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10/7/24 fluid shortage update

October 7, 2024

There have been a lot of updates to the fluid shortage situation today; there are also a lot of unknowns. It appears that the Army Corps of Engineers has built a temporary bridge to the Baxter plant in Marion, NC and will begin work on a permanent bridge soon. It is still to be determined when/if the plant will come back on line. Many people across the System and, of course, many in our department are working hard to mitigate this shortage. While there are many other issues and potential scenarios, the following is a list of actions that our UBs and Clin Specs will be following going forward:

• We have purchased norepinephrine 16 mg / 250 mL premixes to use as our concentrated option. We want to avoid the 32 mg / 250 mL when possible.These will be stored in and dispensed from PSP to avoid sound-alike/ look-alike mixups. Backup supply is in the 1st floor shell space (next door to the Q). 
  

• Tranexemic acid 1000 mg / 100 mL premix (NDC 80830-2329-02) has been ordered as a new item. PharmIT will be adding this as an orderable in Cerner (coming soon). The goal is to avoid compounding the tranexamic acid 2 g in 500 mL orders and send 2 of the 100 mL premixes instead. This was approved by the practitioners through our clinical specialists. This stock in currently in the 1st floor shell space (next door to the Q). 
  

• We are changing remdesivir orders from 100 mg / 250 mL to 100 mg / 100 mL. Eric is changing the recipe in PK and PharmIT will change the orderables in Cerner soon.  Keep an eye out for the change. 
  
  
• We have asked that 1/4 NS orders be avoided to conserve Sterile Water for Injection. Please work with the prescriber to choose a suitable alternative fluid when 1/4 NS is ordered. We have also ordered SWFI vials as a backup if we exhaust our liter bags. 
  
  
• It may be rare, but we occasionally get orders for continuous antibiotic orders in 250 mL.  Please contact AMT if you see a Unasyn 15g or Zosyn 9g, etc. and they will intervene with the ordering physician.
  
  
• Of course, in our adult population, we want to continue with our aggressive IV-to-PO conversion, both small-volume and large-volume bags. If a large-volume bag contains only electrolytes and/or MVI, work with nursing to switch to oral hydration and repletion. If the IV contains other drugs, evaluate for possible switch to PO and work with the prescriber as necessary. Work with Dietary as needed to enhance PO intake in situations where it can spare the use of IV fluids
  
  
• We also learned that pre-filled saline flush syringes are on allocation, although there is no documented shortage. More to come as this develops
  
  
• The damaged Baxter plant also produced D70 and sterile water for injection. This may ultimately impact our ability to admix TPNs. Before entering an adult TPN order, ensure that the patient strictly meets the ASPEN guidelines for TPN - namely that they have a non-functional and/or non-accessible GI tract. Please let me know if there is unreasonable physician resistance or other issues related to this.
  
  
• Irrigations used in surgery are our biggest concern right now. Logistics is working on obtaining a decent supply, but so far we have not been able to procure enough. Nothing for us to work on with this one, just situational awareness.

Brad Pounders put it best in his last email...CONSERVATION - be aggressive and do it now! While we are not stopping the use of IVs in any specific area at this time, we are assessing usage in several areas and will announce any needed restrictions as the situation dictates. Berkley, Donna, Eric, and the entire PSP team along with PharmIT and MANY others are making changes rapidly to head off this evolving shortage. More to come, but please follow the information listed above and feel free to call me if you are not sure how to proceed. 

Thanks for all you do to ensure the best care for our patients! DAVID

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David R. Collette, Pharm.D., FASHP, FALSHP
Operations Manager, Professional Services
Huntsville Hospital Department of Pharmacy
101 Sivley Road, Huntsville, AL 35801
Desk: (256) 265-6741; Cell: (256) 527-2560