Think Outside the Box to Help Conserve IV Fluids

Posted October 7, 2024: Article in progress. We’re releasing this article ahead of our November 2024 issue to quickly provide guidance to our readers. The final version may include revised recommendations. This article is from Hospital Pharmacist's Letter and contains wording directed specifically to that audience. However, the editors are providing it to this Letter's readers due to its potentially relevant content.

 

You’ll be called on to help your hospital conserve IV fluids.

Shortages are expected...due to the impact of Hurricane Helene on Baxter’s North Carolina facility that produces about 60% of the country’s supply of IV solutions. Allocations are already significantly reduced.

Currently, this is impacting bags 250 mL and up...but could have trickle-down effects on smaller volume bags if supply limits continue.

Maximize using po fluids and meds. Work with nursing to evaluate patients receiving IV fluids for transition to oral hydration.

Also look for open-ended continuous infusion orders, and clarify to include a stop date/time or maximum amount to infuse.

Ensure your hospital is maximizing IV-to-po switches...even for meds that don’t have an exact conversion. Use our chart, Considerations for IV-to-PO Conversions for dosing guidance and more.

If needed, work with IT to see if your EHR can help identify candidates for IV-to-po switches.

Also help reinforce use of shorter IV antibiotic durations.

Switch meds to IV push when possible. Help ensure safety.

Use sterile water to dilute IV push meds when possible. Using D5W or normal saline instead of sterile water...or not diluting enough...can increase osmolarity and extravasation risk.

For example, you can dilute many IV push antibiotics with 10 mL of sterile water...but use 20 mL for 1 g doses of meropenem.

And continue to avoid bacteriostatic diluents for IV push doses in neonates...the preservative can cause “gasping syndrome.”

Limit IV push doses to a max of 3 vials/syringe if made at the bedside...due to USP <797> standards. And administer within 4 hours.

Consider batching commonly used antibiotics in unit-of-use syringes for IV push administration.

For meds that shouldn't be pushed, consider alternatives...such as IV push cefepime instead of piperacillin/tazobactam for Pseudomonas.

Save large-volume fluids in short supply. Work with your hospital to allow automatic switches to alternative IV fluids...such as D5W with 0.225% sodium chloride (D5 1/4NS) in place of D5W.

Stop continuous infusions in patients with orders to “keep vein open” or “KVO.” Instead, switch to catheter locks or flushes.

And educate staff NOT to pre-spike IV fluids.

Consider prioritizing large-volume IV fluids for certain situations.

For instance, prioritize dextrose solutions for women or small children...they’re more susceptible to hypoglycemia when fasting.

And reserve isotonic fluids (NS, lactated Ringer’s, etc) for kids under 18 if possible...due to risk of hyponatremia with hypotonic fluids.

Also save lactated Ringer’s for septic patients. Avoid hetastarch for fluid resuscitation...due to kidney injury and bleeding risks.

Consider infusing high-alert meds with a syringe pump.

For example, instead of using a large-volume infusion, consider prepping insulin drips in 50 mL syringes. Label syringes clearly to help avoid accidental IV push...such as “for syringe pump use only.”

Assist with inventory management. Help ensure active back orders are in place for IV fluids...along with orders from alternative suppliers, including 503B outsourcing facilities.

And recommend obtaining premixed medications when available.

Leverage “leftovers” on your TPN compounder. For example, compound D5W using leftover D70...or NS and 0.45% NS using concentrated NaCl.

Also keep a close eye on the inventory of other items, such as syringes, that may increase in usage due to IV bag conservation efforts.

REFERENCES

• ASHP. Fluid Shortages – Suggestions for Management and Conservation. February 28, 2022. https://www.ashp.org/-/media/assets/drug-shortages/docs/drug-shortages-svp-shortages-suggestions-for-management-conservation.pdf. (Accessed Oct 4, 2024).
• ISMP. Safe Practice Guidelines for Adult IV Push Medications. 2015. https://www.ismp.org/sites/default/files/attachments/2017-11/ISMP97-Guidelines-071415-3.%20FINAL.pdf. (Accessed Oct 4, 2024).
• Australian Commission on Safety and Quality in Health Care. Conservation strategies and safety considerations during intravenous (IV) fluids supply disruption. August 2024. https://www.safetyandquality.gov.au/sites/default/files/2024-08/fact_sheet_conservation_strategies_and_safety_considerations_during_intravenous_iv_fluids_supply_disruption.pdf. (Accessed Oct 4, 2024).
• Feld LG, Neuspiel DR, Foster BA, et al. Clinical Practice Guideline: Maintenance Intravenous Fluids in Children. Pediatrics. 2018 Dec;142(6):e20183083. doi: 10.1542/peds.2018-3083.
• Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021 Nov;47(11):1181-1247.
• Weiss SL, Peters MJ, Alhazzani W, et al. Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children. Pediatr Crit Care Med. 2020 Feb;21(2):e52-e106.