Major Drug Shortages Looming

BelgianRN · Mar 7, 2012

I suggest you upgrade to taking in healthy kiddos in your unit because you can't treat anything anymore :|

Our hospital's solution to drug shortages so far has been to either switch to alternative suppliers or alternative meds. We frequently have drugs that are imported from Germany and Spain and relabeled by our pharmacy so we know what's in it. And in other instances we are basically told by the pharmacy to find an alternative e.g. when cisatracurium was in shortage we got atracurium instead. And for example vasopressin was made by our pharmacy in order to combat the shortage.

Good luck anyway in the upcoming time.

Pediatric Critical Care Columnist · Mar 7, 2012

I chuckled, BelgianRN. I wish we could be selective!

There was a story in today's newspaper on this and it looks like our province is seeking alternate sources for a lot of these drugs. The story really downplayed the situation, for fear of provoking hysteria, I suppose. I'm not overly worked up over the analgesia/sedation drugs, but the anticonvulsants and the inotropes have me quite concerned. We use a LOT of epi and norepi on our unit, being primarily a CVPICU. One of the strategies that has been suggested is mixing up only 24 hours' supply of the shortage meds to reduce waste, which will be fine for a lot of things, but may create significant problems when having to change our epi syringes everyday. Coupled with the number of very inexperienced staff we have right now, it could be a real issue.

Aliakey · Mar 7, 2012

From an EMS perspective, we no longer have fentanyl or diazepam available for use. Our seizure medication is now lorazepam, and what limited vials of morphine we have replaces fentanyl. Demerol is available, but at a 25 mg dose (max).

Etomidate and midazolam are very limited, which is not a pleasant thought for PAI intubation, cardioversion, or external pacing. We haven't been given any hints on how we'll handle those patients when the midazolam is gone; I'd be curious to thoughts on alternatives for that.

Just waiting for ondansetron to run out...

BelgianRN · Mar 7, 2012

Took care of a kiddo today in the ER that kept seizing. And all the pediatric intensivist could say was hmmm clonazepam no we don't have that..., midazolam, hmmm do we have that still?... Lorazepam?... no that was out too. It was sad we can't use the medications that we have ample experience with and work well.

P.S. Jan arrange to come over last time I checked our refrigerator we still had 30 vials of epi 25 mg per vial ^^ that will last you many codes...

umcRN, BSN, RN · Mar 8, 2012

Yup. We are short of many of those drugs here. Had to call pharmacy today and beg for zofran for my eight year old s/p mitral valve replacement yesterday, extubated today and screaming for water. A lot of our meds that used to be available in our unit pyxis now have to come directly from pharmacy because they are drawing up multiple doses from one vial/bag what have you in order to get the msot out of it. Its rediculous!

Pediatric Critical Care Columnist · Mar 8, 2012

Took care of a kiddo today in the ER that kept seizing. And all the pediatric intensivist could say was hmmm clonazepam no we don't have that..., midazolam, hmmm do we have that still?... Lorazepam?... no that was out too. It was sad we can't use the medications that we have ample experience with and work well.
P.S. Jan arrange to come over last time I checked our refrigerator we still had 30 vials of epi 25 mg per vial ^^ that will last you many codes...

Quite a few years ago, the ClinPharmD on my unit presented at an education day about "new" treatments for seizures. He mentioned giving the enteral diazepam liquid prep PR. Maybe we'll be doing that?

30 vials of epi might last us a couple of weeks. We run epi infusions on about 30% of the patients on the unit at any given time. We also use the same prep for nebulized epi for kids with stridor, bronchiolitis and some other respiratory conditions.

Yup. We are short of many of those drugs here. Had to call pharmacy today and beg for zofran for my eight year old s/p mitral valve replacement yesterday, extubated today and screaming for water. A lot of our meds that used to be available in our unit pyxis now have to come directly from pharmacy because they are drawing up multiple doses from one vial/bag what have you in order to get the msot out of it. Its rediculous!

I think that's actually a sensible approach to this issue. Reduce the waste to an absolute minimum and it'll hold off the bigger problems of what to do when the drugs run out. I wish that was how my facility chose to deal with this, but then they'd have to hire more pharmacy staff and that'll never fly. The unit I worked on before this one had a pharmacist on the unit around the clock and all our infusions, IV meds and enteral meds were prepared by them then brought to the bedside as needed. Scheduled IV meds were brought out 30 minutes before they were due, PRNs were brought out as several doses in a bag and enteral meds came out at midnight for the next day. The pharmacist also attended all codes and drew up all the code drugs. The money saved by limiting wasted meds more than offset the cost of the pharmacists' wages. Where I work now, we don't even have a tech in the pharmacy between 2230 and 0730, just a night cupboard and a pharmacist on call.

