Outpatient Surgery Magazine

2 2 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • A U G U S T 2 0 1 9 The following drugs are in shortage. Thomas Durick, MD, a consultant anesthesiologist with Envision Physician Services in Walnut Creek, Calif., shares how to make do without them. • Pain relievers. If morphine, fentanyl and hydromorphone are in short supply, try ultra- sound-guided regional anesthesia: interscalene, supraclavicular, infraclavicular and axillary blocks for shoulder and upper extremity surgery; femoral, adductor canal, popliteal and iPACK blocks for lower extremity surgery; rectus sheath and TAP blocks for hernia repairs and abdominoplasties; and PEC 1 and 2 blocks for breast and chest wall surgery. If blocks aren't options, a multimodal approach that includes long-lasting infiltration of a local anesthetic at the surgical site, NSAIDs and pre-op gabapentin can help control post-op pain. • Hydromorphone. Has been intermittently available. Obtainable dosages (0.5mg/ml, 1mg/ml, 2mg/ml, 4mg/ml and 10mg/ml) can vary, making dosing errors more likely. • Fentanyl. With sufentanil in short supply, you can switch to remifentanil and alfentanil. Lack of experience with the alternate drugs, especially for conscious sedation administered by non-anesthesia staff, increases risks of improper dosing and poten- tially serious side effects. • Morphine. Poses similar risks to hydromorphone with variations in available dosages (0.5mg/ml, 1 mg/ml, 10 mg/ml, 25 mg/ml, 50mg/ml). Read the label carefully to make sure you know the dose you're giving, as it might change from day to day. • Bupivacaine. If bupivacaine isn't available, use another local anesthetic such as ropivacaine or add lidocaine with epinephrine to your limited supply of bupivacaine to increase volume and duration with the epinephrine component. Exparel (liposomal bupivacaine) for single injec- tions can eliminate the need for the large vol- umes of local anesthetic required to fill pain pumps and provide excellent analgesia for a variety of blocks, including those used off-label. • Ketorolac. There is no equivalent substitute to give intravenously. Some facilities are resort- ing to combinations of p.o. NSAIDs and p.o. or IV acetaminophen as part of a multimodal regimen. • Dextrose. If 50% dextrose isn't available, you can use 25% dextrose in its place. Glucagon is also an effective alternative, but at the cost of an increased side-effect profile. You can also administer Lactated Ringer's and 5% Dextrose Injection, which has a much longer response to increase blood glucose. The other alternative is to give p.o. glucose when the patient is alert enough to swallow it. — Daniel Cook ADMINISTRATION AUDIBLES • MORE WITH LESS When ketorolac is unavailable, acetaminophen is an effective pain-relieving option. Pamela Bevelhymer, RN, BSN, CNOR Workarounds for Drugs in Short Supply Scott and White Health in Temple, Texas. "It might be best to extend inventories to stock 5 to 7 days' worth of often-used medications." To help combat shortages, Dr. Meyer has added back-up to inventory, lowered par levels in automat- ed medication dispensing cabinets, settled for buy- ing needed drugs at various strengths, and pur- chased more expensive generics and therapeutic alternatives. She's also found that requiring anesthe- sia providers or staff members to request drugs on short supply on a case-by-case basis curtails usage and extends reserve supplies. OSM

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