| Welcome to The New Coffee Room. We hope you enjoy your visit. You're currently viewing our forum as a guest. This means you are limited to certain areas of the board and there are some features you can't use. If you join our community, you'll be able to access member-only sections, and use many member-only features such as customizing your profile, sending personal messages, and voting in polls. Registration is simple, fast, and completely free. Join our community! If you're already a member please log in to your account to access all of our features: |
| Drug Regulation: Good and Bad | |
|---|---|
| Tweet Topic Started: Jan 5 2010, 08:35 AM (768 Views) | |
| George K | Jan 5 2010, 08:35 AM Post #1 |
|
Finally
|
We're having an interesting crisis (at least to me) nationwide because of a drug shortage. Backstory - There are three drugs that are used for induction of anesthesia (I'll use trade names because it's easier). Yes, there are others, but they have so many side effects that we'll disregard them (Ketamine, for example). 1) Pentothal: Been around since the 1940s. Rapid acting barbituate. Advantages: Painless on injection, short duration (10 min). Disadvantages: Can cause nausea and vomiting, slowly cleared from the body resulting in a "hangover" in lots of people, causes severe hemodynamic instability, particularly in the elderly and frail (It's claimed that Pentothal killed more GIs at Pearl Harbor than the Japanese because its hemodynamic effects were not understood). It's a crappy drug, but for decades, it was the best we had. 2) Amidate (Etomidte): Been around since the early 80s. Rapid acting drug. Advantages: No hemodynamic instability. Disadvantages: Severe SEVERE pain on injection. Causes generalized myoclonus (muscle shaking that looks like a seizure) in large percentage of patients. Causes suppression of adrenal stress response. 3) Diprivan (Propofol): Been around since the early 90s. Advantages: Extremely rapidly cleared, with no hangover. Causes euphoria and a sense of well-being. Has an anti-nausea effect. Disadvantages: Some pain on injection. Can cause hemodynamic instability (about the same as Pentothal). If opened, can become a source of infection (bacteria grow in the bottle) within 6 hours. If you don't use it soon, pitch it. Diprivan is the best thing to come onto the anesthesia scene in decades. People go home faster, feel better, and has changed outpatient surgery. Given by infusion, it can be the sole anesthetic for simpler cases (like kidney stone lithotripsy). Okay, with that background, here's the problem: There are three manufacturers of Diprivan. One is the brand name, the other two are generics. In October, iirc, the two generics developed problems. One had contamination in a batch with bacteria. It was caught before it became an issue, and they ceased production while cleaning up the process. The other company found an unspecified "particulate matter" in their stuff, and they shut down as well. The brand name company couldn't keep up with the demand, and they are out. There is no Diprivan to be had - anywhere in the country. They're saying "early this year" - and our pharmacist says that could be April. All we have is about 30 bottles - enough for 1-2 day's cases. Then, we're done, and we have to go to option #1 or 2 (above). As I mentioned, Amidate is a crappy drug. People actually scream when it's injected. It's only advantage is its hemodynamic stability. So, why not go to the old standby, Pentothal? Government regulation. Because Pentothal (and all barbs) is considered a "controlled substance", any manufacturer has to notify the FDA (or DEA) how much they plan to make in the coming year. That amount, the pharmacist tells me, is set in stone. So, when the national shortage of Diprivan came up in November, the manufacturers of Pentothal were already locked in. Besides, it would take them months to ramp up anyway. There is no pentothal - zero - in the hospital. We are so screwed. There are certain types of surgery (neurosurgery) that REQUIRE the use of Diprivan because it doesn't interfere with their monitoring. We're telling the neurosurgeons these cases have to be cancelled for now. Pfft... |
|
A guide to GKSR: Click "Now look here, you Baltic gas passer... " - Mik, 6/14/08 Nothing is as effective as homeopathy. I'd rather listen to an hour of Abba than an hour of The Beatles. - Klaus, 4/29/18 | |
![]() |
|
| QuirtEvans | Jan 5 2010, 08:39 AM Post #2 |
|
I Owe It All To John D'Oh
|
Ouch. |
| It would be unwise to underestimate what large groups of ill-informed people acting together can achieve. -- John D'Oh, January 14, 2010. | |
![]() |
|
| Mark | Jan 5 2010, 08:40 AM Post #3 |
|
HOLY CARP!!!
|
Further proof we have morons working at the FDA. |
|
___.___ (_]===* o 0 When I see an adult on a bicycle, I do not despair for the future of the human race. H.G. Wells | |
![]() |
|
| QuirtEvans | Jan 5 2010, 08:42 AM Post #4 |
|
I Owe It All To John D'Oh
|
So, George, what's the solution? If there's no propofan and no pentothol, do you now have to use Amidate for all surgeries? What an awful outcome. |
| It would be unwise to underestimate what large groups of ill-informed people acting together can achieve. -- John D'Oh, January 14, 2010. | |
![]() |
|
| Jolly | Jan 5 2010, 08:46 AM Post #5 |
![]()
Geaux Tigers!
