Author Archives: Caryn Beck

Lorazepam Injection Shortage 12.5.18

To:            Physicians, Nursing, Pharmacy

From:     Alan Mader, Pharmacy Clinical Coordinator

Date:      12/5/2018

Re:   Lorazepam Injection Shortage

SituationLorazepam 2mg/mL 1 mL vials are on manufacturer on backorder.   The estimated re-supply date of November 2018 has already been exceeded.  Other projections for release include December 2018 to January 2019, with others extending to January 2020.
BackgroundLorazepam 2 mg/mL 10 mL vials have been on backorder since November 2017.
AssessmentThe addition of the 1 mL vials to backorder status severely limits availability of lorazepam injection.  While the pharmacy maintains some supply of lorazepam injection, the probability of depletion of stock before repletion is high.  Use of other benzodiazepines may become necessary.
RecommendationFor patients who currently require lorazepam, please consider use of the PO route whenever possible.

While there are no direct dose conversions between benzodiazepines, please consider the following information on pharmacokinetics to aid in selection of an alternative:

MedicationOnset

IV (minutes)

Onset

IM (minutes)

Duration

IV

(hours)

Duration

IM

(hours)

T ½

(Hours)

Active metabolites
Diazepam

(currently available in MDV’s only)

1 to 5Slow and erratic absorption0.3 to 0.5Slow and erratic absorption20 to120Yes
Lorazepam5 to 2015 to 306 to 86 to 88 to15No
Midazolam

5 mg/1 mL

5 mg/5 mL

2 mg/2mL

1 to 55 to 15≤22*3 to 11Yes

Pharmacologic effect of Midazolam may last up to 6 hours in some patients

Drug Shortage 0.45% NS Liter Bags 11.27.18

To:            Nursing, Pharmacy, Physician Staff

From:     Maryna Shayuk, Chair Pharmacy and Therapeutics

Alan Mader, Pharmacy Clinical Coordinator

Date:        11/27/18

Re:            Drug Shortage:  0.45% NS liter bags

S

Situation

0.45% NS in liter bags have been placed on shortage at this time.
B

Background

This shortage was unexpected and was announced today.
A

Assessment

Substitution during this shortage will be necessary
R

Recommendation

Pharmacy will utilize the following plan to substitute orders written for 0.45% NS:

0.45% NaCl to 0.9% NaCl – for pre & post-surgery.

If patient is hypernatremic, substitute with Lactated Ringers.

All other orders call MD.

Pharmacy services will place “Substituted for ________” in the comment section of the Paragon order so that nursing is aware of the change.

DiphenhydrAMINE Injection Shortage 10.15.18

To:            Physicians, Nursing, Pharmacy

From:     Maryna Shayuk, MD, Chair Pharmacy and Therapeutics

                  Alan Mader, Pharmacy Operations Coordinator

Date:        October 15, 2018

Re:            Diphenhydramine Injection Shortage

S

Situation

Diphenhydramine injection supply is critically low. Estimates indicate less than a 2 week supply throughout NM Northwest system.
B

Background

Diphenhydramine has been on shortage. Pharmacy Purchasing has been able to obtain orders up to this point.
A

Assessment

In order to maintain the limited supply for crash cart exchange, sequestering to pharmacy and therapeutic substitution will need to be instituted.
R

Recommendation

Pharmacy will sequester remaining supply from Pyxis machines to the Pharmacy Department.   Therapeutic Substitution will take place as follows:

Injection to PO – For all patients who can take PO in equivalent dose.

If unable to take PO – Therapeutic substitution to Promethazine Injection in equivalent dose.   Doses greater than 25 mg – consult with MD.

 

Dexamethasone 10 mg/1 mL Preservative Free SHORTAGE 10.4.18

To:             Physician, Nursing, and Pharmacy Staff

From:        Alan Mader, PharmD, Pharmacy Clinical Coordinator

Date:         10/4/18

Re:             Dexamethasone 10 mg/mL 1 mL Injection PF Shortage

S

Situation

 

We have been notified that dexamethasone 10 mg/mL 1 mL PF has been placed on the shortage list.

