Sux shortage

[kmurp]

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We have been informed of non-availability of succinylcholine by our pharmacy. We have a stock of around 50 vials available. We are trying to conserve our supply by using alternatives.
Have any of you seen this at your facilities?
What do you suggest if we completely run out?
We have wondered if we could do kids for example as sux is THE treatment for laryngospasm.
Your thoughts would be appreciated.

 

[seinfeld]

good thing FDA halted suggamadex

 

[pgg]

We have been informed of non-availability of succinylcholine by our pharmacy. We have a stock of around 50 vials available. We are trying to conserve our supply by using alternatives.
Have any of you seen this at your facilities?
What do you suggest if we completely run out?
We have wondered if we could do kids for example as sux is THE treatment for laryngospasm.
Your thoughts would be appreciated.

Most people I know will have it drawn up for a peds case, which leads to a lot of waste as it's rarely actually used. Maybe the pharmacy can draw up some prefilled syringes in their sterile fume hood or whatever it is they use, so you can have it drawn up and immediately available for peds cases without wasting a bottle per room every day drawing up fresh stuff and throwing it out at 5 PM.


No succ shortage here, but the propofol shortage finally arrived. The pharmacy got all gestapo on us for splitting 50 cc vials between patients (obviously with clean needles/syringes and without double dipping), but they were willing to prefill 20 cc syringes for us under sterile conditions and certify them 'ok' for more than 6 hours, which was helpful.

 

[urge]

Propofol, thiopental, labetalol, glyco, remi, neostigmine, panc,...

We are ordering a couple heavy hammers to deal with shortages.

 

[urge]

We have wondered if we could do kids for example as sux is THE treatment for laryngospasm.

You can do them. Might whack a few though.

 

[Idiopathic]

We have been informed of non-availability of succinylcholine by our pharmacy. We have a stock of around 50 vials available. We are trying to conserve our supply by using alternatives.
Have any of you seen this at your facilities?
What do you suggest if we completely run out?
We have wondered if we could do kids for example as sux is THE treatment for laryngospasm.
Your thoughts would be appreciated.

correction: sux is the treatment for laryngospasm UNRELIEVED BY POSITIVE PRESSURE VENTILATION. nice to have it around but you really shouldnt be giving it very often.

 

[Sergio99]

We have wondered if we could do kids for example as sux is THE treatment for laryngospasm.

You just deal with it as you do in kids where sux is contraindicated. I have had cases in whom the laryngospasm had to be treated and sux was contraindicated. Had to give rocuronium. Of course, because you know that roc takes longer to work, you don't wait to the last second to treat it, and then you have to wait longer to have it wear off and usually you have to reverse it. In those cases you have to take your time and all bets for a quick turn over of the room are off. If anyone has a better way, I would love to hear it.

 

[Idiopathic]

what about when the IV quits working? or when they spasm on induction and no IV can be found?

 

[Monty Python]

what about when the IV quits working? or when they spasm on induction and no IV can be found?

25 g needle on syringe, insert into the underside of the tongue, acts just like it's intravenous.

 

[Planktonmd]

I can do anesthesia with just about anything so I don't care what medication is on back order anymore!
Here is my policy: Come to work in the morning and do anesthesia with whatever the administrators, bureaucrats, JACHO... have given you, then go home and have a big Scotch.
This philosophy has worked for me so I hope it works for you.

 

[somedumbDO]

You just deal with it as you do in kids where sux is contraindicated. I have had cases in whom the laryngospasm had to be treated and sux was contraindicated. Had to give rocuronium. Of course, because you know that roc takes longer to work, you don't wait to the last second to treat it, and then you have to wait longer to have it wear off and usually you have to reverse it. In those cases you have to take your time and all bets for a quick turn over of the room are off. If anyone has a better way, I would love to hear it.

a little extra propofol can help quite a bit

 

[Idiopathic]

25 g needle on syringe, insert into the underside of the tongue, acts just like it's intravenous.

so would you give roc this way? how much would you give? how quickly would you expect it to work?

 

[Idiopathic]

a little extra propofol can help quite a bit

this is my answer

 

[kmurp]

Ok, I understand that you "can" do kids without sux being available. But if you do so, are you providing substandard care when the hospital "down the street" is not suffering from such a shortage? It's not the same as taking care of an MH susceptible patient where sux is contraindicated. In our case, it's more like (exaggeration, I know), proceeding with a non-triggering anesthetic in an MH susceptible when no Dantolene is available at the facility.
Also, with our large population of morbidly obese patients, we would be intubating with Zemuron. Most of the time it's OK - until it isn't.........

