Hello, and welcome to today's webcast, IV fluid management during shortages. My name is Emily Miller, and I'm the clinical pharmacy manager at Indiana University Health Adult Academic Health Center in Indianapolis, Indiana. I'll be moderating today's webcast. A recording of the webcast will be available within five to seven business days. Log into myfccm.org, navigate to the My Learning tab, and click on IV fluid management during shortages. Click on the Access button to access the recording. Thank you for joining us today. A few housekeeping items before we get started. To submit questions throughout the webcast, type into the question box located on your control panel. You will also have the opportunity to participate in several interactive polls. When you see the poll, simply click the bubble next to your choice. As a disclaimer, please note stating that the content to follow is for educational purposes only. Now, I'd like to introduce your panelists for today. Jeremy DeGrado is clinical pharmacy practice manager and PGY-2 critical care pharmacy residency program director at Brigham and Women's Hospital in Boston, Massachusetts. Jillian Polis is a nursing professional development practitioner at Cedars-Sinai in Los Angeles, California. And Alejandro Baez is a professor of public health, health care management and policy at UC Houston in Houston, Texas. And now, I'll turn things over to our panelists. We have a few polling questions for you today. First question, has your institution exhausted its supply of any parenteral solution that is 500 mils or greater? Great. It appears so far that institutions are able to reduce its utilization and have not yet reached the point of exhausting full supply. Now, I'd like to introduce your panel. The second polling question we have, how long will the existing supply of IV solutions remain at your institution? Less than 24 hours, less than 48 hours, less than 72 hours, between 3 and 7 days, or more than 7 days? Looks like a majority of voters are more than 7 days, with quite a few followed between 3 and 7 days. How effective have local mitigation strategies been in optimizing the supply of IV solutions? Very effective, somewhat effective, somewhat ineffective, and very ineffective. Most people are feeling that these strategies have been somewhat effective. Some are really doing excellent work and feel very effective, and others ineffective or very ineffective. It's interesting to see if we should have had an unknown for those places who maybe don't have as much transparency in what their supply is of the different solutions. Our fourth question, has the IV solution shortage led to any medication errors or adverse clinical outcomes at your institution? Thankfully, most people here voted that that has not been the case. What alternative fluids have you used during the shortage? rehydration, enteral nutrition formulations, dialysate solutions, IV colloid, or others? It's like most people are using oral rehydration solutions. No one has started using the dialysate solutions, and a few others have listed in other options. And the last question we have for you is, how do you prioritize patients when IV fluids are in short supply based on the severity of the condition, first-come, first-served, other criteria or processes, and we haven't considered this option? have utilized the severity of a condition, and others are either still deciding or have not yet approached that. I think it's a very important question to ask, and it's a very difficult one to consider. And I'm very interested to hear what our panelists have implemented at their institutions and what they have heard about. And so, we will now turn some questions over to the panelists. Describe the process for procuring IV fluids. I think a lot of people on here may have various backgrounds and may not be as familiar with how we actually obtain these products from the different manufacturers. Can anyone take a moment to describe that process? Emily, I can start and just say that, you know, I think for those of us that have facilities that are, you know, specific to the ordering from Baxter and, you know, receiving these solutions, you know, we're largely dependent on this one area, and so, these medications, these fluids, you know, kind of go to our, you know, more regional distribution centers from that one facility, and then, you know, at these local warehouses for us to buy. And so, while there's, you know, at the time of the shortage, there are fluids that are available for us to purchase, and there's clearly a backup and a backlog of a lot that's impacted from a disaster like this. And so, you know, it's interesting that, you know, some hospitals, a lot of hospitals probably around the country are not even as impacted at all by this, depending on where they receive their IV solutions and where their contracts are and who they receive these from. And so, you'll see, I'm sure a lot of folks have differing experiences on whether their hospitals are impacted or not at all, and then to varying degrees. And so, I know there's a lot of things that are being done at the government level, let alone all the things that each hospital is trying to do to mitigate this, but, you know, think of other places to get fluids, whether that's other companies or, you know, looking into bringing products in from, you know, internationally, and I know there's a lot of things that are out of the control of, you know, our own institutions, but clearly there's a strong desire to look elsewhere from where we normally get fluids, because