Hyperbaric bupivicaine shortage

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parcus said:
A low dose of plain or hyperbaric bupivacaine for unilateral spinal anesthesia. - PubMed - NCBI and https://pdfs.semanticscholar.org/ec44/94cac15d46159b2c674c668f2ff8d5c368c8.pdf . But I agree, it doesn't seem very practical at all, maybe one could use this for a surgery in lateral decubitus. Frankly, it would be much better to use hypobaric than rely on that if that is your goal.
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Wow. That has to be one of the worst anesthetic choices I've ever seen studied. Who thought of that?!? Only read the abstract, but i assume they had operative side up for the isobaric? It's unclear from the abstract.

Outpt knee scope. Place a spinal that'll last 2 hrs, and then on top of that wait 20 minutes for it to set?!?

In PP, some of the guys I work with do a scope in 15 minutes. If I tried this, I'd be out of a job by the end of the day.
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Gas said:
We are also running low on hyperbaric. We have 0.5% bupiv, 1.5% and 2% mepiv, and hospital is getting us 0.75% bupiv in separate vials so we have options. The 0.75% they are ordering does not have dextrose in it, so wondering how I dose that for C Sections or total joints?
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the mg dose is the same
 
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Gas said:
We are also running low on hyperbaric. We have 0.5% bupiv, 1.5% and 2% mepiv, and hospital is getting us 0.75% bupiv in separate vials so we have options. The 0.75% they are ordering does not have dextrose in it, so wondering how I dose that for C Sections or total joints?
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12mg 0.75% bupivicaine (1.6cc) then add dextrose to make 2cc total. You want about 0.1-0.15g dextrose total. Someone check my math here.
 
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Most of the data suggests that 10mg/ml up to 50 mg/ml of dextrose added to the local will make the block hyperbaric. Typically, total doses of 50 mg-100 mg of dextrose are added to the isobaric solution.
 
PGG posted in 2009 that he typically mixed the Dextrose in a 1:1 mixture with the tetracaine. This would work with Isobaric Bup as well:

2.5 mls of 0.5% Bup mixed with 2.5 mls of Dextrose (8% or 10% dextrose) results in a hyperbaric mixture in the 4-5% range. This has been studied and works quite well.
 
BLADEMDA said:
PGG posted in 2009 that he typically mixed the Dextrose in a 1:1 mixture with the tetracaine. This would work with Isobaric Bup as well:

2.5 mls of 0.5% Bup mixed with 2.5 mls of Dextrose (8% or 10% dextrose) results in a hyperbaric mixture in the 4-5% range. This has been studied and works quite well.
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I guess it doesn't matter that your bupi would be 0.25% since the amount is the same
 
BLADEMDA said:
2.5 mls of 0.5% Bup mixed with 2.5 mls of Dextrose (8% or 10% dextrose) results in a hyperbaric mixture in the 4-5% range. This has been studied and works quite well.
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I don’t think our hospital has vitals of dextrose. Where would you pull this from...a bag of D10W? I’m assuming the amps of 50% dextrose we use for treating hypoglycemia have preservatives in them that you wouldn’t want to inject intrathecally!
 
Whatever is used for spinal blocks should be preservative free- most vials of bupivacaine contain methylparaben or sodium metabisulfite. There are PF vials manufactured, but are currently on back order from the manufacturer. D10W and D50W generally contain no preservatives.
Just FYI- our spinal trays containing vials of hyperbaric bupivacaine have resulted in a recent large number of failed spinal blocks by many of our anesthesiologists despite good CSF flow from the needles- we have switched to external vials of hyperbaric bupivacaine and the spinal blocks are now working just fine.
 
algosdoc said:
Whatever is used for spinal blocks should be preservative free- most vials of bupivacaine contain methylparaben or sodium metabisulfite. There are PF vials manufactured, but are currently on back order from the manufacturer. D10W and D50W generally contain no preservatives.
Just FYI- our spinal trays containing vials of hyperbaric bupivacaine have resulted in a recent large number of failed spinal blocks by many of our anesthesiologists despite good CSF flow from the needles- we have switched to external vials of hyperbaric bupivacaine and the spinal blocks are now working just fine.
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So what are you planning to use when you guys run out of hyperbaric bupi?
 
