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The first wave of COVID-19 forced hospitals to get creative when treating patients, and they can apply these lessons as the next wave of the pandemic approaches.

"This is teaching us that no one is immune and no one is going to be omitted from this," said David Ferraro, MD, of National Jewish Health in Denver, during a presentation at the virtual CHEST conference, the annual meeting of the American College of Chest Physicians.

"We all have to ... learn how to surge and stock supplies. Be prepared to have a plan A, a plan B, and a plan C," Ferraro said.

Innovative solutions, such as using alternative drugs from another drug class; using an equivalent within the drug class family; or changing the route of administration can help to alleviate medication shortages, which are an ongoing public health crisis, even pre-COVID-19, he said. The pandemic only upended an already vulnerable supply chain, battling lack of incentives to produce less profitable drugs, and a market that had difficulty responding to disruptions.

Because medication production surges do not occur quickly, and the FDA previously acknowledging the potential for drug shortages, this becomes a problem in an ongoing public health crisis, with over 50,000 COVID-19 cases per day in the U.S., Ferraro said.

In particular, sedatives, analgesics, and paralytic agents are among those agents at risk of shortages. Ferraro said, specifically citing propofol, fentanyl, dexmedetomidine, and midazolam among the medications in short supply.

To preserve commonly used critical care drugs, Ferraro cited examples such as using benzodiazepines or phenobarbital for sedation, and ketamine for sedation and/or analgesia, saying, "alternative drugs from other classes can achieve the same effects."

Ferraro also said changing "route of administration was my eye-opening experience," as switching to an enteral route opened up many more options. He also discussed potentially using the transdermal route, as "certain medications may be used for this route to reduce IV dosing."

Prioritization was also key to conserving supply, with drug rotation ("changing practice frequently to avoid overreliance") and using the lowest necessary dose, as well as the appropriate vial size to minimize drug wastage, Ferraro said.

Early COVID-19 studies found 22%-27% of patients ended up in the ICU and, of these, 29%-90% required mechanical ventilation, he said, and this type of care tends to utilize medications, personnel, and equipment.

Ferraro said based on available data on number of patients requiring mechanical ventilation, duration of mechanical ventilation, and ICU admissions, an estimated 10-27 million ventilator days may be required.

And while there may now be a glut of ventilators in the Strategic National Stockpile, Ferraro noted that sharing of ventilators across local and national hospital networks, as well as learning that timing of intubation, is critical. He said using "heated high flow" nasal cannula and noninvasive techniques could ensure patients are not intubated too early if it's not necessary.

"Staving off intubation for later if it's safe might be a good tactic so ICUs are not becoming too top-heavy," he stated.

Ferraro discussed utilizing anesthesiology as a consultative service during COVID-19 surges, as it "helped with drug conservation and freeing up intensivists from one aspect of patient care."

But he warned that staffing, especially in terms of patients on ventilators, may continue to be one of the biggest "pinch points" for critical care, along with "stuff" (likely equipment and medications) and hospital "space" to house patients.

"The most likely limiting factor is human staff to safely manage the number of patients that will require mechanical ventilation," he said.

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