it is such a narrow supply chain. Several of the policies that are probably temporary have been enacted by the FDA to help mitigate some of this crisis. Strategies include allowing compounding by pharmacies or outsourcing facilities, international importation for some solutions. What does this mean for the hospitals and institutions to utilize these measures, and how do they go about, you know, obtaining products and implementing those strategies? I think, Jillian, you had mentioned compounding. Your pharmacy has started to compound even normal saline. Yeah, that was a lesson we learned back from when that other horrible disaster happened in Puerto Rico, so that isn't something we've actually had to start implementing, to my knowledge, quite yet, but it is on the back burner and something we will proceed to do the longer the shortage goes on. And I think we have, you know, we have experience bringing in, you know, some international products with some previous disasters that have had similar impact, and I think while some of those regulations have been lifted or lightened and some of those products, those fluids are, I think, approved to use, I think we're waiting, at least here, we're waiting to actually be able to purchase those and utilize those, so I think it just takes a while for those to get into the supply chain, so that's another challenge that we have seen, is that while those, from my understanding, are coming from, you know, comparable facilities that are, you know, Baxter facilities elsewhere, there's just a delay in getting those products to a point that we can purchase them, and, you know, when you're looking at other companies that are potentially able to help, and when the regulations are lifted, that they're able to help manufacture volume, you know, IV fluid that you could use, by the time that gets ramped up, it's very possible that your acute need is lessened, so it, while those, while there, you know, you may have some more options in terms of what you're allowed to do and where you can get, you know, solutions from, it may not happen in a most timely manner. It takes a while for those things, I think, to get ramped up. Considering that, you know, most people had said that their supply is around that, you know, seven days, and we anticipate that the shortage may be through the end of this year, what types of strategies at your institutions have been implemented to reduce the amount of IV fluid use? I can, I can jump in there. Here at Cedars, we've greatly reduced the PAR stock available in each unit. It's just been a huge collaboration with pharmacy and our central supply, along with executive leadership, all the way down to the bedside nurse. Any possible way to salvage every last drop has really been implemented, from decreasing NPO times to utilizing smaller volume bags, 50 CCs or 100 CC volumes when possible. Pharmacy is making anything that they can IV push, but that doesn't, that also comes with the discussion, right, effects of that for patients, but obviously we're being safe about everything and mitigating whenever and wherever possible as we work through our remaining supply and continue to try to save as much as we can moving forward, but getting the patients what they need. At the VA today, they circulated a very interesting document that I think in essence addressed two major items. One is the inventory and burn rate tracking, which I think it's important, some sort of centralized way of figuring out what you have, where you have it, and controlling that as well. I think a lot of waste happens at the unit level, and I think it's important to monitor that in a centralized way so your conservation strategies are effective. The other piece that I liked about the VA document is that it looked at provider-specific items to address, because if you send out a generic set of recommendations, does it really apply to the PA or the physician or the nurse or the pharmacist? So on the breakdown, it looked at we recommend this, and these are important to address if you're a pharmacist, if you work in operations, if you're a physician, if you're a nurse, which I think is a pretty reasonable, logical way of approaching this. And then lastly, they did look at crisis standards of care and kind of defined what level green, yellow, red, conventional, modern, and critical looks like within this specific shortage that I think in essence just creates an early warning system. If you link that up to your burn rate assessment, then you can have a little bit of a predictive tool so when you can actually call for help and figure out where to call for help. And lastly, the call for help looked at a kind of mutual aid, a mutual aid approach at the regional VISN level and at the national level. So saying, well, if you run short, these are the health systems, the VA health systems you can talk to to see if they can help. And then the step up is at the regional level and then at the national level. I thought it was a pretty comprehensive strategy, and they just circulated today. And I think that's one of the big challenges that we've seen at our institution and system at the system level is figuring out where we even stand. And so that results in a lot of communication. And I think a lot of meetings and a lot of emails that are tough to sift through and be on top of. But of course, it's important to just know what the numbers are. And so if you're centralizing supply, whether that's in NED or across the system, it's important to keep track of where you stand and what you're using and get those