We can get tetracaine, but not tetracaine powder. Another alternative would be meperidine PF for the short cases
 
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okayplayer said:
I believe algosdoc was saying that he/she doesn’t use isobaric bupi because of the preservatives it contains? I may have misunderstood.
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Ah ok. Missed that. FYI, isobaric spinals is certainly standard of care and used all over the world with plenty of data behind it. There's absolutely zero legal risk for using it.

Edit: read again and noticed the concern is the preservatives. That, I agree, should not be used for spinals. But PF isobaric bupi is just fine
 
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algosdoc said:
Whatever is used for spinal blocks should be preservative free- most vials of bupivacaine contain methylparaben or sodium metabisulfite. There are PF vials manufactured, but are currently on back order from the manufacturer. D10W and D50W generally contain no preservatives.
Just FYI- our spinal trays containing vials of hyperbaric bupivacaine have resulted in a recent large number of failed spinal blocks by many of our anesthesiologists despite good CSF flow from the needles- we have switched to external vials of hyperbaric bupivacaine and the spinal blocks are now working just fine.
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This happened in the past in an old thread and I believe they attributed it to the transport. I think the kits came in nonrefrigerated trucks which made the difference.
 
Anyone using ropivacaine for intrathecal injections? It is preservative free and has an offset about 20 min faster than bupivacaine
 
algosdoc said:
Whatever is used for spinal blocks should be preservative free- most vials of bupivacaine contain methylparaben or sodium metabisulfite. There are PF vials manufactured, but are currently on back order from the manufacturer. D10W and D50W generally contain no preservatives.
Just FYI- our spinal trays containing vials of hyperbaric bupivacaine have resulted in a recent large number of failed spinal blocks by many of our anesthesiologists despite good CSF flow from the needles- we have switched to external vials of hyperbaric bupivacaine and the spinal blocks are now working just fine.
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Same problem with bupi from the kit at my institution.
 
BLADEMDA said:
You only need a little dextrose to make the solution hyperbaric. 4% Hyperbaric is sufficient:

The influence of baricity on the haemodynamic effects of intrathecal bupivacaine 0.5%
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We are stocking all of our Pyxis machines with 0.5% bupivacaine 30cc vials, 0.75% bupivacaine 10cc vials, as well as D50 50cc vials. All are preservative free of course. This way people can use 0.5%, or make their own hyperbaric 0.75% by adding some dextrose.

For example, if you add 1cc of the D50 (500 mg dextrose/cc) to the 10 cc of 0.75% bupivacaine, this results in 0.68% bupivacaine with 4.5% dextrose. You can then use this solution for your spinal - 1.4cc, 1.6cc, 1.8cc, or whatever. It's not exactly what was in the spinal kit, but I'm wondering if this is a good compromise. What do you guys think?
 
dr doze said:
The preservative free are labeled "Not For Spinal Anesthesia". I would say that I have no medical concerns about using it. I wouldn't say that I have no medicolwegal concerns about using it.
It would be nice if the ASA and/or SOAP would take an official editorial position that there is no risk using these meds that are labeled as "Not for Spinal Anesthesia" in spinal anesthetics and being used this way was within the standard of care to allay fears of patients and practitioners out there. I can guarantee you that there will be patients who will be upset if they find out that a drug labeled this way was used for their spinal. They now have reason to "look for complications" and a plaintiff lawyer will blow up a picture of the bottle highlighting the big letters "Not for Spinal Anesthesia" for a jury.
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Haha I feel you. I hate having to explain to my crna why its okay to use it despite that damn label every time. I love isobaric bupiv for hip surgery. Less hypotension. Longer duration.
 
Dr.whom said:
Haha I feel you. I hate having to explain to my crna why its okay to use it despite that damn label every time. I love isobaric bupiv for hip surgery. Less hypotension. Longer duration.
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I agree. But I abandoned the technique many years ago because of medicolegal concerns. Might pick it up again. WOULD LOVE SOME COVER FROM OUR PROFESSIONAL SOCIETIES.
 
