As the vials of propofol dwindle down to a precious few in surgical stockrooms across the country, administrators and anesthesia providers are trying their best not to panic. Easier said than done if you have to beg, borrow and back-order to get the drug that outpatient surgery runs on. And much more difficult than it sounds if all of a sudden you have to rely on unfamiliar drugs and techniques to sedate patients.

"We're all pretty crazed trying to find the proper drugs for our patients," says Pam Canfield, RN, MPA, the executive director of The Eye Center of Columbus in Columbus, Ohio. "We're desperate. It's really pretty bad, like an ongoing nightmare. One of our anesthesiologists put it best when he said, 'This is like asking a surgeon to work without suture.'"

Missy Hawley, RN, MSN, administrator of the Springfield (Ohio) Surgery Center, has lost track of how much time she's spent on the prowl for propofol. "I wish I would have logged the hours that I've spent on the phone trying to procure the drug," she says. "We've had to borrow from 2 local hospitals until a shipment comes in and we can replace it."

A propofol panic attack set in last month when a double dose of bad manufacturing news hit the 2 companies that supplied about 60% of U.S. propofol needs and plunged an already strained supply of the anesthetic to new lows.

First, the FDA announced a second recall of Hospira's propofol products. Then Teva, reeling from a $500 million verdict in the infamous case of the Las Vegas colonoscopy patient who was infected with hepatitis after a 50mL vial of propofol was used twice, announced that it's ceasing further production of propofol. "It's pointless to hold a company responsible for practitioners' negligence," says anesthesiologist Gene Viscusi, MD, director of acute pain management at Philadelphia's Thomas Jefferson University. A Teva spokesperson couldn't resist giving propofol a parting shot, saying the drug is hard to manufacture and the company gets little or no profit from it.

With Hospira and Teva on the sidelines, APP Pharma is left standing as the lone remaining American supplier. APP has 3 "flavors" of propofol: APP propofol 1% (generic Diprivan), propofol 1% (Diprivan) and international propofol 1% (Fresenius Propoven 1%), in agreement with the FDA. APP?says it's increasing its production of generic propofol and Diprivan and importing more European-made Propoven, which is contraindicated in patients who are allergic to soy or peanuts.

Coping mechanisms
The propofol shortage has sent surgical facilities of all sizes scurrying to load up on propofol or find suitable alternatives. Here's a look at how your colleagues are coping.

1. Stockpile as much of the drug as possible. Let's call this what it is: hoarding. This was the knee-jerk reaction of many of the facility managers with whom we spoke.

"We're ordering 10 cases every week with the hopes that at least 2 cases will be delivered in time before we run out," says one facility manager. Reports of price gouging are growing. Ms. Canfield says she's paid a premium for the few shipments she's received, 50% more than normal. "We've just paid whatever we have to pay to get it," she says.

Mary Ann Kelly, RN, administrator of the Madison (Ala.) Surgery Center, has been over-ordering propofol to build a reserve supply, even stacking several cases in her office.

One manager plans to install more locked cabinets so that she has space to store and lock the propofol. Others call ordering the drug from multiple suppliers "very costly" and "time-consuming."

2. Use alternative drugs. Surgical facilities are using more inhaled agents, more regional blocks and more hard-to-pronounce IV alternatives with less favorable profiles than propofol: Etomidate (Amidate), methohexital (Brevital), fospropofol disodium (Lusedra), Propoven and thiopental sodium (Pentothal) are the drugs most mentioned in conversations with readers.

Reviews are mixed. Patients at a hospital complained that Amidate burned their veins. On the lone day that the San Antonio Ambulatory Surgical Center in Upland, Calif., ran out of propofol, the anesthesiologists used Amidate. "They hated it and complained, and the patients were more nauseated post-op, but we got through it," says Director of Nursing Maureen Arciniega, RN, CNOR.

"I do induction with Brevital, Pentothal or Versed, and then complete with inhalation," says Charles H. Kates, DDS, associate professor of anesthesia and surgery at the University of Miami (Fla.) Miller School of Medicine. An anesthesia provider says he's "fallen in love with" using Lusedra with a modified inhalation technique (with N2O) to induce general anesthesia. "[Lusedra] has a slower onset than propofol," he says, "but it's very smooth and we have very little changes in the patient's hemodynamics."

