APhA coronavirus watch: Conserving sedation medications amid shortages

As the COVID-19 pandemic rages on, some hospitals are experiencing shortages of sedatives and paralytics used to keep intubated patients comfortably sedated. What can pharmacists do to conserve the supply of these key medications?

As many as 12% of COVID-19 patients need respiratory support through mechanical ventilation, in addition to other patients without COVID-19 who may need sedation. In the May 8, 2020, episode of APhA’s 15 on COVID-19 training series, Daniel Zlott, PharmD, BCOP, vice president of professional education resources at APhA, discussed ways pharmacists can adapt to shortages of sedation medications and maximize their availability in the hospital.  

The first step, said Zlott, is to form a multidisciplinary team of stakeholders, including staff in the ICU, surgery and anesthesia, and outpatient settings, to develop strategies and protocols. This is increasingly important as hospitals and health systems begin to reopen for elective surgeries, he said.  

Clinicians should use the lightest sedation levels possible that would keep patients comfortable. Propofol is typically the mainstay of ICU sedation, but as supplies dwindle, clinicians can use alternate sedatives, such as dexmedetomidine, fentanyl, ketamine, and benzodiazepines. They can also consider other routes of medications, such as oral or transdermal options, to help conserve the supply of I.V. medications.

Pharmacists can look to compounded drugs as an alternative, as well. If a pharmacy and its personnel are already qualified to perform “high-risk” compounding, pharmacists may consider compounding their own I.V. products, said Zlott. Otherwise, hospitals may consider leveraging existing relationships, or forming new ones, with a 503B outsourcing pharmacy to obtain medications they need.

In extreme shortage situations, pharmacists may consider some historical approaches used for anesthesia, such as barbiturates, said Zlott. The use of anesthetic gases may also be an alternative, but pharmacists should be mindful of long-term use, as well as consider airflow and air exhaust to avoid potential exposure or buildup of anesthetic gases in an enclosed space. Barbiturates and anesthetic gases should only be considered as a last resort, said Zlott. Pharmacists should use their clinical judgment to decide if these interventions are appropriate and if their benefits outweigh their risks. APhA takes no responsibility should a pharmacist decide to use one of these approaches.

For more episodes of APhA’s 15 on COVID-19 series and additional resources, visit APhA’s coronavirus resource page at www.pharmacist.com/coronavirus.