Isobaric bupivacaine in spinals is standard of care across the world, with a RIDICULOUS amount of literature supporting it's use. If you can't find an attorney who can prove that in court, get yourself another attorney.

I'd also love to hear of any lawsuit filled over that. If your find one, please post it here.
 
dr doze said:
The preservative free are labeled "Not For Spinal Anesthesia". I would say that I have no medical concerns about using it. I wouldn't say that I have no medicolwegal concerns about using it.
It would be nice if the ASA and/or SOAP would take an official editorial position that there is no risk using these meds that are labeled as "Not for Spinal Anesthesia" in spinal anesthetics and being used this way was within the standard of care to allay fears of patients and practitioners out there. I can guarantee you that there will be patients who will be upset if they find out that a drug labeled this way was used for their spinal. They now have reason to "look for complications" and a plaintiff lawyer will blow up a picture of the bottle highlighting the big letters "Not for Spinal Anesthesia" for a jury.
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You do understand it is labeled that way only because of the volume size of the vial it is packaged in?
 
I understand completely. I also fear having to explain it to hostile patients and jurors.
 
dr doze said:
The preservative free are labeled "Not For Spinal Anesthesia". I would say that I have no medical concerns about using it. I wouldn't say that I have no medicolwegal concerns about using it.
It would be nice if the ASA and/or SOAP would take an official editorial position that there is no risk using these meds that are labeled as "Not for Spinal Anesthesia" in spinal anesthetics and being used this way was within the standard of care to allay fears of patients and practitioners out there. I can guarantee you that there will be patients who will be upset if they find out that a drug labeled this way was used for their spinal. They now have reason to "look for complications" and a plaintiff lawyer will blow up a picture of the bottle highlighting the big letters "Not for Spinal Anesthesia" for a jury.
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From SOAP

https://soap.org/2018-bupivacaine-shortage-statement.pdf


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Beach bum said:
So after investigating we are finding out the 0.5% Bupivacaine that re labeled "not for spinal use" has sulfites in it even though they are labeled "preservative free".
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Where did you hear this from? I've literally done at least 2 or 3k spinals with "not for spinal" 0.5% bupi... Knock on wood, never had an issue.
 
I'd like to see a package insert or something direct from the manufacturer documenting the preservative they're putting in their preservative-free bupivacaine. Or at least whatever it was that led this pharmacist to say it's in there.
 
pgg said:
I'd like to see a package insert or something direct from the manufacturer documenting the preservative they're putting in their preservative-free bupivacaine. Or at least whatever it was that led this pharmacist to say it's in there.
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So it is Hospira brand and she is, again confirming that it says that on the package insert.
 
Your pharmacist is reading the wrong package insert.

Hospira's bupivacaine with epinephrine formulations ("Marcaine E") contain metabisulfite, among other things.

Their plain bupivacaine formulations ("Marcaine" and "Marcaine Spinal") do not.

Here's the package insert: https://www.hospira.ca/en/images/Marcaine Insert English_tcm87-97645.pdf

Hospira package insert said:
What the medicinal ingredients are:
Bupivacaine hydrochloride.
Bupivacaine hydrochloride with epinephrine.

What the non-medicinal ingredients are:
MARCAINE contains sodium chloride, sodium hydroxide and/or hydrochloric acid and water for injection. Multidose vials contain methylparaben as a preservative.

MARCAINE E contains sodium chloride, sodium hydroxide and/or hydrochloric acid, monothioglycerol, ascorbic acid, sodium lactate 60% solution, edetate calcium disodium, sodium metabisulfite and water for injection.

MARCAINE SPINAL contains dextrose, sodium hydroxide and/or hydrochloride acid and water for injection
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Also: http://labeling.pfizer.com/ShowLabeling.aspx?id=4372
 
algosdoc said:
We can get tetracaine, but not tetracaine powder. Another alternative would be meperidine PF for the short cases
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Does anyone have experience with this? I remember in my readings that in addition to the well-known narcotic effect, merperidine has LA properties as well, and I always wondered why it wasn't used, especially given the hyperbaric bupiv shortage.

