Medication Shortages

Continuous IV fluid boluses of normal saline and my patient, admitted with sepsis, is still hypotensive. His systolic blood pressure is staying in the 70’s and his mean arterial blood pressure is 48…. it should be 60.  One of the most important principles (from my perspective) in caring for a patient in septic shock, regardless of the infectious source, is good blood pressure management.  The cascade of complications that come from poor end organ perfusion are significant.

Fluid blouses for this patient was an appropriate place to start.  After a few liters of saline the doctors decided to try Vasopressin.  As a vasoactive agent, it is one of 2 drugs that are considered the gold standard for the treatment of sepsis.  The medication came from the pharmacy, I spiked the bag, programmed the IV pump, and waited.  Vasopressin runs slow (2.4ml/hr), in sepsis treatment it is a non-titrating medication.  I waited about 40 minutes at the bedside and there was no major change in his blood pressure.  My patient was on the ventilator, receiving no sedation, and following simple commands; though he was pretty sick and lethargic.  His urine output was minimal.  I paged the resident on call and we chatted about the next step to take.  He decided on a Norepinephrine infusion.  Norepi as an endogenous hormone (a hormone our body makes naturally) it is the second medication, in combination with vasopressin, that is part of gold standard sepsis treatment.  I faxed the order  to the pharmacy and anticipated a relatively quick delivery. Instead, I received a phone call from the pharmacist “I need to talk with you about what’s going on with this patient… You know there’s a shortage of norepi.  Are you sure he warrants it; or can we try a different pressor?”

How should I answer this question?  As a nurse it is not my role to decide who is worthy or not worthy of medications.  I also don’t know what’s going on with the patients in the rest of the hospital.  My patient is profoundly septic, and showing signs of the early stages of end organ failure.  From my perspective there is no question.  We could try a different vasoactive medication to increase his blood pressure, but vasopressin and norepinephrine work amazingly well and that is why they are part of the gold standard treatment.

My response to the pharmacist was “It is not my job to decide who, in a time of severe medication shortages, should and shouldn’t receive medications. I think he’s appropriately ill enough to be helped by it. ”  I left it at that.

They did send the medication up to but this situation really got me thinking about and reading about the medication shortage that we are facing.

We [nurses]in the hospital, get alerted weekly about additional medications that are on short supply throughout the country.  If you look at the medications that are on the shortage list per the American Society of Health-System Pharmacists; it is very long, filled with medications that are used everyday, and updated continuously.  Norepinephrine and Vasopressin are both on the list.

The FDA states on its website that it:

 ” recognizes the significant public health consequences that can result from drug shortages and takes tremendous efforts within its legal authority to address and prevent drug shortages. “

While I find that to be a fine statement; if you read on, the reporting of medication shortages is on a voluntary basis in the U.S.  That does not make sense.  If drug companies have problems with quality medication production, or they altogether just want to stop making a certain medication then that should be a mandatory reporting situation.

The medication shortage, facing health care, has been discussed on NPR’s health bog Shots and on MSNBC’s Health Care blog with good discussion.  The issue is being addressed by congress: the Preserving Access to Life-Saving Medications Act was sponsored by Amy Klobuchar a senator from MN. The bill would mandate shortage reporting on behalf of drug companies.  This seems like a simple enough bill to me, and though there was testifying in front of congress in July, the last action taken on this bill was in February.

I understand the fact that these medications aren’t money makers, but drug companies shouldn’t need to be incentivized to manufacture the medications that are the bread and butter of our health care system.

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