numbers as accurate as possible. And I know a lot of us have been involved in doing physical counts to sort of set baselines and then tracking from there. We've done some similar things to what Alejandro mentioned about having some specific tasks for certain disciplines. And so we established sort of a rounding checklist. And so on every patient, there's a checklist that we go through at the end of rounds for everyone to and different pearls will apply for different folks. But making sure that all the active fluids are assessed and discussed and future strategies for resuscitation are discussed at that time and looking at all the medications and any pathway. And a lot of it is pushed. One of our biggest pushes seems to be like we saw in the poll through the oral hydration and getting that done as much as possible has been a big change for us during this. Oral hydration has been a topic that a lot of different institutions are trying to implement. And it may be best practice in reducing NPO times and ensuring preoperative adequate hydration. Has there been any specific strategies utilized in order to really get good uptake and utilization for those hospitals who are still not seeing that adopted widely? Do you have any tips or ideas for how that messaging was sent or communicated or any ideas for restrictions that were utilized? Here at CEDARS, we're getting the critical IV shortage updates daily or daily every 24 to 48 hours. And they have those tips in actually the one that came out this morning was specific. I'm kind of working sideways looking, you know, following to our NPO guideline, reinforcing it that way communication kind of from the top down and then making sure it gets dispersed at the unit level through huddles and charge nurses are aware to go through their leaders. But always it has to be safe for the patient, but implementing oral hydration when it's safe to do so seems to be effective. And I would imagine the other panelists are, I hope they're seeing that at their facilities too. Yeah, one thing we sort of noticed from this is that we had a pathway for this in our EHR, and we had, you know, we quickly were able to put together a tip sheet, which essentially outlines what the options are. But that can, of course, vary between different sites. And what we didn't really have was a clinical guideline around like how to do it, and maybe in what patient populations, certain products may be best and, you know, when to steer away from others. So, I think that's something that we were working on and trying to expedite, and potentially will be, you know, very useful going forward. One thing that I didn't hear mentioned, but I'm interested to find out if there had been discussion at your institutions about implementing automatic stop times for maintenance fluids, such as a 24-hour duration, 12-hour duration, or one bag to minimize spiking a new bag for just a short period of time. Well, here at CEDARS, I mean, we're really trying to reduce all fluids when necessary. So, as far as a bolus or a maintenance, if the patient doesn't absolutely need it, they've already been transitioned to that oral hydration of some kind or a different type of fluid resuscitation. A lot of mitigation in the ICU specifically has been around, you know, we're very, very spoiled with our TKOs and continuous running. All of that has stopped, gone by the wayside for right now. We initially, I believe in the first or second update, if you had something spiked at the bedside, it was communicated, do not throw this away. Not single patient use, obviously, but if you can come back to it or use what's remaining in the bag later. There's just been different things over the last 10 days that you can see put in place here. Yeah, we've had similar interventions, you know, kind of put in alerts and restrictions in EHR initially, you know, now requiring the dose and like the rate and a duration. So, that has to be in an override reason if that amounts to over a liter initially. And so, you know, requiring those to basically fall off and be reassessed. Again, trying to emphasize that on all the communications and again on that daily checklist I mentioned that should be assessed for every patient, but just on the ordering side, trying to put those things in the electronic health record to make sure that those just fall off. And of course, it's a little bit of a more manual process to make sure the, you know, talk about the KVO orders and see if those are needed and get rid of those as able. And here I would just chime in. We, our pharmacists in the ICUs were amazing. That was a whole afternoon of work for them to transition the liter bag orders to the smaller volume 100 cc and that was just part of the work. Everyone's jumping up and doing everything they possibly can. We need some, but we have learned quickly. We definitely don't need everything we've been using or having right there, you know, within a hand's reach. Have there been strategies to reduce the amount of flush bags being utilized and secondary, you know, setting up a primary with a flush bag and utilizing for intermittent medication orders? Jillian, I think you maybe mentioned utilization of primary tubing for... So, essentially, outside of the ICU, we are now, no one is to use a primary, or I'm sorry, no one is to use a primary. All secondaries are to be given as primaries as a way to mitigate. In the ICU specifically, you know, we have our flush bags and our transducer systems. We have, though AACN has always said 96 hours for flush bag changes, we were changing