IVF shortage. Doom and Gloom or Overblown?

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Skribbles

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www.nbcnews.com

Hospitals take steps to conserve IV fluid supply after Helene strikes critical factory

Baxter International said it would temporarily close production at its North Cove, North Carolina-based facility, raising concerns about a potential nationwide shortage.
www.nbcnews.com www.nbcnews.com

Anyone’s center making decisions based on this expectation of a shortage?
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Happened with Maria too. Heard on the radio this morning that FDA will allow importation from overseas again.

www.fda.gov

CDER Statement 11142017

The U.S. Food and Drug Administration is actively working with drug manufacturers to address critical shortages of IV fluids aggravated by Hurricane Maria’s impact on Puerto Rican drug manufacturing facilities.
www.fda.gov www.fda.gov
 
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Good excuse for them to raise prices. They will find enough supply, and at the new higher price.
 
We've gotten memos about conserving fluids but that's it so far, and most doesn't really apply to anesthesia. Any KVO orders for the floors are automatically being changed to saline hep-lock flushes. Urologists might have problems - they'll go through 20 3000ml bags of irrigation for a TURP.

Anyone thinking on not using running fluids and just using hep-locks on things like cataracts and endoscopy cases? Or have already been doing that anyway?
 
jwk said:
Anyone thinking on not using running fluids and just using hep-locks on things like cataracts and endoscopy cases? Or have already been doing that anyway?
Click to expand...

I just did a day of simple outpatient general anesthesia cases like this. Really not that big of a deal, more annoying to have to flush meds in each time you give something.
 
jwk said:
We've gotten memos about conserving fluids but that's it so far, and most doesn't really apply to anesthesia. Any KVO orders for the floors are automatically being changed to saline hep-lock flushes. Urologists might have problems - they'll go through 20 3000ml bags of irrigation for a TURP.

Anyone thinking on not using running fluids and just using hep-locks on things like cataracts and endoscopy cases? Or have already been doing that anyway?
Click to expand...


Hep locks are standard for our cataracts unless the IV ends up on the wrong (left) side since we are always on the patient’s right side.
 
crash2500 said:
All elective surgeries cancelled a at our hospital for Monday and Tuesday. Crazy. Didn't think it was that bad.
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We’ve been told we need to reduce crystalloid use by 40% system wide otherwise we’ll see a similar size reduction is surgical volume. We are employed and get paid the same regardless of surgical volume. I suspect this “threat” won’t have the effect admin hopes it will.
 
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jwk said:
We've gotten memos about conserving fluids but that's it so far, and most doesn't really apply to anesthesia. Any KVO orders for the floors are automatically being changed to saline hep-lock flushes. Urologists might have problems - they'll go through 20 3000ml bags of irrigation for a TURP.

Anyone thinking on not using running fluids and just using hep-locks on things like cataracts and endoscopy cases? Or have already been doing that anyway?
Click to expand...
We initially just got a similar floor oriented email about KVO > hep lock, etc. then Friday we got an email saying any surgical case not anticipated to have any significant blood loss or fluid shift shouldn’t have an IV bag hanging, just extension tubing back to anesthesiologist. We’re supposed to just keep a single saline bag to pull flushes off of for multiple patient’s/cases.
 
Beeftenderloin said:
We’ve been told we need to reduce crystalloid use by 40% system wide otherwise we’ll see a similar size reduction is surgical volume. We are employed and get paid the same regardless of surgical volume. I suspect this “threat” won’t have the effect admin hopes it will.
Click to expand...
This is apparently going on at most if not all hospitals in this metro.
 