With regards to the isobaric I've heard somewhere it may not be a bad idea to rotate the spinal needle 45 degrees so the LA doesn't shoot up create a current a travel even higher, thoughts?
 
0kazak1 said:
with regards to the isobaric I've heard somewhere it may not be a bad idea to rotate the spinal needle 45 degrees so the LA doesn't shoot up create a current a travel even higher, thoughts?
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I've done A LOT of iso spinals. I have no idea what direction the needle is pointing when I inject. Needle orientation barely affects spinal height if at all. Check out NYSORA's article on spinals which is great.
 
FFP said:
He's confusing it with bupi with epi, which does not mention preservative-free.

It speaks volumes about how incompetent some pharmacists are.
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Pharmacists are extraordinarily rigid, as a rule. It's the way they're trained. They exist to catch prescribing errors and to advise physicians, not make risk/benefit decisions.

They view the things we do every day with horror. Squirting concentrated vasopressors into an ordinary IV bag to make drips (not even in a sterile fume hood!!!!) freaks them out. Dividing a single dose vial of whatever into 2 or 3 syringes at the start of the day for use with multiple patients is reckless criminal behavior. If I want a drug that I'm going to titrate to effect, they still need the written order to include a starting dose and titration parameters. It's a totally different culture. And given the kind of errors that can be made when they deal directly with patients or through a ward nurse intermediary ... I can understand it.

I would never expect a pharmacist to say it's OK to use the "Not For Spinal Use" labeled 0.5% bupivacaine for a spinal. And I wouldn't expect them to know or care that we're using Wrong Vial #1 (bupiv 0.5%) instead of Wrong Vial #2 (bupiv 0.5% with epi) in our stupidly ill-advised and reckless spinal. They probably think we're ******ed cowboys.
 
pgg said:
Pharmacists are extraordinarily rigid, as a rule. It's the way they're trained. They exist to catch prescribing errors and to advise physicians, not make risk/benefit decisions.

They view the things we do every day with horror. Squirting concentrated vasopressors into an ordinary IV bag to make drips (not even in a sterile fume hood!!!!) freaks them out. Dividing a single dose vial of whatever into 2 or 3 syringes at the start of the day for use with multiple patients is reckless criminal behavior. If I want a drug that I'm going to titrate to effect, they still need the written order to include a starting dose and titration parameters. It's a totally different culture. And given the kind of errors that can be made when they deal directly with patients or through a ward nurse intermediary ... I can understand it.

I would never expect a pharmacist to say it's OK to use the "Not For Spinal Use" labeled 0.5% bupivacaine for a spinal. And I wouldn't expect them to know or care that we're using Wrong Vial #1 (bupiv 0.5%) instead of Wrong Vial #2 (bupiv 0.5% with epi) in our stupidly ill-advised and reckless spinal. They probably think we're ******ed cowboys.
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Pharmacists have two main roles in my activity: advisory and safety.

In the first role, they should be the go-to resource about medications, especially basic stuff that's in package inserts. I am not asking for their approval or blessing, just correct information and possibly opinion. I respect much more people who have the balls to say "I don't know, let me look it up for you".

In the second role, they are supposed to prevent medication errors. Again, they are not there to approve or prevent my medication use, unless it's proven harmful or there is a hospital policy that doesn't allow it. Their role is to question unusual orders, especially from non-attendings, to make sure that there is reason behind the apparent madness. But their role is not to practice medicine, by restricting/directing how I treat patients. They don't get to say: you cannot give medication X for disease Y, or you cannot give that dose etc., unless there is a clear policy that restricts me (e.g. requiring ID approval for certain antibiotics), or they are 100% sure I am making a medication error (e.g. giving grams instead of micrograms). And they cannot be good at safety it they suck at advising (i.e. knowledge).
 
