While states are struggling to bring in more ventilators to support critically ill COVID-19 patients, a new challenge is already on the horizon: a looming shortage of more than a dozen medications needed to intubate patients and keep them on a ventilator.

Demand for many of the sedatives and pain and muscle relaxant medications necessary for ventilator use shot up by more than 50% in March, while the fill rate dropped at least 25% — meaning some hospitals were unable to get the full amount of medication they ordered, according to findings by Vizient, which provides analysis and advisory services for health systems. A surge in COVID-19 patients that is still expected in many states could further strain supply.

“My fear is we’ll look back in a few weeks and have enough ventilators but we won’t have any of the drugs,” said Dan Kistner, a pharmacist and a senior vice president of pharmacy services at Vizient. “It’s like having all these cars and no gas to make them run.”

Ventilating a patient is an invasive and painful procedure that requires inserting a tube down the patient’s airway to his lungs, to allow the machine to take over breathing. Our gag reflexes are so strong that it is impossible to properly place the tube without sedating the patient, and muscle relaxers are often necessary to relax the windpipe, said Marcus Schabacker, CEO of ECRI Institute, a nonprofit in Montgomery County that studies health-care quality, safety, and efficiency.

Once connected to the ventilator, patients must remain in a medical coma, with sedation and pain medications, he said.

“The ventilation process itself is so intolerable that an awake patient would not tolerate it,” said Schabacker, an anesthesiologist and intensive care specialist. “The reversal of lung function is so counter to anything your physiology would allow, we need to put the patient in an artificial coma.”

The amount of medication needed depends how long the patient will need the ventilator and the severity of the lung illness. The coronavirus outbreak has especially strained supply of these medications because COVID-19 patients needing a ventilator are experiencing extreme respiratory difficulty and may need to remain on a ventilator for days or weeks, all the while needing constant high doses of sedatives and pain medications.

“If we continue to see a surge of patients, if we are not able to flatten the curve more substantially, medical supplies, drug supplies, will become the next big issue,” along with a shortage of skilled medical workers, Schabacker said.

Vizient’s analysis of 13 commonly used medications suggests that hospitals are still getting the medications they need, but that supply is beginning to dwindle and shortages may not be far off if manufacturers don’t accelerate production, Kistner said.

Vizient found that at the beginning of March, demand and supply were both low for these drugs — and hospitals were able to obtain nearly all the doses they requested. But as ventilator use picked up, demand for these medications increased, and hospitals were less able to get everything they needed:

  • Demand for sedatives and anesthesia drugs increased 51%, while the fill rate declined to 63%, meaning hospitals were able to obtain about two-thirds of the sedative and anesthesia drugs they ordered.
  • Demand for pain medications, including fentanyl and morphine, increased 67% in March, while the fill rate declined to 73%.
  • Demand for neuromuscular blockers, which are powerful muscle relaxers used to temporarily paralyze muscles during surgery, increased 39%, while the fill rate declined to 70%.

The U.S. Food and Drug Administration, which regulates prescription medications, “has been closely monitoring the supply chain with the expectation that the COVID-19 outbreak would likely impact the medical product supply chain, including potential disruptions to supply or shortages of critical medical products in the U.S.,” said Jeremy Kahn, a spokesperson for the agency.

Andrew Powaleny, a spokesperson for the pharmaceutical industry association PhRMA, said drug companies are working closely with the FDA and global stakeholders “to prevent and mitigate potential shortages.”

In the meantime, hospitals are preparing for how a surge in patients could affect supplies.

Main Line Health has enough of the medications for current patients, but is trying to conserve its supply by getting patients off ventilators as soon as it is safe and making sure no partial vials of medication are wasted, said Clarke U. Piatt, a pulmonologist and medical director of the ICU at Bryn Mawr Hospital.

“We use every drop,” he said.

Among COVID-19 patients who will need to be on a ventilator for an extended period, the health system has been using alternative sedatives that are less common because they keep patients sedated longer than is necessary for most medical procedures, Piatt said.

“The hardest thing from the health-care-provider standpoint is the unknown — we just don’t know what next week is going to be like,” he said. “We’re trying to prepare for the worst but remain positive.”