I don’t think it’s overblown.
We are conserving aggressively.
Feels fairly serious.
Starting to cx cases (i think)
 
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Beeftenderloin said:
We initially just got a similar floor oriented email about KVO > hep lock, etc. then Friday we got an email saying any surgical case not anticipated to have any significant blood loss or fluid shift shouldn’t have an IV bag hanging, just extension tubing back to anesthesiologist. We’re supposed to just keep a single saline bag to pull flushes off of for multiple patient’s/cases.
Click to expand...
OMG, that's not Joint Commission approved and against all pharmacy regulations. 😱
 
crash2500 said:
All elective surgeries cancelled a at our hospital for Monday and Tuesday. Crazy. Didn't think it was that bad.
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That's lousy materials management if your hospital is that short. Maybe they can FedEx some from Europe, probably for less than the cost of a day of canceled surgery. 🙂
 
jwk said:
OMG, that's not Joint Commission approved and against all pharmacy regulations. 😱
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They used to make us switch masks between each case before COVID. Then it became okay to wear them for a week. It’s a matter of adapting to the situation.
 
Not that simple. There are significant rules around importing these materials from out of the country. The FDA may waive the requirements but that has not been done to my knowledge yet. I work in a national healthcare system (you can guess which one) and we are taking this very seriously. We are not cancelling cases and don’t anticipate doing so but we have a significant GPO supplying our needs. Our strategy is essentially using fluids only when needed so lots of saline locks in lieu of continuous flow IVs unless absolutely needed. We are also advocating for adoption of aggressive pre-procedure hydration (ERAS) to reduce the need for intraprocedure hydration fro those procedures that it makes sense. To my surprise there are still many clinicians that do not follow ERAS protocols.

This also involves fluids for irrigation and are reducing the use of devices that irrigate profusely (think aquamantis devices and others). We believe this will last possibly through the end of the year. The good news is that the Baxter plant’s water supply is intact (not true for the greater Asheville area) so it is possible that Baxter may be able to resolve this sooner rather than later but this remains to be seen.
 
Euripides said:
The facilities in this situation are all customers of Baxter. If your facility uses another manufacturer then you are ok. They will continue to meet your needs as usual.
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If the shortage lasts, don’t you think it will spill over to other manufacturers? Wont there be a run on ICU Medical products by facilities that can’t get Baxter?
 
nimbus said:
If the shortage lasts, don’t you think it will spill over to other manufacturers? Wont there be a run on ICU Medical products by facilities that can’t get Baxter?
Click to expand...
Facilities can ask of course and I’m sure everyone will help as they can but contracts have to be honored short of some kind of federal intervention. .
 
Arantius said:
How about first we get some regulation on all these recreational IV bars…. That’s a start
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Ain't that the damn truth? And most of them are run by NPs with absolutely zero oversight. Banana bags, vitamin infusions - friggin ridiculous.
 
I’m on our emergency committee for this disaster in our system. In a nutshell Baxter makes 60% of fluids for the US, those are their estimates. It’s not just iv fluids, it’s all medical fluids. So the impact is massive. We have between 6 and 60 days of stock of these various fluids as of today so we have the luxury of a bit of time to get these conservation efforts in effect. We also have the luxury of lots of tiny patients vs the great obese chronically dehydrated masses at the adult hospitals.
They have started shipping the limited allocation stock again. Some places have almost no stock stored and they are already in emergency only disaster mode as shipments stopped with the 1st storm. Baxter consolidated most production to one huge plant in NC, and it got flooded, contaminated and damaged. So they have to get infrastructure back up, then the clean up and repairs, then sterilize everything, get operational, confirm sterility to whatever agencies regulate them, and then finally restart production. That will take a considerable amount of time, likely months. They have no estimate. In the short term they are selling their stock on a 40% allocation. The answer is buy from overseas, and baxter has 2 big overseas plants, but the .gov is in the way and would have to open that door. I suspect they will, as they will have to. But keep in mind the scope of this problem. Everyone will be desperate for other sources of medical fluids, alternatives, etc. and ramping production to make up for the massive loss of this plant is not a trivial thing. The government doesn’t stockpile any medical fluids, probably because we manufacture them here, so that’s not any help either.
 