Ms. Canfield says some of her cataract patients who received propofol for their first eye and then Versed-fentanyl for their second eye noticed the difference. "They weren't as comfortable," she says.

Some of the alternatives to propofol are causing longer PACU stays and increased nausea and vomiting. One facility that specializes in facial plastic and reconstructive surgery told us that increased straining with vomiting has led to a slight increase in post-op bruising and swelling. Aquavan caused an itching sensation that patients felt "from the inside out," thus ending its short-lived trial at the Madison Surgery Center, says Ms. Kelly.

They all pale in comparison to propofol. Take Brevital, for example. Sheldon Sones, RPh, FASCP, a pharmacy consultant to ASCs, calls it an "outdated barbiturate." Propofol, he says, "is many, many rungs up the ladder as the drug of choice in terms of comfort and recovery." Jay Horowitz, CRNA, of Sarasota, Fla., says the "beauty of propofol is that it's metabolized so fast. I can do an 8-hour plastic surgery case and the patient will be up and walking 15 minutes after I turn it off."

The lesson here is to be prepared with alternative drugs and techniques. "You have to have more than a single source for anesthesia meds for times like this," says an administrator.

3. Ration. Some facilities are making the propofol they have in stock last as long as possible by discouraging the use of continuous infusions, increasing gas inhalation inductions and combining propofol with other agents. "Docs who usually use straight propofol have now added Versed to their regime to cut back the dose of propofol," says one manager. Another told us, "Our anesthetist tried using more ketamine and Versed and less propofol. The result was unacceptable — post-op nausea, wild dreams and delayed recovery."

Norman P. Tomaka, BPharm, CPh, LHRM, of Doctor's GI Partnership in Melbourne, Fla., shares 2 ways to make propofol last longer: use fospropofol with propofol and add up to 100mg of intravenous lidocaine and midazolam 2mg to 4mg.

Others are giving in to the temptation to use single-use vials more than once, breaking the "1 syringe for 1 patient" rule by dividing up 50cc or 100cc vials under aseptic conditions into single-use 10cc or 20cc syringes to be used within several hours on different patients. This is a big no-no. Even in the face of the shortage, no government or professional body will endorse a practice where practitioners reused syringes and vials on multiple patients, especially in the wake of a Las Vegas jury handing down a $500 million verdict against Teva for making propofol vials that encouraged multiple use, thus triggering cross-infection of patients with hepatitis.

One manager told us that instead of the 20cc vials that she normally orders, she's only able to get 50cc or 100cc vials. So as not to pour the precious drug down the drain, her anesthesia providers draw up the propofol simultaneously each morning, put it in pre-loaded syringes and label it. "Not the preferred way," she admits. "It says 'single use' on the vial, but honestly we're getting as much out of it as we can."

"This isn't an option," says Mr. Sones. "People are going to jail over propofol. We cannot cross the line." He understands the dilemma you're in, though. "It's 1 vial for 1 patient, but if you have a 500mL vial and you use 100mL on a patient, you're throwing 400mL down the drain."

He suggests you benchmark how much propofol you're using per case and consider using less. Of course, this only works if you're able to procure small enough vials. Ed Harrich, director of surgical services for Pullman (Wash.) Regional Hospital, can only get 50cc vials. "This has increased our wastage," he says.

Canceled cases
Patients, too, are feeling the pinch. The propofol shortage has impacted scheduling. "We've almost had to cancel cases due to the fact that we didn't have any medications that could put a patient to sleep," says Karen Blackwell, RN, BSN, CASC, the nurse administrator of the Outpatient Surgery Center St. Augustine (Fla.). When last month's Hospira recall claimed all but 5 vials at Ms. Canfield's facility, she sent messages out to all her surgeons that any general surgery had to be cleared through anesthesia first. "That's how critical it became for us," she says. "It's so ludicrous that we should have to deal with something like this in this country."