B

Background

 

This shortage has been newly announced.

A

Assessment

The quantity of 1 mL PF vials available at NWM, NWH, NWW is 110.  The usual consumption at NWH is approximately 18 per day, with NWM and NWW being less.  Based on that number and the ability to shift product between campuses, we have about a 5 day supply available.  The shortage is expected to last from the end of October to mid-November, so that likelihood that supply will become depleted is strong.
R

Recommendation

 

Utilize dexamethasone 10 mg/mL 1mL Injection with preservatives wherever possible.

Sodium Bicarbonate Inj Shortage 10.1.18

To:      Physician, Nursing and Pharmacy Staff
From: Maryna Shayuk, MD, Chair, Pharmacy and Therapeutics
            Alan Mader, PharmD, Pharmacy Clinical Coordinator
Date:   9/26/2018
Re:        Sodium Bicarbonate Injection Shortage

Situation

Sodium Bicarbonate 8.4% Injection 50 mL is currently on shortage. There are different projections on how long this shortage will last, with some continuing until 2019. Sodium Bicarbonate is used for CODE BLUE situations and is available in Crash Carts. It is also used for Open Heart Surgery and for Toxicologic Emergencies.

Background

The supply of Sodium Bicarbonate 8.4% Injection has not been stable for some time.

Assessment

With uncertain supply, steps to maintain availability for Crash Cart Supply and for Open Heart Surgery need to be implemented.

Recommendation

Pharmacy will sequester supply to maintain stock for Crash Carts and for the surgical Open Heart room. When orders are received for sodium bicarbonate infusion, pharmacy will directly provide recommendation with the ordering physician to use sodium acetate injection. Information on the use of sodium acetate infusion is shown below:

Toxicologic Emergencies – Use Sodium Acetate 2 mEq/mL
a. Bolus (if required) – 1 mEq/kg/D5W 500 mL infused over 20 minutes (consistent
with information presented by ASHP). 150 mEq maximum to avoid osmolarity issues.
For patients over 100 Kg, infuse over 30 minutes.
b. Maintenance: Na Acetate 150 mEq/D5W 1000mL infused at 200 mL/hr for adult
patients. 3 bag limit. The same rate would be used for urine alkalinization.

We are anticipating that the shortage will end before supply becomes depleted. If that is not the case, sodium acetate may also be used in Code situations as follows:

Crash Cart/Code situation – Requires dilution/infusion. 50 mEq Sodium Acetate added to 100 mL D5W (125mL TV) administered over 10 minutes

Sodium Phos and Potassium Phos Inj Shortage 10.1.18

To:      Physician, Nursing and Pharmacy Staff
From: Alan Mader, Pharmacy Clinical Coordinator
Date:  10/1/2018
Re:       Sodium Phosphate Injection Shortage
             Potassium Phosphate Injection Shortage

Situation

Both Sodium Phosphate and Potassium Phosphate Injection are on shortage. Currently the system is in very low supply of Sodium Phosphate and pharmacy has transferred supply from the Huntley campus to the McHenry campus. The Sodium Phosphate shortage is projected to last 2 to 4 weeks. The Potassium Phosphate shortage is projected to last until late December.

Background

These shortages have been newly announced.

Assessment

Sodium Phosphate supply is very low within the system (17 vials). While Potassium Phosphate is currently in greater supply, projections indicate that it may remain on the shortage list an additional month longer that Sodium Phosphate.

Recommendation

Please conserve both Sodium and Potassium Phosphate Injection. Wherever possible, please consider oral replacement with Neutra Phos equivalent. Each packet contains: Sodium 160 mg (7.1 mEq), Potassium 280 mg (7.1 mEq), Phosphorus 250 mg (8 mMol).

Influenza Vaccination in Patients with Egg Allergy

Guideline Watch | GENERAL MEDICINE, INFECTIOUS DISEASES

January 11, 2018

Influenza Vaccination in Patients with Egg Allergy

David J. Amrol, MD reviewing Greenhawt M et al. Ann Allergy Asthma Immunol 2018 Jan .

