Drug supply and demand during the COVID-19 pandemic

It will have escaped no one’s notice that at the moment a lot more patients are needing intensive care than is usually the case. Where possible, critical care units across the United Kingdom are doubling, tripling or even quadrupling their capacity and the new Nightingale hospitals are expanding that capacity even further.

As anaesthetists we are seeing our ventilators, theatres, recovery areas, and indeed ourselves, being redeployed to help manage the intensive care workload, whilst intensivists are having to work with new equipment and a new workforce in a radically altered working environment. Even people such as myself, a long in the tooth obstetric anaesthetist, have been cross-skilled to help out.

We’ve seen a lot about companies such as Dyson and Rolls Royce being asked to help produce ventilators but we all know that without the drugs to sedate, paralyse and provide cardiovascular support to our patients, such ventilators would be lying idle. That’s why headlines such as ’We’re running out of drugs to treat the sickest patients’ and ’NHS supply crisis’ will have worried both healthcare professionals and importantly the public and our patients.

We’re used to dealing with temporary shortages of drugs. Recent ones that spring to mind are diamorphine, hyperbaric bupivacaine, and the neostigmine / glycopyrronium mix, to name but a few. What usually happens is that your pharmacy department alerts you to the shortage and you then reserve supplies of that drug for priority areas, whilst also drawing up protocols for the use of suitable alternatives. For example, when diamorphine was in short supply some units prioritised it for use in neuraxial administration in obstetric patients, whilst using alternatives such as fentanyl or morphine for others. This is normal practice for us, but it does need coordinated management to ensure that alternatives are sourced and used correctly. The current situation is the same but on a bigger scale and we all, intensivists, anaesthetists, pharmacists, government and the drug industry to name but a few, need to work together to make sure we provide our patients with safe and effective care.

You will have seen the guidance produced by the College, the Faculty of Intensive Care Medicine, the Association of Anaesthetists, and the Intensive Care Society which gave practical advice about how to manage patients in these times of increased demand. For anaesthetists, this was providing guidance on how to use less of the drugs that are likely to be needed in intensive care. Propofol is an obvious one and our advice was to use inhalational agents such as sevoflurane for maintenance of anaesthesia where this was practicable, but also to think about alternative techniques such as neuraxial or regional anaesthesia. For intensivists there was advice around which patients might be suitable for sedation with midazolam and morphine, rather than propofol and alfentanil as well as suggestions for use of oral adjuncts. There’s a lot more than this in both sets of guidance so take a look if you haven’t done so already, as they are both useful and practical.

However, we all know that when we haven’t used a particular drug for a while we need a bit of a refresher on things like dosage and characteristics in use. Let’s take the example of sodium thiopental for induction of anaesthesia. Many of us are old enough to remember when it was the most often used induction agent. We know that it is a safe and effective drug but some younger colleagues may only know about it through use in neuro intensive care, banter about “the old days”, or as part of revision for the FRCA exams – although even there its presence has waned. You may not know that it has the distinct advantage that it’s really obvious when your patient has gone to sleep nor that it is painless on injection, providing it’s given into a vein. For that reason we are producing some simple, practical infographic advice that will refresh people’s memories – keep an eye out for this on the College’s twitter channel and the COVID-19 guidance and information hub.

In addition to the measures that we can all take to rationalise our use of drugs, the Chief Pharmaceutical Officer and his team at NHS England are liaising closely with the pharmaceutical industry. Companies are being asked to look at how they could prioritise and increase production of the drugs we need, and efforts are being made to source them from elsewhere.

The bottom line is that whilst the increased demand for drugs is a reality, there are alternatives that we can use and our patients can be reassured that they will be able to get the treatment they need when they need it.

Fiona Donald