(Oh, umcRN... there are a number of papers that indicate ondansetron doesn't really work...)

umcRN, BSN, RN · Mar 9, 2012

(Oh, umcRN... there are a number of papers that indicate ondansetron doesn't really work...)

I haven't heard of that...will have to take a look. I'm sure it doesn't work for everyone based on what I have witnessed. I will say though that when I was extremely nauseous and vomiting after brain surgery the zofran perked me right up...I still wasnt able to eat much but was able to keep fluids down and take my meds which I hadn't been able to before the zofran. All in the mind? Maybe, but it worked for me :lol2:

GatorRN21 · Mar 26, 2012

Thank you for posting this info. I did not know so many drugs are going are going to be on short supply!

At our hospital, I feel like every week that I have an e-mail about another change related to the drugs that we use frequently--it's down-right difficult to keep up with all the new updates. In our CICU, our pharmacy now specifically prepares smaller dose vials of ativan, versed, etc.

Also, kids on drips of Versed or Fentanyl, will have each syringe prepared specially for them. We used to have at least a few standard concentration syringes of these medications available at any time in the Pyxis. Thus, this leads to another job for the nurse to add to her check-list-- reordering these meds and/or checking to make sure another syringe is available in the Pyxis. Also, during emergency situations specifically on night shift (i.e. pt crashing onto ECMO leading the pt to need a whole medication gang prepared); without the readily available standard prepared syringes the nurses now has to formulate his/her own drips in this chaotic situation. I am younger nurse with 5 years experience and do not have much practice in mixing drips unlike other nurses with much more experience, where that used to be a standard of practice. I personally get nervous about formulating drips and think this is going to lead to be potential medication mistakes. I feel this is more of a pharmists' job but the drug shortage has put this now frequently on nurse. Just another thing to worry about when you have an unstable kid

Pediatric Critical Care Columnist · Mar 26, 2012

On our unit it's ALWAYS been the nurse's responsibility to mix infusions. We prepare the majority of our meds ourselves at the bedside. Exceptions are things like ATGAM, tacrolimus and MMF infusions, chemo drugs and anything that's really, really expensive. Then pharmacy prepares. We're still using the Rule of Sixes on our unit for the time being, with standard concentrations for our infusions, for example epi and norepi are mixed so that 1 mL/hr = 0.1 mcg/kg/min, milrinone is 1 mL/hr = 0.5 mcg/kg/min, nitroprusside is 1 mcg/kg/min, midazolam is 2 mcg/kg/min for kids under 8 kg, 1 mcg/kg/min for kids up to 16 kg and 0.5 mcg/kg/min for all the rest. You get the idea. We also prepare our own electrolyte replacements. It's all part of the critical care nurse role. Trust me when I say it's far faster for two bedside nurses to mix an infusion on the spot than it is to have pharmacy involved. Yesterday I cleaned out the crash cart of epi, bicarb and vasopressin during a code/ECPR. When I needed more vasopressin someone who wasn't in the room pulled it from Pyxis for me. Someone else was making epi, heparin and morphine infusions. It's not a perfect system but it works when it needs to.

GatorRN21 · Mar 26, 2012

I think it is great that your nursing unit prepares most your own infusions. Nurses on our unit have had little training in mixing infusions independently outside of the pharm--we do more training. So, this is a change from our typical everyday practice and training--I feel for the most part we aim for mixing the infusions to be not only the nurses role but a joint/collaborative role with the pharmacy. We aim for the pharmacist to be another check along the spectrum before a medication gets to the patient and also the pharmacist to best able to prepare the medication in an environment more geared towards medication preparation (more sterile, etc. compared to the unit because we don't have a designated area for medication preparation like the pharm does).

jelly221,RN, MSN · May 22, 2012

I haven't heard of that...will have to take a look. I'm sure it doesn't work for everyone based on what I have witnessed. I will say though that when I was extremely nauseous and vomiting after brain surgery the zofran perked me right up...I still wasnt able to eat much but was able to keep fluids down and take my meds which I hadn't been able to before the zofran. All in the mind? Maybe, but it worked for me

Could you share what you find? I've seen Zofran work on countless patients, not to mention myself! Reglan & Compazine give me dystonia, but good ol' Zofran has yet to let me down.