Essential ICU drug shortages for COVID-19: what can frontline clinicians do?

Dear Editor,

As the coronavirus disease 2019 (COVID-19) pandemic persists, preparing intensive care units (ICUs) for sustained service becomes a challenge. Based on China’s experience, Li and colleagues highlighted ten critical issues [1], top-most being a severe shortage of critical medical resources including physicians, nurses, and ICU beds. We would like to highlight a related issue in Singapore that will likely also apply elsewhere. Despite having adequate staff, beds, and equipment, supply chain disruptions has led to several ICU drugs being in short supply. For instance, drugs like propofol, atracurium, and noradrenaline have been projected to last less than 1 month in Singapore without fresh supplies.

From an organizational standpoint, the American Society of Health-System Pharmacists has provided valuable guidance regarding operational assessment, therapeutic assessment, shortage impact analysis, and inventory system changes [2]. Adding to a systems approach, frontline clinicians can help alleviate these drug shortages by identifying the drugs in short supply, considering alternatives and assessing the risks when using these alternatives (Table 1).

Table 1 Essential ICU drugs and suggestions to manage drug shortages

Optimizing current drug stocks and reducing waste would require a concerted effort by frontline clinicians. Physicians can use light sedation targets or even no sedation with analgesia only, avoid neuromuscular blockade, use train-of-four measurements to avoid overdosing of neuromuscular blockade, and allow permissive hypotension (lowering the mean arterial pressure target to 60–65 mmHg) [3]. Nurses can standardize intravenous drug dilutions to negate the need for re-dilution when patients are transferred between different clinical units, use low rather than high concentration drug infusions for more accurate titration to the lowest permissible dose, and perform daily or twice-daily awakening trials for suitable patients. Pharmacists can reinforce physician and nursing practice by monitoring drug use patterns, suggesting viable alternatives, checking for drug interactions, and advising on safe administration practices.

It is not inconceivable that even alternative medications can run out, especially in regions that are already resource-limited. In such cases, non-pharmacologic or unconventional measures should be explored. For instance, analgesia may be attained through acupuncture, and anxiety can be alleviated with patient-directed music intervention [4]. Another example is oral midodrine, which is currently being investigated as a means to wean critically ill patients from intravenous vasopressors [5]. Drug shortages may compel clinicians to use oral midodrine as a sole agent for blood pressure augmentation. Physicians, nurses, and pharmacists would then need medicolegal protection when using therapies that are off-label, but that would be necessary for the well-being of patients.