“Did we ever really need a second I.V. set in every patient? It’s possible we discover that we can permanently reduce our environmental footprint of plastic I.V. tubing/packaging by placing I.V. catheters we need so that we are adequately prepared, but waiting to assemble and connect ‘extra’ I.V. tubing and fluids until needed.”
The Baxter manufacturing plant located in North Cove, North Carolina, closed for production September 29 after rain and storm surges triggered a levee breach, flooding the site. Baxter produces 1.5 million I.V. bags annually, so this hit impacted nearly every hospital in the U.S. Dextrose 70% IV Solutions, Lactated Ringers I.V. Solution, and Peritoneal Dialysis Solution were added to the U.S. Food and Drug Administration’s shortage list in the wake of the hurricane (asamonitor.pub/3YGIJzl). Though the shortage is expected to persist for several months, the company is reporting faster than expected recovery. As of October 31, the highest-throughput I.V. solutions manufacturing line restarted, representing 50% of the site’s production of 1 liter I.V. solutions, which is the most commonly used size. Baxter’s goal is to return to 90%-100% allocation of certain I.V. solutions product code for U.S. customers by the end of 2024. Per the company’s November 26 update, they are on track to achieve the goal. Barring any unanticipated developments, Baxter expects to share details on planned, phased increases in allocations again in mid-December and at year-end, which includes reaching 100% allocation across several I.V. product codes by the end of 2024.
Baxter’s ability to adjust allocation levels is based on 1) the current and projected status of their North Cove remediation efforts; 2) expectations regarding their ability to reallocate capacity from other Baxter facilities; 3) temporary importation of certain products. This was a hot topic at ANESTHESIOLOGY® 2024, with a special session added to address the crisis.
Anesthesiologists are feeling the pinch. One private practice anesthesiologist at a community hospital in greater Seattle reported utilizing an I.V. “pigtail” and direct bolusing of medications with no free-flowing I.V. drip for the first time in his career. Other cases required “mainlining” a propofol infusion directly via the pigtail with no carrying I.V. fluid. While his hospital is still using bags of flowing I.V. in trauma/emergency and obstetrics, he’s avoided providing any I.V. fluids by sometimes running a multi-drug TIVA with no carrier (when possible during fairly complex neurosurgery and neurointerventional procedures). This is another career first. Patients who need an arterial line require fluid resuscitation and have been exceptions to the I.V. fluid rule. When the pigtail is not easily accessible (i.e., patient’s arms are tucked, etc.), the anesthesiologist has put a small extension tubing on it and used a 10 ml saline flush. Saline flush syringes were never routinely used in the OR prior to the shortage, but the hospital has been able to put a box of them in each OR, given these new workarounds.
Rationing realities
Most hospitals are postponing some surgeries. This hospital outside Seattle has postponed nonurgent surgeries with an anticipated fluid requirement >2L (including surgical irrigation and PACU/recovery fluids to replace large blood loss). Normal protocol is a spinal anesthetic for total joints (knees and hips), but a spinal predictably causes peripheral vasodilation best treated with a fluid bolus. Since the fluid shortage, the hospital decided to not routinely perform spinal surgeries. “People might not realize how much fluid our surgical and procedural colleagues are using for wound irrigation, for creating a surgical field like arthroscopy or cystoscopy, for flushing interventional vascular sheaths. It’s liters of fluid! Here I am trying to save a liter of fluid during an aneurysm coiling while the interventional neurosurgeon is using 8-liter bags of NS to flush all the vascular sheaths and their components,” remarked this anesthesiologist, who wished to remain anonymous.
Other hospitals are triaging which surgeries can be delayed. At Brigham & Women’s, Beverly Philip, MD, FACA, FASA, shared that the enterprise response is based upon the inventory available at the beginning of the week. The first step is always fluid conservation. Then, the major lever for reducing I.V. usage is lessening the volume of surgeries, as this organically diminishes the number of patients relying on I.V. fluids over many days. Life-saving procedures – transplants, cancer-related surgeries, Caesareans, infections that could become fatal – are still proceeding as usual. Rationing affects cosmetic procedures, screening, and operations managing stable diseases. Severe rationing requires functionally limiting chronic disease or high-risk screening procedures.
Dr. Philip points out that this isn’t the first crisis to result in rationing. Hospitals restricted salt water after Hurricane Maria in 2017. One lesson learned from that time was the importance of an incident management process that can be implemented quickly so clinicians aren’t making ad hoc – and potentially unsafe – decisions. Resource-sharing is critical, especially since there’s no national stockpile of I.V. fluids. Some states have more supply than others, and many institutions have existing policies about sharing resources locally so others can avoid asking for government assistance. For larger health systems, gamified approaches have been successful in incentivizing hospitals to “compete” with one another on resource conservation.
Leadership positioning
Patricia Mack, MD, FACHE, FASA, found one silver lining in the I.V. crisis – it showcases the importance of anesthesiologists on a national scale. “Anesthesiologists work with everyone in the hospital, and few other stakeholders are as acutely aware of how much fluid is actually used in the OR,” she reasoned.
She encouraged her colleagues to be a “repository of good ideas.” Similar to what took place during the COVID-19 pandemic, hospital administration is requesting actual guidance from anesthesiology departments and inquiring about which fluid to focus on, alternatives for unnecessary carrier fluids, and other questions.
Dr. Mack also framed this crisis as an opportunity to reconsider some best practices. “Did we ever really need a second I.V. set in every patient? It’s possible we discover that we can permanently reduce our environmental footprint of plastic I.V. tubing/packaging by placing I.V. catheters we need so that we are adequately prepared, but waiting to assemble and connect ‘extra’ I.V. tubing and fluids until needed,” she said.
Not everyone is so optimistic. At the ASA annual meeting special session Q&A, one audience member speculated whether hospitals will continue asking anesthesiologists to monitor I.V. fluid to save money after Baxter’s manufacturing is restored. To that, Dr. Philip countered, “Now that we’re being heard, we should do our best to retain the processes that are valuable.”
Others commented that the I.V. fluid catastrophe exposes flaws in the just-in-time philosophy, as the drive to get the best contract resulted in most of the nation using only one vendor. An anesthesiologist at Kaiser Permanente thought the crisis drives home the opportunity to use data to more mathematically track utilization. “It’s very vague to leave it to our own judiciousness to cancel surgeries,” he noted. “Could we instead look at fluid use across a continuum to help with supply side analytics?” Dr. Philip observed that the EMR data isn’t available in enough granular detail, but it could be a future action item.
Many more theories will pop up in the days and weeks ahead. For now, ASA is committed to helping members navigate this emergency. Visit the Hurricane Helene Baxter Shortages resource center for updates, society and external recommendations, and more (Hurricane Helene – Baxter Shortages).