Patient Risk Rises with Local Anesthetics Shortage

Advocates urge clinicians to consult with elective surgery patients about local anesthetics shortages, the potential health risks, and alternative forms of pain management.

A global shortage of local anesthetics threatens patient care and could worsen the opioid crisis as patients and their caregivers use other methods of pain relief, the American Society of Regional Anesthesia and Pain Medicine says.

Because of that, ASRA is urging hospitals, physicians and other clinicians who provide elective surgery to consult with their patients ahead of the procedure to warn of potential local anesthesia shortages and their potential health risks, and to discuss alternative strategies for pain management.

"This conversation needs to be taken to the public," says Edward R. Mariano, MD, a professor of Anesthesiology, Perioperative and Pain Medicine Stanford University School of Medicine.

"If I were helping a family member make a decision about when and how to have a knee replacement surgery scheduled, I would want to know whether the hospital where my mom or dad was having knee replacement actually has suitable stock of local anesthetics so my family member is going to get good care," Mariano says.

Even minor surgical procedures can lead to long-term opioid use. Regional anesthesia, especially with continuous peripheral nerve block techniques, has been shown repeatedly to reduce patients’ need for opioid analgesia, Mariano says.

Now, this care is threatened with ongoing global shortage of local anesthetic drugs, including bupivacaine, lidocaine, ropivacaine. Targeted injections of these numbing drugs at the surgery site can eliminate the need for injectable opioids such as fentanyl, hydromorphone, morphine, which also are in short supply.

Mariano says elective surgery patients oten know the date of their procedure months in advance, which provides an excellent window of opportunity for clinicians to consult with them about pain management.

"From the patient point of view, when you show up for your surgery you don't necessarily know when you go in whether that hospital is suffering from a local anesthetic shortage," he says. "It is not a reason that most hospitals would consider for delaying or even cancelling elective procedures. But, we know from our data that certain types of anesthetics and pain control modalities have a direct positive effect on decreasing opioid use."

Mariano says patients must be fully informed about any potential health risks before elective surgery.

"For knee replacement patients, for example, there is an association between having a spinal or an epidural anesthetic and having a lower risk of 30-day mortality. That's huge," he says.

"We know this effect is greater if you happen to be a patient with obstructive sleep apnea. There was a recent article that brought up general anesthesia and memory loss," he says. "So, if you have a reason to avoid general anesthesia and you have a surgery that doesn't require general anesthesia, then as a patient you have a right to request a spinal anesthetic, and you have the right to schedule when you know that that is going to be the anesthetic available to you."

 ASRA will take up the issue during a session on April 21, held in conjunction with the 2018 World Congress on Regional Anesthesia and Pain Medicine. Mariano is asking clinicians and healthcare administrators who are dealing with local anesthetics shortages to help find solutions.

"I'd be interested if they have found alternative vendors or, if they've come up with strategies to avoid effects on clinical care, I'd like to hear about it," he said. "If their hospital has started introducing these drug shortage conversations in their process of surgical informed consent I'm interested in hearing about that."

(Providers interested in sharing their solutions can reach Dr. Mariano at emariano@stanford.edu)