Local Anesthesia Shortages—Adapting to a New Way of Life

Abstract

To the Editor Over the past several months, there have been increasing numbers of medication shortages throughout North America, exacerbated (but not solely caused) by Hurricane Maria's effect on the pharmaceutical manufacturing industry on the island of Puerto Rico. 1,2 Medication shortages are affecting health care facilities in new ways on a weekly basis without imminent solutions. In particular, within the field of facial plastic and reconstructive surgery, we have noted a shortage in formulations of lidocaine and bupivacaine. We have received various sizes of bottles of these anesthetics in varying concentrations with varying concentrations of epinephrine, further complicating our "typical" anesthesia protocol. Our clinic's typical anesthesia was a 1:1 mixture of lidocaine, 1%, with a dilutional ratio of 1:100 000 and bupivacaine, 0.5%, with a dilutional ratio of 1:200 000.It is important to remember that the toxic effects of lidocaine are apparent at a dose of 4.5 to 5 mg/kg administered without epinephrine and 7 mg/kg with epinephrine. The toxic effects of bupivacaine are apparent at a dose of 2 mg/kg administered w ithout epinephrine and 3 mg /kg w ith epinephrine. 3,4 Combining anesthetics means that the toxic effects are additive, such that 50% of the toxic dose of lidocaine with 50% of the toxic dose of bupivacaine is equal to the toxic dose for that patient.Epinephrine is described as a dilutional ratio (eg, 1:100 000) as opposed to a concentration (mg/kg). We are now using concentrated epinephrine (1:1000) and adding it to our anesthetic mixture. The Table describes common dose equivalents for epinephrine when mixing with local anesthesia without epinephrine.After discussions with our staff on the medication shortages and current medication stock, new local anesthesia protocols were developed to maintain anesthetic and vasoconstrictive concentrations for our most common procedures, including rhinoplasty, upper and/or lower blepharoplasty, and cervicofacial rhytidectomy with or without blepharoplasty (Box).Our current protocol (based on our current stock of anesthetics) is posted within the operating room and discussed prior to each case by the surgeon, anesthesiologist, and nurse. The epinephrine (which is drawn up in an insulin syringe) and the local anesthetics are confirmed by 2 staff members prior to drawing up the medications and placing in a mixing bowl. Anesthesia is then injected in a graduated approach before a given stage of the surgery.We encourage all surgeons to make similar protocols, which will adjust as medications become available. We believe that a team approach with excellent communication between surgeons, anesthesiologists, and nurses is paramount to prevent medication-related complications. Finally, we must continue to alert the public and our respective governments about this worsening crisis.