)

cisatracurium --> atracurium (don't ask)

IV metoprolol --> IV metoprolol (it magically appears if you stamp your feet)

IV Ativan --> PO

epinephrine --> thank goodness there weren't enough codes to run out completely

Levophed --> various stupid combinations of phenylephrine, dopamine or dobutamine

and the list goes on.

edelweiss said:

I'm starting to keep a running tally of substitutions I've done in the past couple years with all the random shortages.

remifentanil --> sufentanil

propofol --> propofol (somehow we never ran out for real - hah!)

vecuronium --> rocuronium

rocuronium --> vecuronium

fentanyl --> whatever else is lying around

pink tape --> silk tape for ETT (I've never gone back to pink tape since)

cisatracurium --> atracurium (don't ask)

IV metoprolol --> IV metoprolol (it magically appears if you stamp your feet)

IV Ativan --> PO

epinephrine --> thank goodness there weren't enough codes to run out completely

Levophed --> various stupid combinations of phenylephrine, dopamine or dobutamine

and the list goes on.

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When it comes the the epi shortage remember tht the spinal tray have epi in them. We started keeping the vials every time we placed a spinal and didn't crack the vial. We now have enough epi to staff a MASH unit.

btbam said:

Our pharmacist said we have an extreme shortage of fentanyl and versed with no supply arriving in the near future...what's a good alternative to versed, haldol? She said she can't get ativan. How are you guys dealing with these seemingly random shortages?

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Out of PF morphine, so now the c/section spinals get 100 mics of dilaudid added. The individual dilaudid vials do not indicate PF, but their large shipping box does say PF (verified with pharmacist).

We were out of 20 ml vials of propofol, so the pharmacy started drawing up 20 ml syringes of it from 100 ml vials under their hood, and shrink-wrapping each individual syringe. They were supposedly good in the refrig for 2 weeks, or for 8 hours after being removed from the refrig. I can't count the number of times I went into a room at 0630 and found an unwrapped syringe left in there from (when? yesterday? middle of the night? last week?), with no idea if it had passed it's expiration hour. Lots of syringes got tossed as a result.

Noyac said:

Op,
Tell us why you think Haldol might be a good replacement for versed.

Also, if you could get Ativan, would you use that?

What exactly are you using (being told to use) versed for?

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btbam said:

Disclose their true training? I don't even know what that means. We had/have drug shortages, I asked what people were using as replacement drugs. Sometimes a cigar is just a cigar dude.

I'm not "being told" to use versed for anything. I am capable of independent thought

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Sure you are.

Keep it up.

You have no idea what kind of impact your comments and behavior on this site can can make.

btbam said:

Do you honestly believe my attending tells me how much versed to give to patients and the specific "reason" for it every morning?

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So in your " independent thinking" you came up with Haldol as a substitute for versed?

Sorry dude.... you had that coming from the start of this thread.

Haldol....? Really?

btbam said:

Our pharmacist said we have an extreme shortage of fentanyl and versed with no supply arriving in the near future...what's a good alternative to versed, haldol? She said she can't get ativan. How are you guys dealing with these seemingly random shortages?

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I’ll be more diplomatic. Sorry.

If you want anxiolysis there are better agents:

Precedex, propofol, diazepam (met. to oxazepam... just make sure your IV is working and understand it’s phamacokinetics/dynamics), along with you’re other narcotics... which will also cause anxiolysis. Versed, as others have stated, is overused and is more “cook book” than anything. I use it pre-op in the very anxious. Don't use ketamine...

btbam said:

I rotated at a hospital that gave virtually everyone Haldol in preop. Did I say that was a smart thing to do? No I didn't, but you're crazy if you think I am forced to consult my attending for every "independent" decision.

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you asked for a "good" alternative. That sure sounds like you think it could be one to me. And if that is what you think independently, then I have made my point as to why you should not be thinking independently.

I would think that if you saw this practice in the past you would understand why it is a poor choice in today's environment. Unless you were working in a psych hospital.

Keep digging!

Dude, you are an AA. You are there to be an extension of the doctor, right? If this is a problem, then may I suggest another line of work. That's not to say as an AA you aren't allowed to think for yourself. I never said that. Look at JWK, that guy can join my group whenever he wants to. I'd be happy to work with him. You on the other hand still have some things to learn.

btbam said:

I think it's easy to twist words and project a distorted image on an internet message board. You seem to have it out for me for reasons I don't understand.

I am a very easy going person IRL. My attendings and fellow anesthetists like me, and I have zero problem taking orders from attendings. It's degrading to me as a human being for you to think I am incapable of independent thought, anesthesia aside. I come on here to learn like everyone else. If you want to turn posts into personal attacks, how do you expect me to respond?

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Am I twisting your words? Let's see, you told me to "Feel free to blow your load in the Martin thread along with everyone else.".

btbam said:

I rotated at a hospital that gave virtually everyone Haldol in preop. Did I say that was a smart thing to do? No I didn't, but you're crazy if you think I am forced to consult my attending for every "independent" decision.

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If you haven't realized it by now, using Haldol pre-op is not the norm. If you rotate back there or know any one working there, it'd probably be worth asking why they do it that way.

Some places start at-risk patients on scheduled haldol post-op for delirium prevention, but I haven't read anything about starting it in pre-op.

The only benefit I can think of is that it would cut down on the amount of pre-op conversation...

WholeLottaGame7 said:

If you haven't realized it by now, using Haldol pre-op is not the norm. If you rotate back there or know any one working there, it'd probably be worth asking why they do it that way.

Some places start at-risk patients on scheduled haldol post-op for delirium prevention, but I haven't read anything about starting it in pre-op.

The only benefit I can think of is that it would cut down on the amount of pre-op conversation...

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I think it's more that our friend didn't understand why it was being given. Maybe they were out of zofran and Droperidol was unavailable to them so they attempted to ward off PONV with some pre-op Haldol. Or maybe they were doing just as you said, trying to prevent the delirium in their older population and our friend misunderstood the use. Either way, I'm sure they are not still doing it.

To play debil's advocate, there are decent data for haloperidol to prevent ponv...

btbam, you need to be a bit less defensive. That's all I'll say about comments in this thread...

But just remember this is the student DOCTOR forums, and WE are guests here. I think it stands to reason that you should show maybe a bit more respect for everyone here, for you sake, and for our profession.

Just sayin'....

Sure it does, but sometimes it has to be earned.

btbam said:

I am not disagreeing with you, but to me respect goes both ways. I am trying to stay on topic and keep the discussions relevant at this point.

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You claim respect goes both ways.
Please refer to post #35.

Irony here, as you were arguing with me earlier today I got an email that my state has put the AA bill on hold. Funny how these things work. I couldn't have been happier at that moment. I'm not saying that I no longer support AAs in my state but you have really got me thinking as to whether it is a good idea or not.

btbam said:

I'm sorry you feel that way. If you'd like to continue wasting posts to target me, feel free to message me privately.

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Public disagreements are the norm on this forum.

btbam said:

I'm sorry you feel that way. If you'd like to continue wasting posts to target me, feel free to message me privately.

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I see that you are making a halfhearted attempt to end this slaughter but your not making any headway. You still slide in a quick jab because your personality can't help it. These are not wasted posts because if other anesthesiologist find themselves in the position to decide if their group should hire an AA instead of a nurse because the AA's are supposed to be easier to work with, then they now may have more information with which to help make that decision.

So I prefer to keep this public so that others can learn from you.

btbam said:

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What's that supposed to mean?

FWIW, I've presonally sat across the table with Noy and have had long conversations about the use of AA's. We both support AA's. I would not continue this conversation if I was you.