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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 drugAlternatives to first-line agentsClinical 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
  1. IV intravenous