Table 1 Essential ICU drugs and suggestions to manage drug shortages
From: Essential ICU drug shortages for COVID-19: what can frontline clinicians do?
Preferred drug | Alternatives to first-line agents | Clinical considerations and contraindications |
|---|---|---|
Analgesics | ||
Fentanyl (IV) | Non-opioid analgesics (Enteral/IV) e.g., acetaminophen and nonsteroidal anti-inflammatory drugs | • Can be used as part of analgesic ladder, barring conventional contraindications |
Morphine (IV) • As infusions and/or breakthrough boluses | • Avoid in patients with renal and hepatic impairment • Associated with higher rates of ICU delirium, especially in elderly • May cause histamine release | |
Ketamine (IV) • As infusion in mechanically ventilated patients | • Unlabeled use as an adjunct to opioid analgesia and sedation • To be used together with a benzodiazepine to reduce dissociative effects and agitation • Avoid in patients with tachyarrhythmias, significant hypertension, ischemic heart disease, traumatic brain injury, raised intracranial pressure, prolonged sepsis, hepatic and renal impairment, thyroid storm | |
Remifentanil (IV) • As infusion in mechanically ventilated patients | • Preferred in hepatic and renal impairment • Rapid onset and offset • No drug interaction concerns with cytochrome P450 isoenzymes | |
Oxycodone (oral/IV) | • Enteral formulation has good bioavailability and can be used to transition from continuous opioids • Use with caution in patients with renal and hepatic impairment • In patients who are able to swallow, the sustained released coupled with an antagonist formulation provides sustained analgesia with less gastrointestinal side effects and decreased likelihood for abuse | |
Propofol (IV) | Midazolam (IV) • Infusion and/or breakthrough boluses | • Useful for deep sedation • Preferred for younger patients (lower risk of delirium) • Less hemodynamic side effects compared to propofol or dexmedetomidine • Avoid in patients with renal or hepatic impairment |
Dexmedetomidine (IV) • Infusion for light sedation | • Useful for light sedation and patients who may be extubated soon • May cause bradyarrhythmias, especially when used with fentanyl or beta-blockers to treat hypertension • Can be used to treat alcohol, benzodiazepine and opioid withdrawal. When stopped, rebound hypertension can occur. Treatment with beta-blockers can make rebound hypertension worse due to upregulation of alpha-adrenergic receptors • Cannot be used for patients requiring paralysis | |
Thiopentone (IV) | • Useful for treatment of status epilepticus and patients with raised intracranial pressure • To use with caution in patients with hemodynamic instability, asthma and hepatic failure | |
Clonidine (oral) | • Can be used to transit from dexmedetomidine for ICU sedation • Can be used as adjunct to treat opioid withdrawal • To use with caution in patients with hemodynamic instability • Requires gradual weaning in prolonged use | |
Neuromuscular blockade | ||
Atracurium (IV) | Rocuronium (IV) | • Some patients may experience prolonged recovery of neuromuscular function especially after prolonged use, in the presence of hepatic and renal impairment or when used with corticosteroids • Minimal histamine release |
Cisatracurium (IV) | • Preferred in hepatic and renal impairment • Less accumulation than atracurium after prolonged use • Minimal histamine release | |
Pancuronium (IV) | • A longer acting neuromuscular blocking agent as an alternative for atracurium, especially in patients who require prolonged paralysis • Can be given as intermittent boluses • Some patients may experience prolonged recovery of neuromuscular function especially after prolonged use, in the presence of hepatic and renal impairment or when used with corticosteroids • Minimal histamine release | |
Vasopressors | ||
Noradrenaline (IV) | Adrenaline (IV) | • May precipitate peripheral ischemia, gut ischemia, and lactic acidosis • May cause hyperglycemia |
Phenylephrine (IV) | • May precipitate reflex bradycardia and visceral vasoconstriction • May have tachyphylaxis and ceiling effect | |
Dopamine (IV) | • May precipitate tachyarrythmias. Avoid in uncorrected, pre-existing tachyarrhythmias or malignant tachyarrhythmias, e.g., ventricular fibrillation • Avoid as first-line agent or sole agent for sepsis | |
Vasopressin (IV) | Terlipressin (IV) | • Increased risk for digital ischemia with terlipressin infusion |
Others (fluids and medications) | ||
Commonly used solutions include • Lactated Ringer’s solution • 0.9% sodium chloride (normal saline) | • Drug dilutions with normal saline can be switched to other compatible solutions: o Dextrose 5% o Lactated Ringers’ solution o Sterile water o No dilution at all, administered as neat bolus • Irrigation can be done with alternative solutions: o Sterile water o Clean/sterilized tap water • Fluid resuscitation can be done with alternative balanced crystalloid solutions: o Plasmalyte o Stereofundin | |
Antimicrobials | • Strong antimicrobial stewardship with daily review of de-escalation or cessation of antimicrobial when clinically appropriate • Select a more frequent dosing regimen for time-dependent antibiotics to optimize pharmacodynamic parameters and minimize wastage • Indicate specific duration of antimicrobials | |
Insulin (short-acting forms) | • Short-acting insulin is commonly used in ICUs for glycemic control • Requirements per day can be averaged out and converted to a medium to long-acting alternative for glycemic control, accepting slightly more fluctuations in blood glucose levels • Enteral agents can be introduced earlier if the patient has demonstrated clinical stability, to reduce the need for short acting insulin | |