|
Amen. |
| The main obstacle to a stable and just world order is the United States.- George Soros | |
![]() |
|
| George K | Jan 5 2010, 08:49 AM Post #6 |
|
Finally
|
There are always alternatives: 1) Induce with a drug like Versed. In doses enough to get to sleep, it'll last hours and hours. Day surgery units will be overflowing with people (slowly) waking up. 2) Induce anesthesia with a mask. It can be done, but it ain't pretty. Also, many people have an objection to having a mask put on their faces - they freak out. 3) Amidate it is. I used it half a dozen times on Friday, Saturday, and Sunday. Suffice it to say that the 6'2" 190 lb. football player 19 year old with appendicitis on Sun AM objected to the pain. |
|
A guide to GKSR: Click "Now look here, you Baltic gas passer... " - Mik, 6/14/08 Nothing is as effective as homeopathy. I'd rather listen to an hour of Abba than an hour of The Beatles. - Klaus, 4/29/18 | |
![]() |
|
| brenda | Jan 5 2010, 08:50 AM Post #7 |
![]()
..............
|
I'm surprised there are only three, and that two are not so great to use. I'd have expected more options were available. |
|
“Weeds are flowers, too, once you get to know them.” ~A.A. Milne | |
![]() |
|
| George K | Jan 5 2010, 08:53 AM Post #8 |
|
Finally
|
There are others too, of course. One can use a large dose of Fentanyl (like I do when I do hearts), but don't expect to go home The list is pretty short. |
|
A guide to GKSR: Click "Now look here, you Baltic gas passer... " - Mik, 6/14/08 Nothing is as effective as homeopathy. I'd rather listen to an hour of Abba than an hour of The Beatles. - Klaus, 4/29/18 | |
![]() |
|
| George K | Jan 5 2010, 08:54 AM Post #9 |
|
Finally
|
http://www.asahq.org/news/asanews110909.htm |
|
A guide to GKSR: Click "Now look here, you Baltic gas passer... " - Mik, 6/14/08 Nothing is as effective as homeopathy. I'd rather listen to an hour of Abba than an hour of The Beatles. - Klaus, 4/29/18 | |
![]() |
|
| Mark | Jan 5 2010, 08:55 AM Post #10 |
|
HOLY CARP!!!
|
![]() & ![]()
|
|
___.___ (_]===* o 0 When I see an adult on a bicycle, I do not despair for the future of the human race. H.G. Wells | |
![]() |
|
| George K | Jan 5 2010, 08:59 AM Post #11 |
|
Finally
|
Option #1 is for use on me. Option #2 is for use on surgeons. |
|
A guide to GKSR: Click "Now look here, you Baltic gas passer... " - Mik, 6/14/08 Nothing is as effective as homeopathy. I'd rather listen to an hour of Abba than an hour of The Beatles. - Klaus, 4/29/18 | |
![]() |
|
| blondie | Jan 5 2010, 09:01 AM Post #12 |
|
Bull-Carp
|
I'm thinking of is an ad campaign : but truly, this is a serious problem.George, what do you think 'the powers that be' will do? Can regulations for barbituates be relaxed in the short term? Is there some national association for you guys who goes to bat for you in the short term? How fast do these people move? |
![]() |
|
| George K | Jan 5 2010, 09:06 AM Post #13 |
|
Finally
|
The Powers that Be can't do anything. There's no way to ramp up production of Pentothal in the space of a few months, even if regs were loosened. As I posted, we have the ASA (American Society of Anesthesiologists), but they are helpless, and more importantly, a bureaucracy. |
|
A guide to GKSR: Click "Now look here, you Baltic gas passer... " - Mik, 6/14/08 Nothing is as effective as homeopathy. I'd rather listen to an hour of Abba than an hour of The Beatles. - Klaus, 4/29/18 | |
![]() |
|
| blondie | Jan 5 2010, 09:12 AM Post #14 |
|
Bull-Carp
|
I misread George. Yikes. This is bad. |
![]() |
|
| QuirtEvans | Jan 5 2010, 09:25 AM Post #15 |
|
I Owe It All To John D'Oh
|
Give me Versed, or Fentanyl, or the mask. I'll pay for the extra day in the hospital. Can you give laughing gas or some such before the Amidate? Something to make the Amidate less objectionable? By the way, what's the anesthetic agent in conscious sedation? |
| It would be unwise to underestimate what large groups of ill-informed people acting together can achieve. -- John D'Oh, January 14, 2010. | |
![]() |
|
| George K | Jan 5 2010, 09:55 AM Post #16 |
|
Finally
|
A lot of people (and I mean A LOT) don't want the mask on their face. Lots of clautrophobia, etc. Versed and Fentanyl are what's used for conscious sedation. It's possible to get someone loopy enough to tolerate a mask, and then breathe them down with whatever you're going to use for the maintenance of the anesthetic (sevoflurane, desflurane, whatever), but, there's always going to be some who require more than you expect - who will fight you, and short of a shot of Amidate (or sux), you're going to end up giving a lot of either. By the way, I never understood the concept of "conscious sedation." Every time I see it done by the GI guys, the patients are not conscious. "Conscious" to me means if I call your name, you'll open your eyes. I know there are alternatives, it just pisses me off that a great drug like Propofol is not available, and there's not a good alternative. And no, I ain't got milk. It's a rant, indulge me. |
|
A guide to GKSR: Click "Now look here, you Baltic gas passer... " - Mik, 6/14/08 Nothing is as effective as homeopathy. I'd rather listen to an hour of Abba than an hour of The Beatles. - Klaus, 4/29/18 | |
![]() |
|
| Kincaid | Jan 5 2010, 10:05 AM Post #17 |
|
HOLY CARP!!!
