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Propofol shortage & recommended alternatives (including benzodiazepines)


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Re: Propofol shortage & recommended alternatives (including benzodiazepines):

 

https://www.ashp.org/drug-shortages/current-shortages/Drug-Shortage-Detail.aspx?id=651

5/5/2020

 

Propofol Emulsion Injection

Products Affected - Description

Propofol intravenous emulsion injection, Dr. Reddy's, 10 mg/mL, 100 mL vial, 10 count, NDC 43598-0549-10

Propofol intravenous emulsion injection, Dr. Reddy's, 10 mg/mL, 20 mL vial, 10 count, NDC 43598-0265-58

Propofol intravenous emulsion injection, Dr. Reddy's, 10 mg/mL, 20 mL vial, 25 count, NDC 43598-0265-25

Propofol intravenous emulsion injection, Dr. Reddy's, 10 mg/mL, 50 mL vial, 20 count, NDC 43598-0548-21

Propofol intravenous emulsion injection, Pfizer, 10 mg/mL, 100 mL vial, 10 count, NDC 00409-4699-24

Propofol intravenous emulsion injection, Pfizer, 10 mg/mL, 20 mL vial, 25 count, NDC 00409-4699-30

Propofol intravenous emulsion injection, Pfizer, 10 mg/mL, 50 mL vial, 20 count, NDC 00409-4699-33

Propofol intravenous emulsion injection, Sagent, 10 mg/mL, 100 mL vial, 10 count, NDC 25021-0608-51

Propofol intravenous emulsion injection, Sagent, 10 mg/mL, 20 mL vial, 25 count, NDC 25021-0608-20

Propofol intravenous emulsion injection, Sagent, 10 mg/mL, 50 mL vial, 20 count, NDC 25021-0608-50

Propofol intravenous emulsion injection, Teva, 10 mg/mL, 100 mL vial, 10 count, NDC 00591-2136-68

Propofol intravenous emulsion injection, Teva, 10 mg/mL, 20 mL vial, 25 count, NDC 00591-2136-95

Propofol intravenous emulsion injection, Teva, 10 mg/mL, 50 mL vial, 20 count, NDC 00591-2136-51

Reason for the Shortage

 

Dr. Reddy's has propofol on shortage due to increased demand.[1]

Fresenius Kabi has Diprivan available but may experience intermittent back order due to increased demand. Check wholesaler for inventory.[2]

Pfizer has propofol on shortage due to increased demand.[3]

Sagent has propofol on shortage due to increased demand.[4]

Teva has propofol on shortage due to shipping delays related to COVID-19.[5]

 

Available Products

Diprivan intravenous emulsion injection, Fresenius Kabi, 10 mg/mL, 10 mL vial, 10 count, NDC 63323-0269-10

Diprivan intravenous emulsion injection, Fresenius Kabi, 10 mg/mL, 100 mL vial, 10 count, NDC 63323-0269-65

Diprivan intravenous emulsion injection, Fresenius Kabi, 10 mg/mL, 20 mL vial, 10 count, NDC 63323-0269-29

Diprivan intravenous emulsion injection, Fresenius Kabi, 10 mg/mL, 50 mL vial, 20 count, NDC 63323-0269-50

 

Estimated Resupply Dates

Dr. Reddy has propofol 20 mL, 50 mL, and 100 mL vials available in limited supply. The next estimated release date is October 2020.[1]

Pfizer has propofol 20 mL and 100 mL vials available in limited supply for direct shipment only. The 50 mL vials are on back order and the company estimates a release date of May 2020.[3]

Sagent has propofol 20 mL, 50 mL, and 100 mL vials on allocation.[4]

Teva has propofol 20 mL, 50 mL, and 100 mL vials on intermittent back order and the company is allocating upon release. [5]

 

Implications for Patient Care

These recommendations are in alignment with the Surviving Sepsis Campaign: Guidelines on the Management of the Critically Ill Adults with Coronavirus Disease 2019 (COVID-19) and 2018 PADIS clinical practice guidelines

1. For mechanically ventilated adults with COVID-19 and moderate to severe ARDS - patients without persistent ventilator dyssynchrony, use of intermittent boluses of neuromuscular blocking agents (NMBAs) as needed over continuous infusions.

2. For mechanically ventilated adults with COVID-19 and moderate to severe ARDS - patients with persistent ventilator dyssynchrony, use of continuous NMBAs up to 48 hours along with other lung recruiting measures.

3. Critically ill patients requiring deep sedation should not use dexmedetomidine (with or without NMBAs).

Alternative Agents & Management

Historically, providers commonly used benzodiazepines to sedate critically ill patients. Practice has shifted over the last decade to lighter sedation and the minimization of benzodiazepine use due to an association with prolonged mechanical ventilation.[7-8] In a time of drug shortages and supply delays, ICU providers may have to resort to older sedation practices that are out of favor. The tables below contain sedation and monitoring strategies to targeted sedation goals (eg, RIKER) for mechanically intubated adults.

 

Summary of sedative use considerations:

Propofol is preferred over benzodiazepines, especially in the setting of prolonged intubation and deep sedation.

An elevated triglyceride is not considered a strict exclusion to propofol use, but continued monitoring and strategies for dose-reduction are encouraged if triglyceride is >400 mg/dL to minimize risk of pancreatitis.

Due to limited supply or other contraindications to propofol, a benzodiazepine may be an alternative agent.

If midazolam supply is limited, consider allocating to patients with moderate to severe renal or hepatic dysfunction. For all others, consider lorazepam as the benzodiazepine of choice to preserve midazolam supply.

Midazolam has a higher propensity than lorazepam to accumulate metabolites that produce CNS depression and altered mental status. Half-life elimination is especially prolonged in cirrhosis, CHF, and obesity.

There is little use for dexmedetomidine as a primary sedative agent when patients require deep sedation for ventilator compliance.

Ketamine and phenobarbital may be considered as adjunctive agents for sedation, but not as primary sedatives for ICU sedation.

Consider the use of scheduled atypical anti-psychotic agents for hyperactive delirium.

Intravenous agents are preferred in the setting of NMBA use due to concern over impaired absorption of enteral agents.

Narcotics and paralytics put patients at high risk for ileus and aggressive bowel regimens should addressed.

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  • 3 weeks later...

I had surgery for idiopathic subglottic stenosis on April 4th, 2020.

 

I adamantly said I would not accept  midzolam (versed), and I pretty much demanded propofol, and that’s what I got.

 

However, full disclosure here: I was told that  midzolam was too short acting to be used for this type of surgery anyway. 

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