title: The Impact of a Shortage of Pharmacy-Prepared Ephedrine Syringes on Intraoperative Medication Use.
abstract: BACKGROUND
  Anesthesia-related medication shortages have become increasingly common in the United States. We tested whether a local shortage of pharmacy-prepared ephedrine syringes, replaced by provider-prepared ephedrine, was associated with provider-level changes in ephedrine and phenylephrine use and patient-level changes in intraoperative hemodynamics.
  
  
  METHODS
  Consecutive patients undergoing general and orthopedic surgery at a tertiary care center were included 1 month before and 1 month after the start of the pharmacy-prepared ephedrine syringe shortage. Lowest mean arterial blood pressure and slowest heart rate were obtained as measures of hemodynamics. Adjusted associations were tested using mixed-effects regression with repeated measures.
  
  
  RESULTS
  Three hundred four patients before the shortage and 298 patients after the shortage began were included. The administration of at least 1 bolus of ephedrine was significantly more common before versus during the shortage (148/304 [48.7]% vs 117/298 [39.3]%; P = 0.0199). After adjusting for age, sex, ASA physical status, surgery type, anesthesia provider, and operative duration, patients were significantly less likely to receive ephedrine during the shortage (relative risk [RR] = 0.78 [95% confidence interval {CI}, 0.61-0.96]; P = 0.0198) and more likely to receive a phenylephrine bolus (RR = 1.27 [95% CI, 1.02-1.51]; P = 0.0357). Patient hemodynamics assessed by slowest heart rate or lowest mean arterial blood pressure did not differ significantly during the shortage.
  
  
  CONCLUSIONS
  There was an alteration in medication administration patterns during a shortage of pharmacy-prepared syringes. Changes in ephedrine and phenylephrine use were noted; however, patient hemodynamics remained comparable. Provider use patterns were sensitive even to a relative and not absolute medication shortage as observed in this study.
authors.affiliation: From the *Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts; †Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; and ‡Harvard Medical School, Boston, Massachusetts.
authors.forename: Karim S
authors.initials: KS
authors.lastname: Ladha
authors.forename: Karen C
authors.initials: KC
authors.lastname: Nanji
authors.forename: Eric
authors.initials: E
authors.lastname: Pierce
authors.forename: K Trudy
authors.initials: KT
authors.lastname: Poon
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Hyder
mesh_terms: D018663:Adrenergic Agents / Q000008:administration & dosage / Q000600:supply & distribution*; D000328:Adult; D000368:Aged; D062186:Arterial Pressure / Q000187:drug effects; D016009:Chi-Square Distribution; D017723:Drug Utilization Review; D004809:Ephedrine / Q000008:administration & dosage / Q000600:supply & distribution*; D005260:Female; D006339:Heart Rate / Q000187:drug effects; D006801:Humans; D007267:Injections; D007430:Intraoperative Care / Q000639:trends; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000639:trends; D016017:Odds Ratio; D010607:Pharmacy Service, Hospital / Q000600:supply & distribution*; D010656:Phenylephrine / Q000008:administration & dosage / Q000600:supply & distribution*; D010818:Practice Patterns, Physicians' / Q000639:trends*; D012189:Retrospective Studies; D013594:Syringes / Q000600:supply & distribution; D013997:Time Factors
chemical_list: D018663:Adrenergic Agents; D010656:Phenylephrine; D004809:Ephedrine