All available flu vaccines are safe in all egg-allergic patients.

Sponsoring Organizations: American Academy of Allergy, Asthma, and Immunology (AAAAI); American College of Allergy, Asthma, and Immunology (ACAAI)

Target Audience: All providers who administer influenza vaccines

Background

Historically, patients with egg allergy have been told to avoid flu vaccines, because most flu vaccines are produced in embryonated chicken eggs; the concern was that a vaccine might contain residual egg protein, which could lead to anaphylaxis. Many studies have shown that flu vaccines are safe for egg-allergic patients, but many physicians still have been hesitant to vaccinate such patients. This updated practice parameter incorporates recent data on flu vaccine safety in egg-allergic patients, including children.

Key Recommendations

  • Flu vaccines should be administered annually to patients with egg allergy of any severity, with no need to ask recipients about egg-allergy status and no special precautions beyond those recommended for administering any vaccine to any patient. This recommendation applies to both injected and intranasal formulations (although the latter should not be used in the 2017−2018 flu season).
  • Non−egg-containing vaccines can be used but are not necessary or preferred over standard vaccines.
  • The intranasal live attenuated flu vaccine also might be used, if it’s shown to be efficacious and is approved for use.
Comment

Egg-allergic patients can be vaccinated safely with any available age-appropriate flu vaccine, with no special precautions, regardless of egg-reaction history (including anaphylaxis). Concern for egg allergy only adds another barrier to universal flu vaccination, and this practice parameter concludes by stating the following: “Vaccine providers and screening questionnaires do not need to ask about the egg allergy status of recipients of influenza vaccine.”

Editor Disclosures at Time of Publication

Disclosures for David J. Amrol, MD at time of publication

Consultant / Advisory boardCSL Behring; Horizon Pharmaceuticals
Citation(s):

Greenhawt M et al. Administration of influenza vaccines to egg allergic recipients: A practice parameter update 2017. Ann Allergy Asthma Immunol 2018 Jan; 120:49. (http://dx.doi.org/10.1016/j.anai.2017.10.020)

DOBUTamine Shortage 11.15.17

Physicians,

There is a nationwide shortage on DOBUTamine 500 mg/250 mL IVPB.  At present consumption, we expect CHS has about a 12 day supply.  We may continue to receive backordered quantity, but we cannot rely on this.  Please be aware of this shortage and consider alternatives as our supply depletes.

Thank you,

Alan Mader, PharmD, BCPS

Clinical Coordinator

Department of Pharmacy Services

Centegra Health System

815-759-4407

Morphine Injection Shortage

Morphine Injection Shortage 10.18.2017

There is a nationwide shortage of morphine injection that expected to last until early to mid-November. The Pharmacy Department is running very low on supply and expects that the drug will become unavailable.  Please consider ordering an alternate injection product for pain management.  An opioid dose conversion chart is included below for your convenience.

A

Analgesic

B

Oral

C

Parenteral

D

Oral: Parenteral Ratio

E

Oral Morphine: Analgesic Ratio

F

Analgesic Duration

G

Half Life

Morphine30 mg10 mg3 : 11 : 14 – 6 hrs3 hrs
Oxycodone20 mg1.5 : 13 – 5 hrs4 – 5 hrs
Hydromorphone7.5 mg2 mg 4: 14: 13 – 4 hrs2 – 3 hrs
Fentanyl100 mcgSee Table B on page 21 hr3 – 12 hrs
Methadone20 mg10 mg2 : 1See Table C on page 24 – 12 hrs15 – 50 hrs
Codeine200 mg130 mg1.5 : 11 : 74 – 6 hrs3 hrs
Hydrocodone30 mg1 : 13 – 6 hrs3 – 4 hrs
Meperidine300 mg75 mg4 : 11 : 102 – 4 hrs2 – 3 hrs
Nalbuphine10 mg1 : 13 – 6 hrs5 hrs