Norepinephrine Shortage Led to Increased Deaths from Septic Shock.

Though drug shortages are common, their impact is rarely studied.

Association Between US Norepinephrine Shortage and Mortality Among Patients With Septic Shock.

Importance: Drug shortages in the United States are common, but their effect on patient care and outcomes has rarely been reported. Objective: To assess changes to patient care and outcomes associated with a 2011 national shortage of norepinephrine, the first-line vasopressor for septic shock. Design, Setting, and Participants: Retrospective cohort study of 26 US hospitals in the Premier Healthcare Database with a baseline rate of norepinephrine use of at least 60% for patients with septic shock. The cohort included adults with septic shock admitted to study hospitals between July 1, 2008, and June 30, 2013 (n = 27 835). Exposures: Hospital-level norepinephrine shortage was defined as any quarterly (3-month) interval in 2011 during which the hospital rate of norepinephrine use decreased by more than 20% from baseline. Main Outcomes and Measures: Use of alternative vasopressors was assessed and a multilevel mixed-effects logistic regression model was used to evaluate the association between admission to a hospital during a norepinephrine shortage quarter and in-hospital mortality. Results: Among 27 835 patients (median age, 69 years [interquartile range, 57-79 years]; 47.0% women) with septic shock in 26 hospitals that demonstrated at least 1 quarter of norepinephrine shortage in 2011, norepinephrine use among cohort patients declined from 77.0% (95% CI, 76.2%-77.8%) of patients before the shortage to a low of 55.7% (95% CI, 52.0%-58.4%) in the second quarter of 2011; phenylephrine was the most frequently used alternative vasopressor during this time (baseline, 36.2% [95% CI, 35.3%-37.1%]; maximum, 54.4% [95% CI, 51.8%-57.2%]). Compared with hospital admission with septic shock during quarters of normal use, hospital admission during quarters of shortage was associated with an increased rate of in-hospital mortality (9283 of 25 874 patients [35.9%] vs 777 of 1961 patients [39.6%], respectively; absolute risk increase = 3.7% [95% CI, 1.5%-6.0%]; adjusted odds ratio = 1.15 [95% CI, 1.01-1.30]; P = .03). Conclusions and Relevance: Among patients with septic shock in US hospitals affected by the 2011 norepinephrine shortage, the most commonly administered alternative vasopressor was phenylephrine. Patients admitted to these hospitals during times of shortage had higher in-hospital mortality.

Vasopressor use in adult patients.

Vasopressors are a heterogeneous potent class of medications designed to increase blood pressure in emergent hypotensive situations. The goal of therapy is to increase blood pressure and maintain adequate perfusion, allowing nutrient and oxygen delivery to vital organs. Norepinephrine, phenylephrine, dopamine, epinephrine, and vasopressin are five vasopressors available in the United States. All vasopressors, with the exception of vasopressin, are titratable and dosed on a continuum according to clinical effect. With their different clinical features, adverse effects, and range of potency, the clinical situation usually guides therapy. Outcome data comparing different vasopressors have not demonstrated a clear mortality benefit of any one vasopressor over another, and physician preference also guides therapy. Norepinephrine, nonetheless, remains one of the preferred choices for a variety of hypotensive states, including cardiogenic and septic shock.

The extension of epidural blockade for emergency Caesarean section: a survey of current UK practice.

The conversion of epidural analgesia during labour to surgical anaesthesia for Caesarean section can have important medical and medicolegal implications. This survey sought to establish the current management for extending epidural blockade for emergency Caesarean section. A postal questionnaire was sent to the lead obstetric anaesthetist in all maternity units in the UK (n = 254). The response rate was 82% (n = 209). Of those surveyed, 68% (136) give the full dose of the local anaesthetic mixture in the delivery room, whilst 12.5% (25) initiate the top-up in the delivery room and give the remainder of the dose in theatre. Fifteen per cent (30) transfer the woman to theatre before commencing anaesthesia and 34% (68) give a test dose before the full anaesthetic dose. Guidelines for converting labour analgesia to anaesthesia for emergency Caesarean section were available in 64% (128) units. Bupivacaine 0.5% was the most commonly used agent, being used as the sole agent by 41.5% (81) units and in combination by a further 18% (36). Adrenaline was added to the chosen local anaesthetic by 30% (60) whilst 12% (24) added bicarbonate. In all, 13 combinations of local anaesthetics and adjuncts were used. The mode time to transfer the patient to theatre was 1 min. Of the 161 respondents who commenced anaesthesia in the delivery room, 71% (114) did not monitor the patient during transfer, whilst 87% (140) had ephedrine immediately available. Thirty-three respondents reported a total of 43 adverse incidents associated with the extension of epidural blockade. These included high blocks, inadequate blocks and possible intravascular injections, the latter resulting in two seizures and one cardiac arrest.