IV Fluid Shortage Mitigation Practice and Policy Considerations
Hurricane Helene was a devasting storm across the southeastern United States that caused widespread destruction and tragic loss of life. One of the rippling effects of this storm is an interruption in IV fluid manufacturing due to flooding of the Baxter International Factory in North Carolina. The following recommendations are provided by the AANA for informational purposes only and do not constitute medical or legal advice. Individual clinicians should use professional judgment and each facility should establish policies based on their patient population, resources, and circumstances
Certified Registered NurseAnesthetists (CRNAs), also referred to as nurse anesthesiologists and nurse anesthetists, play an integral role on the interdisciplinary team. They actively participate in policy development and implementation, as well as in decision making that promotes patient safety related to mitigating the effects of drug shortages.
Optimize Fluid Management
Individualized Assessment
Conduct a thorough preanesthesia assessment and evaluation to determine each patient's fluid status and needs. Tailor fluid administration based on the patient's condition, type of surgery, and expected fluid losses rather than using standardized protocols
Goal-Directed Fluid Therapy
Utilize goal-directed fluid therapy techniques, employing hemodynamic monitoring to guide fluid administration. This approach can help minimize unnecessary fluid use while ensuring adequate perfusion.
Preoperative Fasting Guidelines
Review and potentially revise preoperative fasting guidelines to minimize preoperative dehydration. Consider allowing clear fluids up to 2 hours before elective procedures for appropriate patients.
Alternative Strategies
Regional Anesthesia
When suitable, prioritize regional anesthesia techniques that may reduce the need for IV fluids compared to general anesthesia.
Oral Hydration
Encourage oral hydration whenever possible for preoperative patients who are not NPO. This can reduce the need for IV fluids in the immediate preoperative period.
Crystalloid Alternatives
Consider using available balanced crystalloid solutions as alternatives to normal saline and other unavailable solutions when appropriate, taking into account the patient's electrolyte status and the type of surgery.
Colloids
In cases where larger volume expansion is needed, judiciously use colloid solutions, being aware of their potential risks and contraindications.
Medication Administration
IV Push
Convert appropriate medications from infusions to IV push administration when possible. This can significantly reduce the volume of IV fluids used.
Concentrated Formulations
Work with the pharmacy to obtain more concentrated formulations of commonly used medications to reduce the volume of diluent required.
Equipment and Technique
Smaller Bag Sizes
Use smaller volume bags (e.g., 250 mL instead of 1000 mL) for low infusion rates and medication administration.
Precise Infusion Devices
Utilize precise infusion pumps and syringe drivers to administer fluids and medications accurately, minimizing waste.
Blood Conservation
Implement blood conservation techniques to reduce the need for volume replacement, such as cell salvage and antifibrinolytic use when appropriate.
Institutional Strategies
Interdisciplinary Policy Development
Collaborate with anesthesia professionals, surgeons, pharmacists, and nursing staff to develop institution-wide strategies for fluid conservation.
Inventory Management
Work with supply chain management to monitor IV fluid stock levels and source supplies. Collaborate with pharmacy and supply chain management to purchase prefilled syringes and premixed medication solutions. Collaborate with care teams to prioritize clinical allocation of IV fluids.
Compounding Capabilities
Assess the feasibility of in-house compounding of certain IV fluids, adhering to USP standards.
Outcome Tracking
Track patient outcomes related to modified fluid management practices to monitor the safety and efficacy of conservation strategies.
Education and Training
Provide education and training for anesthesia, nursing, surgical and other clinical staff on fluid conservation strategies and the rationale behind them.
Drug Shortage Reporting
Report drug shortages the facility is experiencing to the FDA Drug Shortages team
CRNAs play a crucial role in implementing strategies to effectively manage patient care during IV fluid shortages. By adopting a multifaceted approach that includes individualized assessment, goal-directed therapy, and alternative fluid management techniques, providers can navigate the challenges posed by supply constraints while maintaining patient safety. It's essential to remain flexible, continuously reassess the situation, and adapt these recommendations to individual patient needs, facility resources, and evolving shortage conditions. Collaboration with interdisciplinary teams and ongoing education will be key to successfully mitigating the impact of IV fluid shortages on anesthesia practice and patient outcomes.
Additional Resources and Informational Websites
• AORN. Update on Intravenous (IV) Fluid Shortages.
• ASHP. Small- and Large-Volume Fluid Shortages – Suggestions for Management and Conservation. 2024.
• ASHP Guidelines on Managing Drug Product Shortages. 2018.
• ASPR TRACIE. Intravenous Fluid Shortage Strategies. Oct 9, 2024.
• ASPR TRACIE. Medical Product Shortages and Scarce Resources Page. 2024.
• ASPR TRACIE. Partnering with the Healthcare Supply Chain During Disasters. 2024.
• ASPR TRACIE. Template – Hospital Crisis Standards of Care ResourceAllocation Annex. 2024.
• Baxter Newsroom. Hurricane Helene Updates
• Baxter Sept 30 Medical Information Letter for Healthcare Facilities
• Baxter Oct 9 Update
• CDC HealthAlert Network: Disruptions in Availability of Peritoneal Dialysis and Intravenous Solutions from Baxter International Facility in North Carolina. Oct 12, 2024.
• ECRI. Patient safety nonprofit releases guidance for navigating medical supply chain disruptions caused by Hurricane Helene.
• FDA. Hurricane Helene: Baxter's manufacturing recovery in North Carolina. Information and updates on CDER-regulated drug and biologic products.
• FDA. Temporary importation sources to help mitigate shortages.
• FDA. Temporary Policies for Compounding Certain Parenteral Drug Products. Oct 2024.
• HHS. Letter to Health Care Leaders and Stakeholders on Impacts of Hurricane Helene from Secretary Becerra. Oct 9, 2024.
• NHIA. IV Fluid Shortage Resource Center
Updated on Oct 16, 2024