 

[hoyden]

I can do anesthesia with just about anything so I don't care what medication is on back order anymore!
Here is my policy: Come to work in the morning and do anesthesia with whatever the administrators, bureaucrats, JACHO... have given you, then go home and have a big Scotch.
This philosophy has worked for me so I hope it works for you.

Makes me wonder if you always practiced anesthesia in USA only 😉

 

[Consigliere]

I can do anesthesia with just about anything so I don't care what medication is on back order anymore!
Here is my policy: Come to work in the morning and do anesthesia with whatever the administrators, bureaucrats, JACHO... have given you, then go home and have a big Scotch.
This philosophy has worked for me so I hope it works for you.

I like your philosophy since it's mine as well.

 

[SleepIsGood]

so would you give roc this way? how much would you give? how quickly would you expect it to work?

I agree use some propofol.

But I dont think you can give propofol sublignually like you can with sux if need be.

Man who are these companies with these shortages. I mean sux shortage? Yes we can all go without it. But it's a very basic drug to have in our toolbox. Maybe one of us should go into producing it......

 

[Monty Python]

so would you give roc this way? how much would you give? how quickly would you expect it to work?

Never thought about giving roc sublingually .... this would just be my emergency, gotta-give-sux to break a spasm mode, when PP doesn't work, and when the IV has dislodged.

 

[Idiopathic]

Never thought about giving roc sublingually .... this would just be my emergency, gotta-give-sux to break a spasm mode, when PP doesn't work, and when the IV has dislodged.

yes i get that, the question is about what if there is no sux?

 

[Idiopathic]

or better yet, heres a good question: is it negligence/malpractice to do peds anesthesia without succinylcholine available? could you defend yourself if a kid spasmed, you couldnt break it and he suffered some injury whether it was a forced intubation or an hypoxic insult?

 

[jwk]

Man who are these companies with these shortages. I mean sux shortage? Yes we can all go without it. But it's a very basic drug to have in our toolbox. Maybe one of us should go into producing it......

Very basic off-patent drugs are cheap, meaning little profit. It only takes a few scumbag lawyers (I've about decided each and every one of them is a scumbag) to totally screw things up. You want to know why all these drugs are in short supply? Lawyers and lawsuits. It's that damn simple. When the cost of a lawsuit is more than the profit on the drugs, the manufacturers just say to hell with it.

 

[soorg]

Speaking of sublingual drugs, what is the dose of Sux given SL? I've been told it's the same as IV, and that the onset is the same as IV as well.

What about SL atropine? What dose and onset time does that have? Anybody ever try it?

 

[bigeyedfish]

25 g needle on syringe, insert into the underside of the tongue, acts just like it's intravenous.

I've heard people talk about this before but it seems like if you nick a vessel you're going to turn a bad situation a whole lot worse with a bloody airway. Is it really worth the few seconds faster than IM?

The few times I've had to do this I just stabbed them in the thigh and it worked quick enough.

 

[Idiopathic]

Speaking of sublingual drugs, what is the dose of Sux given SL? I've been told it's the same as IV, and that the onset is the same as IV as well.

What about SL atropine? What dose and onset time does that have? Anybody ever try it?

close enough to where you cant tell the difference - patients still blue and not gray

 

[Idiopathic]

I've heard people talk about this before but it seems like if you nick a vessel you're going to turn a bad situation a whole lot worse with a bloody airway. Is it really worth the few seconds faster than IM?

The few times I've had to do this I just stabbed them in the thigh and it worked quick enough.

you have to give a lot IM, and not much under the tongue. anyway, the right answer is to inject into the muscle of the tongue, you probably wont hit a great vessel, and if you cant afford to wait then you take that chance, i suppose. its where i would go

 

[Jay K]

These nationwide shortages have made it like real-life oral boards.

Me: I reach for my propofol to induce.

Them: There's a nationwide shortage of propofol, so you've got none.

Me: I reach for my stick of etomidate.

Them: There's a national recall on etomidate, so you've got none.

Me: I turn on the Ultane for mask induction.

Them: Japan has just declared war on the U.S. and have subsequently stopped shipments of Ultane.

Me: I turn on isoflurane? desflurane?

Them: Your anesthesia machine is suddenly revealed as a hidden Decepticon that transforms into it's robot self and begins rampaging through the hospital in search of Megan Fox.

Me: Can I cancel the case now?

Them: Is it inappropriate to continue the case as a TIVA with scopolamine?.... By the way, you'll have to distill it from patch form first...

