Fluid Dynamics: Tackling the IV Fluid Shortage Challenge

October 15, 2024

By: Jesse Sherratt, DO, FCCP
Chest Infections and Disaster Response Network

INFOGRAPHIC ON CONSERVATION STRATEGIES »

The recent IV fluid (IVF) shortage triggered by Hurricane Helene underscores a persistent issue in health care that has been exacerbated by natural disasters.

Shortages of saline and other IV solutions are not new. Hurricane Maria demonstrated the vulnerability in the IVF supply chain in September 2017 with the devastating impact on a major Baxter International manufacturing plant in Puerto Rico that was responsible for supplying approximately 50% of US hospitals with small-volume IVFs. Damage to the electrical grid from the hurricane delayed power restoration until January 2018, significantly limiting the production of IVFs.

Not only is demand for IVFs immense, with health care facilities requiring more than 40 million bags per month, but their manufacturing process is complex and requires strict adherence to sterility and particulate-free standards. Producing each batch of saline involves 29 meticulous steps over 10 days, alongside 350 regulatory requirements as of 2015. Additionally, the weight and size of saline bags make them expensive to transport by air and difficult to stockpile.

As of 2018, the IVF market was dominated by a small number of suppliers, with Baxter, ICU Medical, and B. Braun being the three largest manufacturers. This concentration further complicates the supply chain.

In September 2024, Hurricane Helene caused significant damage, resulting in the shutdown of a Baxter manufacturing plant that produces 60% of the nation's IV fluids and peritoneal dialysis solutions. Baxter has subsequently implemented distribution limitations to prevent hoarding and ensure equitable access to the available IVF supply. Additionally, the US Food and Drug Administration has approved 19 IVF products from foreign countries to help meet patient needs during this ongoing shortage.

To combat the IVF shortage effectively, regional strategies must be implemented. Partnering with other health care institutions and public health coalitions can facilitate collaboration, allowing organizations to share vital information and resources during times of scarcity. By coordinating efforts, these groups can optimize distribution and ensure that essential supplies reach those who need them most.

On an institutional level, health care facilities can adopt various strategies to address the IVF shortage. Restricting high-fluid volume medications, such as esmolol, can help conserve resources. Additionally, prioritizing IVFs for essential, lifesaving treatments and avoiding the use of maintenance IVFs can help allocate supplies more effectively. Defaulting to oral electrolyte replacement protocols and extending the beyond-use dates of IVFs are a few additional ways to further mitigate the impact of the shortage.

Frontline health care providers play a crucial role in managing IVF shortages and preserving their supply. Successful strategies to help reduce the demand for IVF include prioritizing enteral nutrition over parenteral nutrition; switching medications to subcutaneous, intramuscular, or IV push; not removing plastic protective wrapping from bags until time of use; refraining from prespiking bags; and encouraging nurses to question the necessity of spiking another bag. Additionally, implementing front-facing electronic medical record alerts to providers to review current orders can help set time or volume limits on all infusions.

While lessons learned from past crises have prompted the implementation of systems to mitigate IVF shortages, these measures are far from foolproof. The situation remains precarious, with Baxter aiming to reach 90% to 100% of allocations for certain IVFs by the end of the year, with no clear timeframe as to when they will be fully operational. As we navigate these challenges, it is crucial to continue developing robust strategies that address both immediate needs and long-term solutions to ensure the availability of lifesaving IVFs and other solutions.

References

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Mazer-Amirshahi M, Fox ER. Saline shortages - many causes, no simple solution. N Engl J Med. 2018;378(16):1472-1474. Preprint. Posted online March 21, 2018. PMID: 29561694. doi: 10.1056/NEJMp1800347

Shore C, Brown L, Hopp WJ, editors; National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Sciences Policy; Committee on Security of America's Medical Product Supply Chain. Building resilience into the nation's medical product supply chains. Washington (DC): National Academies Press (US); 2022. PMID: 36070409. doi: 10.17226/26420

Hurricane Helene Updates. Baxter. 2024. https://www.baxter.com/baxter-newsroom/hurricane-helene-updates

Hurricane Helene: Baxter’s manufacturing recovery in North Carolina. US Food and Drug Administration. 2024. https://www.fda.gov/drugs/updates-2024-hurricane-season/hurricane-helene-baxters-manufacturing-recovery-north-carolina 

Nirappil F, Roubein R. IV fluid shortage due to hurricane prompts hospitals to postpone surgeries. The Washington Post. October 14, 2024. https://www.washingtonpost.com/health/2024/10/14/iv-fluid-shortage-baxter/