VOLUME 34, ISSUE 1

It’s become an all-too-familiar situation: Hey, where’s my ______? (insert pretty much any supply you can think of here) “Sorry doc, it’s on back-order!”

The COVID-19 pandemic has resulted in massive disruptions in the supply chains of almost every major economic sector and, while healthcare supplies are just one area, it is one that hits home for all of us as anesthesiologists.

These disruptions have arisen from a perfect storm of factors that have exposed vulnerabilities in global supply chains. The first, and arguably most important element, is supply shock, where we have experienced unanticipated decreases in production of many commodities, usually due to insufficient labor or raw materials. Given the complex nature of modern medical goods, many medical supply companies rely on fragmentation, where manufacturing of a product is divided into multiple stages. Different suppliers, who are highly specialized and often located in different countries, make each of the various components, which are then assembled into the final product by the company. With fragmentation, delays from even a single one of the suppliers can upend production cycles and lead to shortages or delays in the final device.

However, other important factors must not be overlooked: the system has also been strained by increased demand (recall the ventilator shortage early in the pandemic); the commonly utilized strategy of just-in-time manufacturing, where manufacturers have a bare minimum of stock in their own factories to save on space and costs; shortages of dock workers and truck drivers to offload and transport goods; and gridlock at global ports, with heavy traffic leading to prologed waiting times at the destination ports. Limited understanding of local and demand-driven shortages, lack of federal regulation, and failure of pharmaceutical wholesalers to adequately allocate supplies have also been implicated in medication shortages ^{[1, 2]}.

All of these factors have culminated in a scarcity of a large number of important products used by anesthesiologists every day. Many hospitals are experiencing backlogs of very basic patient care items such as intravenous (IV) fluids, IV catheters/tubing, needles, syringes gloves, central line kits, endotracheal tubes, and a multitude of our disposable monitoring devices. These circumstances are very frustrating because they impact our ability to care for our patients.

For these products, the impact on our cardiothoracic anesthesiology practice ranges from being a minor inconvenience to being a critical product that is very difficult to replace. For example, it’s easy to find alternatives for medium gloves or 20mL syringes, but if we are out of pulse oximeters, what options do we have? For the rapid infusion device, we have no alternative tubing, and this renders the device unusable without it (as an aside, when you need the rapid infusion device, you NEED it!). I am sure that everyone has their own extensive list of items that are not currently available and has led to frustrations.

While this can surely be frustrating, it is important to recognize that shortages are not a new phenomenon. The scale of global supply chain issues in the wake of the COVID-19 pandemic certainly feels unprecedented, but shortages of medical supplies and drugs have been a longstanding problem for anesthesiologists ^[3]. Drug shortages have plagued the US market for years ^[4]; select instances from the past decade include norepinephrine shortages in 2011 ^[5], saline shortages when Hurricane Maria devastated Puerto Rico in 2017 ^[6,7], IV opioid shortages in 2018, and spinal bupivacaine shortages in 2018. In fact, at the time of this writing, there are over 150 drug shortages listed on the FDA database (accessible online at https://www.accessdata.fda.gov/scripts/drugshortages/default.cfm). And in the future, drug and supply shortages will assuredly continue to be an issue even once the acute supply chain problems created by the COVID-19 pandemic have been addressed.

So, what can we do about it?

While it is not practical or possible for most anesthesiologists to influence international supply chain policies and procedures, there are steps that each of us can take to mitigate the impact we feel at our own institutions.

The first is to work closely with your hospital’s or institution’s supply chain division. Anesthesiologists rely heavily on equipment and supplies to take care of patients. As such, we are uniquely positioned to be able to help ensure that adequate stock of supplies is maintained and that supplies are ordered ahead of time before they run out, anticipating delays and back-orders. We are also able to work with our institutions to find suitable alternatives if one vendor is unable to provide the supplies.

Secondly, we can reduce the utilization of supplies where possible, using more of a “bare bones” approach, when that is safe for the patient. This may help to reduce waste and keep supplies in stock.

Third, we can use alternatives when an adequate substitute is available. For example, a different IV catheter may be suitable for a given patient / procedure when another becomes out of stock. However, a word of caution is warranted here. It may be tempting to use a device for an unintended purpose or to modify an existing device to meet your needs. Although there is a long and proud history of “MacGyvering” in anesthesiology, we must ensure that any substitutions we make are safe for the patient. Anesthesiologists are masters of adaptation and of patient safety, but any improvised devices we may develop have not been assessed by federal regulatory agencies to meet standards of safety and quality. “MacGyvering” supplies or devices represents a deviation from best practice and should only be considered in emergency situations when alternatives are not available ^[8].

It is also tremendously helpful to openly communicate about current shortages within your division. We have noticed significant changes, even on a day-to-day basis, about which supplies are in stock, and which are back ordered. One powerful tool that we have utilized is a simple whiteboard, where our anesthesia techs maintain an updated list of items that are out of stock (see Figure). The white board is displayed in a prominent location..

And lastly, it is important to keep informed. The FDA and the American Society of Health-System Pharmacists (ASHP) both maintain active databases of current drug & device shortages. Helpful links are listed below:

• FDA Current Drug Shortages: https://www.fda.gov/drugs/drug-safety-and-availability/drug-shortages
• ASHP Current Drug Shortages: https://www.ashp.org/drug-shortages/current-shortages
• FDA Medical Device Shortages due to COVID-19: https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/medical-device-shortages-during-covid-19-public-health-emergency

In summary, supply chain issues related to the recent pandemic resulting in shortages of drugs and supplies are not a new phenomenon and will likely persist. While long-term solutions will require changes by individual manufacturers and policymakers, it is possible to mitigate the impact of these shortages on a local scale. ♦