 

[maceo]

hypoxia is the ultimate relaxant

 

[Sergio99]

Very basic off-patent drugs are cheap, meaning little profit. It only takes a few scumbag lawyers (I've about decided each and every one of them is a scumbag) to totally screw things up. You want to know why all these drugs are in short supply? Lawyers and lawsuits. It's that damn simple. When the cost of a lawsuit is more than the profit on the drugs, the manufacturers just say to hell with it.

You are right. Some of these drugs are so dirt cheap and the profit margin so small, that the companies making them are almost doing it as a favor to us or as a charity work. It suffices for one of them to have some shortfall in any area, and they will first cut the production of their least profitable product, even if it is not related to the area of the shortfall. That is standard operating procedure in the business world.

The way to stop the shortage is to find a new and improved sux with a patent for enough years to make it profitable.

 

[Bertelman]

hypoxia is the ultimate relaxant

bingo.

 

[doctor712]

These nationwide shortages have made it like real-life oral boards.

Me: I reach for my propofol to induce.

Them: There's a nationwide shortage of propofol, so you've got none.

Me: I reach for my stick of etomidate.

Them: There's a national recall on etomidate, so you've got none.

Me: I turn on the Ultane for mask induction.

Them: Japan has just declared war on the U.S. and have subsequently stopped shipments of Ultane.

Me: I turn on isoflurane? desflurane?

Them: Your anesthesia machine is suddenly revealed as a hidden Decepticon that transforms into it's robot self and begins rampaging through the hospital in search of Megan Fox.

Me: Can I cancel the case now?

Them: Is it inappropriate to continue the case as a TIVA with scopolamine?.... By the way, you'll have to distill it from patch form first...

👍👍

 

[Idiopathic]

bingo.

yeah we all say this (i like to call it the triple H anesthetic: hypotension, hypoxia, hypercarbia) but its hard to consider waiting until the oxygen level was so low that the brainstem reflexes disappear

 

[SevoInduction]

These nationwide shortages have made it like real-life oral boards.

Me: I reach for my propofol to induce.

Them: There's a nationwide shortage of propofol, so you've got none.

Me: I reach for my stick of etomidate.

Them: There's a national recall on etomidate, so you've got none.

Me: I turn on the Ultane for mask induction.

Them: Japan has just declared war on the U.S. and have subsequently stopped shipments of Ultane.

Me: I turn on isoflurane? desflurane?

Them: Your anesthesia machine is suddenly revealed as a hidden Decepticon that transforms into it's robot self and begins rampaging through the hospital in search of Megan Fox.

Me: Can I cancel the case now?

Them: Is it inappropriate to continue the case as a TIVA with scopolamine?.... By the way, you'll have to distill it from patch form first...

👍 That gave me a good laugh...

Hell at that point, you should just go down to your local co-op and pick up a can of diethyl ether.

 

[pgg]

hypoxia is the ultimate relaxant

And all bleeding stops eventually.

 

[Bertelman]

yeah we all say this (i like to call it the triple H anesthetic: hypotension, hypoxia, hypercarbia) but its hard to consider waiting until the oxygen level was so low that the brainstem reflexes disappear

I'm not saying I would live by this, but I also don't think turfing ALL pedi cases down the road to a sux-enabled hospital is the best solution.

 

[Idiopathic]

i think its a valid point - would you do a full day of peds cases without sux available?

 

[pgg]

i think its a valid point - would you do a full day of peds cases without sux available?

I wouldn't do any elective peds cases without it available.

I also wouldn't do any elective case without dantrolene available, and I've needed that a hell of a lot less than I've needed succ in my short time in anesthesia-land.


The OP has 50 bottles available, I don't see the problem. Quit using it for adults unless there's a reason 1.2 mg/kg of roc can't satisfy your RSI needs. Quit drawing it up as a precaution and throwing it away at 5 PM every day. 50 bottles will last near forever if it's treated as an emergency drug and not a routine part of every anesthetic.

 

[Bertelman]

The OP has 50 bottles available, I don't see the problem. Quit using it for adults unless there's a reason 1.2 mg/kg of roc can't satisfy your RSI needs. Quit drawing it up as a precaution and throwing it away at 5 PM every day. 50 bottles will last near forever if it's treated as an emergency drug and not a routine part of every anesthetic.

This sums up my feeling on the situation. I was joking about the hypoxia.

I guess I don't have strong feelings on the topic, because I hope to never do a full day of peds post-residency.

 

[Impromptu]

This last week there was a shortage of the pre-filled syringes of Sux at my institution.

 

[kraphtymac]

Awake FOI. Boom.