|
I'm glad we are here to let you rant. I can't imagine getting a shot that would make me want to scream in pain. I had surgery when I was about four years old. The only thing I remember was a mask being put up to my tiny face and it covered my mouth, nose and eyes. I remember looking down the black tube until the lights went out. I still wonder if that was a real or imagined memory. In 1986 I had a burst appendix. I remember getting a shot as I waited in the ER, then I remember a flash of memory as I was sitting in a hallway looking up at the lights on the ceiling, then I woke up in my recovery room. Anyways, George - what do patients say the Amidate pain feels like? Is it like a burning in their vein or something? |
| Kincaid - disgusted Republican Partisan since 2006. | |
![]() |
|
| QuirtEvans | Jan 5 2010, 10:17 AM Post #18 |
|
I Owe It All To John D'Oh
|
My recollection of conscious sedation (I've had it done to me twice) is that I was marginally aware, once, of the discomfort of the procedure. I still recall exactly what was happening, and when, when I experienced the discomfort. Maybe there wasn't enough juice in the cocktail. However, it was basically just some discomfort, not actual pain. My understanding of conscious sedation is that you will cooperate. If they say roll on your side, you'll at least make an effort to roll on your side. And I thought that at least part of the conscious sedation protocol (or, so I've been told) was an amnesiac agent, so that, even if you were in pain, you don't remember it. |
| It would be unwise to underestimate what large groups of ill-informed people acting together can achieve. -- John D'Oh, January 14, 2010. | |
![]() |
|
| Phlebas | Jan 5 2010, 10:19 AM Post #19 |
|
Bull-Carp
|
When I had my minor surgery last Oct., they put something in the IV to relax, and then while I was awake, used the mask. I remember counting to ten, getting to about 3, and waking up in the recovery room. I wonder what that shot in the IV was. |
|
Random FML: Today, I was fired by my boss in front of my coworkers. It would have been nice if I could have left the building before they started celebrating. FML The founding of the bulk of the world's nation states post 1914 is based on self-defined nationalisms. The bulk of those national movements involve territory that was ethnically mixed. The foundation of many of those nation states involved population movements in the aftermath. When the only one that is repeatedly held up as unjust and unjustifiable is the Zionist project, the term anti-semitism may very well be appropriate. - P*D | |
![]() |
|
| George K | Jan 5 2010, 10:22 AM Post #20 |
|
Finally
|
Yep, that's what it's like. Now, to be fair, Diprivan burns as well (it's not water-soluble, so it's an emulsion - and the carrier is what burns. There's an alternative undergoing testing now - "Aquavan"). But the burning from Diprivan is minor compared to Amidate. And then there's the myclonus. Here's a list of bad things about etomidate (Amidate®):
|
|
A guide to GKSR: Click "Now look here, you Baltic gas passer... " - Mik, 6/14/08 Nothing is as effective as homeopathy. I'd rather listen to an hour of Abba than an hour of The Beatles. - Klaus, 4/29/18 | |
![]() |
|
| George K | Jan 5 2010, 10:24 AM Post #21 |
|
Finally
|
You probably got some Versed as a sedative. Then they probably gave you just oxygen to breathe. Then, once you had breathed the O2 for a few minutes, they induced you with an intravenous drug. |
|
A guide to GKSR: Click "Now look here, you Baltic gas passer... " - Mik, 6/14/08 Nothing is as effective as homeopathy. I'd rather listen to an hour of Abba than an hour of The Beatles. - Klaus, 4/29/18 | |
![]() |
|
![]() Our users say it best: "Zetaboards is the best forum service I have ever used." Learn More · Register Now |
|
| « Previous Topic · The New Coffee Room · Next Topic » |










but truly, this is a serious problem.

4:31 PM Jul 10