key: cord-0966756-nqpoecq1 authors: Siow, Wen Ting; Tang, Simeon H.; Agrawal, Rohit Vijay; Tan, Addy Y. H.; See, Kay Choong title: Essential ICU drug shortages for COVID-19: what can frontline clinicians do? date: 2020-05-26 journal: Crit Care DOI: 10.1186/s13054-020-02971-x sha: 47bc6e740e8d99e30795669d149600de9e71b019 doc_id: 966756 cord_uid: nqpoecq1 nan and colleagues highlighted ten critical issues [1] , top-most being a severe shortage of critical medical resources including physicians, nurses, and ICU beds. We would like to highlight a related issue in Singapore that will likely also apply elsewhere. Despite having adequate staff, beds, and equipment, supply chain disruptions has led to several ICU drugs being in short supply. For instance, drugs like propofol, atracurium, and noradrenaline have been projected to last less than 1 month in Singapore without fresh supplies. From an organizational standpoint, the American Society of Health-System Pharmacists has provided valuable guidance regarding operational assessment, therapeutic assessment, shortage impact analysis, and inventory system changes [2] . Adding to a systems approach, frontline clinicians can help alleviate these drug shortages by identifying the drugs in short supply, considering alternatives and assessing the risks when using these alternatives (Table 1) . Optimizing current drug stocks and reducing waste would require a concerted effort by frontline clinicians. Physicians can use light sedation targets or even no sedation with analgesia only, avoid neuromuscular blockade, use train-of-four measurements to avoid overdosing of neuromuscular blockade, and allow permissive hypotension (lowering the mean arterial pressure target to 60-65 mmHg) [3] . Nurses can standardize intravenous drug dilutions to negate the need for re-dilution when patients are transferred between different clinical units, use low rather than high concentration drug infusions for more accurate titration to the lowest permissible dose, and perform daily or twice-daily awakening trials for suitable patients. Pharmacists can reinforce physician and nursing practice by monitoring drug use patterns, suggesting viable alternatives, checking for drug interactions, and advising on safe administration practices. It is not inconceivable that even alternative medications can run out, especially in regions that are already resource-limited. In such cases, non-pharmacologic or unconventional measures should be explored. For instance, analgesia may be attained through acupuncture, and anxiety can be alleviated with patient-directed music intervention [4] . Another example is oral midodrine, which is currently being investigated as a means to wean critically ill patients from intravenous vasopressors [5] . Drug shortages may compel clinicians to use oral midodrine as a sole agent for blood pressure augmentation. Physicians, nurses, and pharmacists would then need medicolegal protection when using therapies that are off-label, but that would be necessary for the well-being of patients. • 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 IV intravenous Covid-19 in China: ten critical issues for intensive care medicine ASHP guidelines on managing drug product shortages Effect of reduced exposure to vasopressors on 90-day mortality in older critically ill patients with vasodilatory hypotension: a randomized clinical trial Effects of patient-directed music intervention on anxiety and sedative exposure in critically ill patients receiving mechanical ventilatory support: a randomized clinical trial Feasibility, utility, and safety of Midodrine during recovery phase from septic shock Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations Wen Ting Siow: Drafted and revised the article and table Simeon H Tang: Revised, proofread, and edited the table and Availability of data and materials Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.Ethics approval and consent to participate Not applicable The authors declare that they have no competing interests.