Funny update today. They increased our allocation to 60%… BUT the supplier we get the stock from has zero stock. Also got word that some systems are cancelling elective cases until they figure out how much fluid they will have to conserve for trauma/emergency cases. That has been discussed, but we are waiting to see what the suppliers can supply and implementated conservation protocols.
 
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IMHO this is the best preop hydration. Ensure has a copycat product but the taste isn't as good. Maltodextrin which is slowly metabolized and electrolytes the best way to go. Have surgeons call patients scheduled a week from now and have them order it. Patients that request me for anesthesia get instructions from me to buy it and take as directed. When I have had surgery or colonoscopy I have used it.
 
Drwine said:
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Preparing for surgery? Learn more here about our pre-surgery drink, CF(Preop)®, including information on product ingredients, benefits, & patient testimonials.
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IMHO this is the best preop hydration. Ensure has a copycat product but the taste isn't as good. Maltodextrin which is slowly metabolized and electrolytes the best way to go. Have surgeons call patients scheduled a week from now and have them order it. Patients that request me for anesthesia get instructions from me to buy it and take as directed. When I have had surgery or colonoscopy I have used it.
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Who has requested you for anesthesia and why?
 
Looking at the list here:

1728740012674.png




I'm not seeing isolyte or plasmalyte on the list (plasmalyte is baxter, I believe), so hopefully we'll still have some access to these when enteral pre-hydration isn't enough.
 
It would be nice if being more conservative with fluids in the wake of this stuck around like curbside pick up did after Covid. The system is so wasteful. There are real harms when people just auto order fluids and forget to turn them off. We are too sloppy with them imho
 
IVF shortage is nothing more than a monopoly & bureaucracy issue. How hard is it to make sterile distilled water with salt and electrolytes in a bag? Mexico, China, Japan, France, UK.... can supply us with all the fluids if allowed.
 
Ramon deLeon said:
IVF shortage is nothing more than a monopoly & bureaucracy issue. How hard is it to make sterile distilled water with salt and electrolytes in a bag? Mexico, China, Japan, France, UK.... can supply us with all the fluids if allowed.
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The problem isn't that it's hard in a technical sense.

The problem is that it isn't profitable. The margins on IV fluids are tiny, so it only makes economic sense to make that kind of thing at large scale. This has something of an anti-competitive effect, because any kind of small manufacturer redundancy or excess capacity is even less profitable.

IV fluids in particular are bulky and heavy, and consumed in VAST quantities, so overseas shipping is an enormous added expense. (There are also nontrivial regulatory issues concerning importing medications.) So you can essentially eliminate any foreign sources of IV fluids.

There's also no brand effect for IV fluids. There are people who buy name-brand Motrin instead of generic ibuprofen because they don't know or don't care that generic drugs are every bit as good, so there's an economic case for excess domestic manufacturing capacity for some cheap OTC medications.

We see periodic shortages for cheap meds like dexamethasone ... again, thin profit margins, manufacturing only makes economic sense at scale, small facilities or startup producers with small facilities can't compete.

When margins are thin, unused/excess capacity is very expensive.
 
All of a sudden we can extend the expiration date 2 years on all Baxter fluid??!?!!!??!?!?!?!?!
 
Drangue said:
All of a sudden we can extend the expiration date 2 years on all Baxter fluid??!?!!!??!?!?!?!?!
Click to expand...


The expiration dates are very conservative. Even milk is good way past expiration date if stored properly and nobody backwashed into the container.
 
narcotics999 said:
Where is JCAHO?
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JCAHO doesn't care what you do as long as it's consistent with whatever policies the facility has.

The funny thing is that we all hate the JC, but the hits they mark are often self-inflicted wounds. Some good-idea fairy at your hospital made a stupid policy which sensible people ignore, and some troll from JC gets to hell aha! when they catch you breaking your own policy.

If your PACU policy was to roll gurneys out into traffic Frogger style as part of the discharge process JC would be cool with it.
 
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