A U G U S T 2 0 1 9 • O U T PA T I E N T S U R G E R Y. N E T • 3 9
10mg/ml) can vary, making dosing errors more likely.
• Fentanyl. With sufentanil in short supply, you can switch to
remifentanil and alfentanil. Lack of experience with the alternate
drugs, especially for conscious sedation administered by non-
anesthesia staff, increases risks of improper dosing and poten-
tially serious side effects.
• Morphine. Poses similar risks to hydromorphone with varia-
tions in available dosages (0.5mg/ml, 1 mg/ml, 10 mg/ml, 25
mg/ml, 50mg/ml). Read the label carefully to make sure you
know the dose you're giving, as it might change from day to day.
• Bupivacaine. If bupivacaine isn't available, use another local
anesthetic such as ropivacaine or add lidocaine with epinephrine
to your limited supply of bupivacaine to increase volume and
duration with the epinephrine component. Exparel (liposomal
bupivacaine) for single injections can eliminate the need for the
large volumes of local anesthetic required to fill pain pumps and
provide excellent analgesia for a variety of blocks, including
those used off-label.
• Ketorolac. There is no equivalent substitute to give intra-
venously. Some facilities are resorting to combinations of p.o.
NSAIDs and p.o. or IV acetaminophen as part of a multimodal
regimen.
• Dextrose. If 50% dextrose isn't available, you can use 25%
dextrose in its place. Glucagon is also an effective alternative,
but at the cost of an increased side-effect profile. You can also
administer Lactated Ringer's and 5% Dextrose Injection, which
has a much longer response to increase blood glucose. The
other alternative is to give p.o. glucose when the patient is alert
enough to swallow it. — Daniel Cook
