Drug Shortages: are they with us Forever?

Drug shortages have become such a persistent problem that the FDA has released smartphone apps to keep you up on the latest shortages. The Apple iOS version works on both iPhone and iPad and is available here. Or, in iTunes just search for "DrugShortages." There is also an Android app that works on Android 2.3.3 and higher and is available here.

The current drug shortage list on the FDA website is amazingly long and at the time of this post included 19 drugs of direct interest to anesthesia by my count, including ephedrine, fentanyl, and ketorolac (Torodol). If your OR pharmacy hasn't done so already, you might consider asking them to post a list of drugs that are in shortage at your location. Buying groups and pharmacy acquisition procedures can result in shortages hitting different areas and different hospitals at different times.

Michael A. Fiedler, PhD, CRNA

Magnetic Ropivacaine – Full Journal Article Available

In April, we reported about ropivacaine being injected IV and directed to it's site of action by magnetic nanoparticles; just too interesting to pass by. Well, in case you were as intrigued by this development as we here at Anesthesia Insights were, here is the citation for the full journal article that has since been published:

Anesth Analg 2014;118:1355–62. Nanoanesthesia: A Novel, Intravenous Approach
to Ankle Block in the Rat by Magnet-Directed Concentration of Ropivacaine-Associated Nanoparticles.

Will ultrasound guidance eventually give way to directing local anesthetic to the desired nerve with an external magnet?

Sustained Release Bupivacaine for Femoral Nerve Block

Data on Phase III trials of Sustained Release Bupivacaine (Exparel) were presented at the American Society of Regional Anesthesia and Pain Medicine meeting in April. While not initially FDA approved for nerve blocks, this data suggests that it is quite effective in preventing pain after total knee replacement. Pain was reduced, more patients were pain-free, and more patients were "extremely satisfied" with their pain relief. Pacira pharmaceuticals, maker of Exparel, has said they intend to submit a supplemental New Drug Application to the FDA yet this year seeking approval for use of Exparel in nerve blocks. Sustained release (liposomal suspension) local anesthetics are of interest in preventing post-operative pain because a one time injection may significantly reduce pain for three days. Injecting another local anesthetic can result in the immediate release of a large dose of the liposomal encapsulated local anesthetic resulting in systemic toxicity and it remains to be seen whether or not this becomes a significant safety risk. Click here for more information.

NBCRNA Recertification News

In years past you could not start accumulating CE credits for your next recertification period until after your last recertification period had ended, so after July 31 of your recertification year. NBCRNA recertification rules have changed a bit. Now the NBCRNA says that once your recertification has been approved you can start earning CE credits for your next recertification period. For example, say your recertification deadline is July 31, 2014. Once you have completed the recertification process for this year you can start earning CE that will count towards your 2016 recertification.

Here is a quote from the NBCRNA web site: "For example, an individual whose 2014 recertification application is approved on April 18, 2014 may start to earn credits for their 2016 recertification cycle the following day, April 19."


So, if you recertify early, once you've received your approval from the NBCRNA you may start earning CE credits that will count towards your next recertification period. This might be a reason to recertify early if you have CE money you want to spend right away or there is a meeting you really want to go to this summer but you already have all the CE you need to recertify this year.

Details are available on page 5 of this NBCRNA document.

Stethoscopes are as Contaminated with MRSA as Your Hands

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A recent study in May Clinic Proceedings showed what so many studies before it have shown; our hands and the equipment we use are easily contaminated with pathogens that can be spread to the next patient. In this case, the diaphragm of a stethoscope was shown to be contaminated with methicillin-resistant Staphylococcus aureus (MRSA) more often than any part of the clinicians' hands except the finger tips. Finger tips had a median 12 colony forming units (CFU, a way to count bacterial cultures per square cm surface area) and the stethoscope diaphragm had a median of 7. Other parts of the hand had half or less of this level of contamination. Of note, there was a strong correlation between the level of contamination on the clinicians' finger tips and the diaphragm of their stethoscope (r = 0.76, p < 0.001). So, there was a direct relationship between hand contamination and stethoscope contamination.

We are learning that health care providers, and anesthesia providers in specific, are easily contaminated with patient pathogens and can spread them to the next patient just as easily. While we are generally left wondering how to address this problem that seems too big to solve, this study suggests one thought that can easily be put into practice. When we think we need to wash or disinfect our hands, if we've used our stethoscope we need to clean it as well.

Labor Epidural may Prolong Labor by 2 Hours or More

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An upcoming retrospective study in Obstetrics & Gynecology finds that labor epidural analgesia may prolong the second stage of labor much more than previously reported. This is at odds with a landmark 2005 prospective study in the New England journal of Medicine (Wong CA et al. The risk of cesarean delivery with neuraxial analgesia given early versus late in labor. N Engl J Med 2005;352:655–65.) but that study involved only spinal analgesia for labor, not epidurals. If epidural analgesia really does significantly prolong labor, it may change obstetrical thinking. We will watch for the full text of this study to become available and evaluate it for inclusion in an upcoming issue of Anesthesia Abstracts.

Monitor Alarms & Patient Safety

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Some groups believe that "alarm fatigue" is a "top patient safety concern." They define alarm fatigue as "clinicians becoming desensitized to the constant noise ... or overwhelmed by the sounds and turning alarms down or off."

The Joint Commission believes there is a problem with alarms and issued a National Patient Safety Goal which went into affect the first of January, 2014. Basically, the Joint Commission is requiring that hospitals "improve the safety of their clinical alarm systems." This is important to anesthesia because hospitals will probably enact policies anesthesia is required to follow. These new policies will go into effect by January 1, 2016 and likely include sanctions if they are not followed. Unfortunately, alarm policies usually apply most directly to locations where a professional provider isn't standing right next the the equipment like we are in the OR. Alarms are often intended to call a provider to check on whatever is being monitored. If you don't want to be ruled by alarm policies intended for the masses in the rest of the hospital now is the time to become involved in the development of policies on alarms. The Joint Commission requires that there be input on these policies from, "medical staff and clinical departments." The complete Joint Commission R3 Report on alarm safety is only about 2.5 pages long and available online.

This is important to anesthesia because hospitals will probably enact policies anesthesia is required to follow.

Fierce Healthcare has reported that there are an average of 350 alarms per ICU patient per day. Missing from this discussion is how many of those alarms were clinically important and how many were nuisance alarms. Also not considered were how the alarms were set. Were they set based upon perceived institutional liability if there wasn't an alarm, or were alarms set in ways that alerted clinicians about things they needed to know? In a Boston University study resetting the alarm limits for HR to limits defined as a "clinical crisis" reduced alarms by 89% without any harm to patients. (J Cardiovasc Nurs. 2013 Dec 19. [Epub ahead of print].) In the OR with an anesthesia provider continuously attending to each patient some would argue that alarms can and should be set even more conservatively - and alarm much more quietly.