Doctors brace for shortages of sedation drugs needed for surgeries, intubation

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The federal government has flagged serious concerns over shortages of drugs used to sedate patients and help them breathe – drugs that are critical in the treatment of COVID-19.

Health Canada has placed 19 drugs on its “Tier 3” list, which is reserved for shortages that “have the greatest potential impact on Canada’s drug supply and health-care system.”

Most of those on the list are used to help patients breathe or to sedate them, such as when a COVID-19 patient needs to be intubated before being placed on a ventilator. The medications, which include injectable fentanyl, propofol, salbutamol and midazolam, are experiencing a surge in demand around the world as a result of the pandemic.

“In a lot of cases, we don’t have any alternatives if they were to be short,” said Christina Adams, chief pharmacy officer with the Canadian Society of Hospital Pharmacists. “The risk is very, very high if we run short. The potential is there and is quite significant.”

While many of the medications are not currently in short supply, they have been placed on the Tier 3 list to help the government, hospitals, industry and other stakeholders manage stockpiles. Ms. Adams said putting drugs on the list allows Health Canada to take a number of steps, such as expediting the importation of lots of medication that have been approved in the United States or Europe, but are not properly labelled for the Canadian market.

Three of the drugs on the list – atracurium, pancuronium and vecuronium – are not currently sold in Canada, but giving them a Tier 3 designation means Health Canada can try to source them from other countries, Ms. Adams said.

Jim Kim, head of the anesthesia department at St. Paul’s Hospital and Mount Saint Joseph Hospital in Vancouver, said the reality of the global drug supply means Canada must rely on other countries for most of its prescription medications, which is posing a significant challenge during the pandemic.

“Anything with medical supply chains, they’re all disrupted,” Dr. Kim said. “All our anesthesia and sedating drugs we use a lot in the ICU are strained.”

Between 50 per cent and 80 per cent of the drugs used in Canada come from India or China, said Barry Power, the senior director of digital content with the Canadian Pharmacists Association. Most of the production in China has been shut down for months because of COVID-19, which has led to supply issues with all kinds of drugs, not just those used in the pandemic fight, Mr. Power said.

“When China shuts down, the production of drugs for the world kind of shuts down,” he said.

For instance, Mr. Power said his association is hearing reports of shortages of amoxicillin, an antibiotic commonly prescribed for childhood ear infections and other ailments. To help guard against widespread shortages, the association is asking pharmacists across the country to only dispense 30-day supplies of medications to patients.

The drugs on the Tier 3 list used to treat COVID-19 patients are also used to sedate patients undergoing surgery and to help manage other illnesses.

Ms. Adams said one drug in particular, propofol, is a widely used anesthetic and has no alternative.

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“It would be unthinkable to actually run out of propofol,” she said.

Dr. Kim said he and his colleagues have started using a new technique during surgery in an effort to conserve drugs such as propofol. Instead of giving patients general anesthesia, which renders them unconscious, Dr. Kim is using nerve-blocking drugs delivered through the spine during some types of surgery, such as partial mastectomies. He said eight of these surgeries were performed last Friday and the results were good.

Dr. Kim added that patients who do not receive general anesthesia typically recover faster and require fewer narcotic painkillers, but said he and his colleagues will continue to study the satisfaction levels with his new surgical technique.

One of the few drugs on the Tier 3 list that is actually in short supply is inhalable forms of salbutamol, sold under the brand name Ventolin. Inhalers of salbutamol are commonly used by people with asthma or chronic obstructive pulmonary disease.

Hospitals typically use a liquid form of the drug, which is converted into a mist using a nebulizer machine. But for COVID-19 patients, nebulizer treatments can increase the amount of the virus that is circulated into the air, which raises the risk of infection for health care workers. Now more hospitals are using inhalable forms of the drug, depleting the supply much more quickly, Mr. Power said.

Health Canada issued an alert about the shortage last week, advising individuals that they will only receive one-month refills and should not throw away expired inhalers until they receive a replacement.

In a statement, Health Canada spokesperson Geoffroy Legault-Thivierge said the government has been “proactively looking” at potential supply chain issues to mitigate potential shortages and is working with provinces, the industry and foreign governments on securing a stable supply of many of those medications.

This week, the department issued several requests for information to companies to ask if they have any additional supplies of several drugs, including salbutamol, fentanyl for injection and propofol. The RFIs indicate the government wants to provide up to a 12-month supply of the drugs.

Concerns over shortages of sedating drugs will make it more difficult for hospitals to ramp up surgeries that had been postponed to make way for a possible surge of COVID-19 patients, said Daniel Bainbridge, president of the Canadian Anesthesiologists’ Society.

“At some point, we’re all hoping the [operating rooms] are going to start doing elective and urgent cases again. I think that’s probably when the shortage may suddenly rear its ugly head,” Dr. Bainbridge said. “We’re not going to have the supplies to do it.”

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