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I didn't mean to imply we need permission from the pharmacists. Just that if we ask them for advice, the only answer they can give is one grounded in their own training and standards.

Just like ER doctors don't need our permission to "sedate" full stomach patients with induction size doses of etomidate. But if they ask us for advice, the only answer we can give is one grounded in our own standard of care.

These aren't knowledge deficits, per se.

Now, Beach bum et al asked this pharmacist what seems to have been a simple question of fact, and it appears the pharmacist screwed it up. But I'm not sure what they actually asked. He first said it was Hospira, then that it was generic. I'm not sure it's much of a stretch to think the wrong question got answered correctly. 🙂
 
Since I started practicing critical care, I have lost quite a bit of respect for pharmacists. When I get called why I need calcium in a patient with hyperkalemia ("his calcium is normal!!!"), I get pissed. I don't have time for this ****, and frankly neither has the patient. Let's not mention when they tell me that less than q15 min prn for fentanyl (in the PACU or ICU!) is "too frequent".
 
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Maybe somebody can explain this...

I recently started a PP gig and we have no hyperbaric bupi. Some of the partners are using conventional epidurals for all their sections and others are using the 0.5% bupi.

I have only done 3 sections necessitating a spinal so far. The first went off w/o a hitch. The other two had the same "patchy" coverage. I used 2.4mL 0.5% bupi + 15mcg fentanyl and 0.2mg duramorph for one and 2.5mL 0.5% bupi +0.2mg duramorph (no fentanyl d/t cholestasis). Both patients had little to no coverage in the RLQ but otherwise had no complaints. I had read/heard that the addition of fentanyl and duramorph may make the mixture slightly hypobaric so I put both in a little L side down to try to cover the area. The patient that received fentanyl eventually had decent enough coverage to begin but the other I ended up supplementing to get through the procedure. Needless to say, it wasn't a great case.

Does anyone have a reason for why this happened and maybe a better idea to troubleshoot it?

Thanks
 
How long did you let the block set up before incision? 0.5% takes a bit longer

I’m using almost the same recipe except with 0.75% isobaric bupi. Usually I do a full 15 mg + 15 fent + 0.1 morphine. Less on the vertically challenged (<5’4” or so). It’s actually been working pretty well. I haven’t had to redo a spinal since the shortage
 
Both were probably given a little more than 5 minutes before the first clamp test with another 3 minutes or so of waiting to see if it would improve. The block with fentanyl gradually improved throughout the case but was still suboptimal. The other one never really got better hence supplementing
 
d9sccr said:
Maybe somebody can explain this...

I recently started a PP gig and we have no hyperbaric bupi. Some of the partners are using conventional epidurals for all their sections and others are using the 0.5% bupi.

I have only done 3 sections necessitating a spinal so far. The first went off w/o a hitch. The other two had the same "patchy" coverage. I used 2.4mL 0.5% bupi + 15mcg fentanyl and 0.2mg duramorph for one and 2.5mL 0.5% bupi +0.2mg duramorph (no fentanyl d/t cholestasis). Both patients had little to no coverage in the RLQ but otherwise had no complaints. I had read/heard that the addition of fentanyl and duramorph may make the mixture slightly hypobaric so I put both in a little L side down to try to cover the area. The patient that received fentanyl eventually had decent enough coverage to begin but the other I ended up supplementing to get through the procedure. Needless to say, it wasn't a great case.

Does anyone have a reason for why this happened and maybe a better idea to troubleshoot it?

Thanks
Click to expand...
Not saying these will fix your issues but I'd consider a bigger iso bupi dose, depending on pt height. And I'd also consider putting the pt in a little trendelenberg (I know, I know, it's isobaric so position shouldn't affect it but , trust me, there is an effect.)
 
Ezekiel2517 said:
Not saying these will fix your issues but I'd consider a bigger iso bupi dose, depending on pt height. And I'd also consider putting the pt in a little trendelenberg (I know, I know, it's isobaric so position shouldn't affect it but , trust me, there is an effect.)
Click to expand...

Are you using larger doses then? If so, are you using fentanyl and duramorph still?
 
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