The US is experiencing severe supply constraints involving commonly used intravenous (IV) fluids. At present, the most serious IV solution shortage involves liter bags of 0.9% sodium chloride injection (0.9% NaCl). Supplies of lactated ringer’s injection and 5% dextrose and water injection are also running low. To help safely meet the needs of patients who require IV hydration, we have expanded upon recommendations listed on the American Society of Health-System Pharmacists website (www.ismp.org/sc?id=286).
Use alternatives. The use of alternative solutions should be maximized whenever possible, which may include: 5% dextrose in water, 5% dextrose with lower concentrations of sodium chloride, or 5% dextrose in lactated ringer’s injection. (Use of plain 5% dextrose in water by itself or hypotonic saline solutions is risky in pediatric patients. These solutions can lead to acute water intoxication, hyponatremia, and death in children [www.ismp.org/sc?id=287].) Manufacturer- specific products such as (Hospira), (Baxter), or (B. Braun) may also suffice as replacement solutions (refer to product labeling before use). In some cases, admixtures routinely prepared in 0.9% NaCl can be prepared in other fluids such as 5% dextrose and water injection. It may also be possible to reduce routine use of 0.9% NaCl injection in certain areas of the hospital such as the emergency department and the operating room. If feasible, oral hydration should be considered.
Also, 0.9% NaCl may be available in smaller IV bag sizes (e.g., 150 mL, 250 mL, 500 mL) and should be considered for use. If drugs are added to the smaller bags, ensure the concentration is consistent with liter preparations since differences can affect infusion pump library settings, drug protocols, and pharmacy labels. If supplies warrant, stock the smaller bags in clinical areas for nurses who might otherwise use liter bags. Also consider removing bags in short supply from unit stock and keeping them where pharmacy can best manage supplies. Low infusion rates in adults (i.e., 40 mL/hour or less) can often be discontinued and replaced with a saline lock.
One hospital recently used 0.9% sodium chloride irrigation to replace the injection. This should be avoided because sterility requirements and limits on particulate matter differ between these two products.
Extend “hang” times. Some hospitals are considering or have begun to extend the usual 24 hour maximum IV solution “hang” time (e.g., 36 hours or beyond) to preserve solutions during the shortage. Such a decision must be made with joint agreement of nursing, pharmacy, medical staff, infection control, and others that may be affected. While nationally established standards are not available for “hang” time from the Centers for Disease Control and Prevention (CDC), US Food and Drug Administration (FDA), US Pharmacopeial Convention (USP), or the Infusion Nurses Society (INS), at least one publication supports “hang” times beyond 24 hours (www.ismp.org/sc?id=288).
Extended “hang” times should not be used with IV lipids, parenteral nutrition, solutions for immunocompromised patients, and solutions used in hospital-designated clinical areas considered unsuitable (e.g., critical care). If extended “hang” times are used, manufacturers’ recommendations must be followed for specific medications.
Compound as a last resort.We can’t stress enough the importance of exhausting all other alternatives before compounding IV sodium chloride solutions. As a last resort, pharmacies may be forced in some circumstances to compound 0.9% NaCl injection using the proper amount of sodium chloride concentrate 23.4% injection, or starting with bags containing lower concentrations (e.g., 5% dextrose and 0.45% NaCl) and increasing the sodium chloride content by adding the concentrate to the bag. Or, the proper amount of sodium chloride concentrate 23.4% might be used as an additive with bags of sterile water for injection. If starting with any commercial IV solution bag, the final prepared sodium chloride concentration might be slightly less than expected due to overfill in the container. When adding sodium chloride concentrate 23.4% to bags containing less than 0.9% NaCl, we do not recommend removing fluid from the bag first. Further, we do not recommend starting with an empty bag unless the hospital’s IV compounding process is highly automated. Under no circumstances should vials of concentrated electrolytes or liter bags of sterile water be sent to patient care units for non-pharmacists to prepare solutions.
With any compounding, a planned process must be in place to minimize the risk of serious errors. For example, inadvertent dispensing and administration of plain sterile water for injection has led to fatal hemolysis (www.ismp.org/sc?id=289), and fatal hypernatremia has resulted from compounding errors with sodium chloride concentrate 23.4% (and 14.6%) injection (www.ismp.org/sc?id=290). Quality control checks and independent doublechecks must be conducted and documented to verify quantities and ingredients. (Consult ISMP’s Guidelines for SAFE Preparation of Sterile Compounds at: www.ismp.org/sc?id=291.)
It should be noted, if compounding sodium chloride solutions becomes routine, it could worsen shortages of concentrated sodium chloride injection, which is already in short supply in certain dosage forms and container sizes. This would jeopardize use in patients who require parenteral nutrition. Also, supplies of empty bags and sterile water for injection could be adversely affected.
Extend expiration dates. Some warehouses, hospitals, and controlled storage locations may be holding cartons of IV solutions that recently have expired or will reach expiration soon. FDA authorization to extend expiration dates requires data from manufacturers that support longer shelf life, which, so far, has not been submitted. Before extending expiration dates, we urge hospitals to explore other alternatives. A decision to use expired products must involve agreement by the leadership of each organization, including its legal and ethics experts, and be based on an evaluation of risk vs. benefit, and laws and regulations.
A note about dialysis solutions. In hospitals that prepare hemodialysis solutions for continuous venovenous hemodiafiltration (CVVHDF), investigate commercial products that can be used as alternatives to compounding solutions that require use of 0.9% NaCl injection bags.