American Society of Regional Anesthesia and Pain Medicine August 2018 - 13
Only regional blockade with local anesthetics can block patients'
sensation during and after surgery. Without local anesthetics for
nerve blocks, spinals, and epidurals, patients will experience
greater-than-expected acute pain, require additional opioid
treatment, and are potentially at higher risk for developing chronic
pain.
ASA recently surveyed members29 to gather stories about drug
shortages affecting clinical care, receiving approximately 2,500
responses with 98% reporting personal experiences with drug
shortages, and has now launched a new online registry that ASA
members can use to report new and ongoing drug shortages
affecting their practices.
INCREASED HEALTH CARE COSTS
Approximately 31% of costs related to inpatient perioperative care
is attributable to the ward admission.21 As perioperative physicians,
anesthesiologists have an opportunity to influence the cost of
surgical care by decreasing hospital length of stay through effective
pain management and by developing coordinated, multidisciplinary
clinical pathways.22,23 Regional anesthesia and analgesia can
improve outcomes through integration into clinical pathways that
involve a multipronged approach to streamlining surgical care.24,25
Inadequate pain control can delay rehabilitation, prolong hospital
admissions, increase the rate of readmissions,26 and increase the
costs of hospitalization for surgical patients.
Dr Landau shared Columbia University Medical Center's experience
of managing shortages of hyperbaric 0.75% bupivacaine and
other local anesthetic solutions since February 2018. She and the
central hospital pharmacy stockpiled remaining 0.75% hyperbaric
bupivacaine for emergency cesarean deliveries, and these cases
have taken priority over all other surgical cases for access to
hyperbaric bupivacaine. For other nonurgent cesarean deliveries,
Dr. Landau and her team are using other preservative-free local
anesthetic solutions as alternatives. Conservation strategies have
included dividing large, single-use vials in the pharmacy under
sterile conditions into multiple syringes good for 24 hours, which
are delivered to labor and delivery and exchanged with new
syringes daily. While implementing these local practice guidelines,
Dr Landau spearheaded the SOAP Advisory with the SOAP Board
of Directors, which is the first Societal statement to be released
nationally, with careful consideration for potential liability and
ongoing review and revision based on member feedback.27
ADDRESSING THE PROBLEM OF DRUG SHORTAGES
ASRA convened a late-breaking session on April 21, 2018, at the
World Congress of Regional Anesthesia and Pain Medicine in New
York City to address the continuing problem of analgesic drug
shortages. Dr Jim Grant, president of the American Society of
Anesthesiologists (ASA), returned to New York to participate in the
live session. Other special guests included Paul Pomerantz, chief
executive officer of ASA, and Dr Ruth Landau, first vice president
of the Society for Obstetric Anesthesia and Perinatology (SOAP)
and author of the SOAP Advisory in Response to Shortages of Local
Anesthetics in North America.27
The meeting room was full of attendees representing academic
and private practices from the United States, Canada, and Europe.
Dr Grant opened with an update of ASA efforts to advocate for a
long-term solution to drug shortages, specifically mentioning the
lifting of production quotas through the Drug Enforcement Agency
and decreasing delays at the Food and Drug Administration (FDA)
in processing generic drug application approvals and imports of
pharmaceuticals produced outside North America. He emphasized
that this is ASA's number one priority. The present shortages
have multiple contributing factors, but big ones included Pfizer's
acquisition of Hospira28 with subsequent closing of a major
Hospira facility because of quality issues and the slow recovery of
manufacturing facilities based in Puerto Rico. Dr Grant also pointed
out important collaborators in this fight: the American Hospital
Association, American Society of Health-System Pharmacists,
American Association of Clinical Oncology, and Institute for Safe
Medication Practices. In my research, I discovered a letter sent to
the FDA specifically about local anesthetic shortages from multiple
societies representing dentists, dermatologists, and head and neck
surgeons.
The attendees, both residents and practicing anesthesiologists,
were actively involved in the discussion with questions for Drs
Grant and Landau, sharing their own experiences with managing
ongoing drug shortages, which have been remarkably similar
around the world. Examples of alternative dosing strategies and
techniques, using other available medications, and improving
communication between anesthesiology and pharmacy were
presented. Dr Grant referred to this session as the "first real think
tank" on this topic that he has participated in.
KEY TAKE-AWAYS
Here are some take-home points raised by attendees that
anesthesiologists facing analgesic drug shortages should consider:
* Always have up-to-date information from your pharmacy
department regarding inventory of local anesthetics and other
medications affecting anesthesia care and perioperative pain
management. One suggested best practice is to have a daily
update (eg, conference call, e-mail, dashboard) on current drug
shortages to facilitate communication between anesthesiology
and pharmacy and among networked facilities within the same
health system.
* Avoid excessive medication waste. Identify opportunities
for pharmacy to split commercially available large vials into
multiple, single-dose syringes. Many single-use vials contain
excessive amounts of medication. When done under proper
sterile conditions, a pharmacy can divide those vials into
American Society of Regional Anesthesia and Pain Medicine
2018
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Table of Contents for the Digital Edition of American Society of Regional Anesthesia and Pain Medicine August 2018
American Society of Regional Anesthesia and Pain Medicine August 2018 - 1
American Society of Regional Anesthesia and Pain Medicine August 2018 - 2
American Society of Regional Anesthesia and Pain Medicine August 2018 - 3
American Society of Regional Anesthesia and Pain Medicine August 2018 - 4
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