them every 24 hours, so that's another way we've reduced that, you know, duration of change, trying to make those solutions last as long as possible. You know, just the simple thing, the doctor said, we're going to put an A-line in, and then they're still on round, so they know they're not coming back for four hours. Please don't set up the transducer tubing or spike that flush bag. Please don't set up the transducer tubing or spike that fluid until the physicians are right there, and you know that line is definitely going in. And then one TKO, which I know it sounds dingy. Some of the ICUs were spoiled, as ICU nurses sometimes, speaking for myself, where we would have two or three TKOs because we're continuously giving all the electrolytes and antibiotics. My background is cardiac surgery ICU, so I was always spoiled with that, but now it's one or none. And again, outside of the ICUs, no primaries at all, just all secondaries are to be given as a primary. I think with the reduction in the attention drawn to reduce the use of crystalloids, one question that we commonly get then is, should we be utilizing more colloids and blood pressures or in blood products? How has your institution had that discussion or implemented any changes in increased utilization of albumin or blood products or been able to avoid that reaction? Yeah, it's definitely come up here, and we've been talking about it extensively. I think it's extremely complicated because obviously we can talk about the data for the last 36 minutes, but I don't think that's the best use of time. But there's just such a history with albumin in particular in the critically ill. And I think for us, we generally don't utilize it in shock resuscitation, given the data and the non-inferiority or just equal efficacy and safety compared to crystalloids. I think that in a situation like this, the pendulum swings really far and the discussions start to be, can we just use albumin? To what extreme can we use albumin? And it becomes less of the usual, these are equally efficacious and it's a cost thing to, is it safe to be giving albumin in all these situations? And so these patients that are on general floors that are not critically ill that may have hypotension from whatever indicate, whatever ideology and giving them a colloid is definitely not without risks. And so we've struggled to slightly increase our use and our patient eligibility criteria to be a little bit more lax, because I think it makes a lot of sense to use that for a patient in shock, for example, that needs resuscitation, as opposed to kind of just a substitute for a crystalloid. And I think that's been tough for us to navigate. It looks like most people are trying to utilize crystalloids based on acuity of the patient and make sure that we maintain supply for those where evidence-based medicine shows that that is an effective first-line strategy. For example, in patients who are septic, have any patients or any institutions, excuse me, utilized assessments of fluid responsiveness more in order to restrict the amount of boluses utilized or passive leg raises, IVC of the ultrasound of the, in ways to identify which patients actually need those fluid boluses? I don't think we've rolled anything out clinically that is a recommendation to change that. I think people are probably being more restrictive and conservative with fluid administration in the critically ill. And we know that from the literature, one of the ways to do that is to not just give fluids, but assess what happens when you get fluids. And we know that the dynamic markers are better than static markers and seeing what changes. So I think in practice that's happening. There hasn't really been a lot of discussion around doing that, but I think certainly I've heard through, you know, report out through various units that that's the goal. And, you know, while it's, you know, established in guidelines to use the dynamic markers and to do things like passive leg raise, and, you know, that's sometimes tough in practice. But I think in these scenarios, it's done, it's being done more, but it just hasn't really made it into kind of the, maybe the bigger picture, you know, hospital-wide or system-wide strategies. But I think clinically, certainly that's the way to go. We know that early volumetric resuscitation is important, but we also know that the shortly thereafter and, you know, moderate term after that, it's important to be very conservative and, you know, deescalate fluids quickly. I think this also opens up a conversation on what are standards of care. I think it's a little bit different when you work in a, you know, level one quaternary academic medical center than when you're working in a rural hospital. And you understand the evidence if you're in an academic center and all those things, whereas a lot of the paradigm in a lot the paradigm in a lot of rural hospitals is payers drive practice. And a lot of the policy items that come from the payer side of things is lagging five to 10 years. So I think it's an interesting conversation of what defines standards of care, because right now we're talking about addressing crisis standards of care and what does that look like. So it's an interesting conversation, maybe not necessarily for the now, but maybe as a, you know, what have we learned from this and how can we prevent similar things happening in the future? I think that also brings the question in the chat too was, you know, in talking about what is the standard of care for fluid administration, is there a discussion around or any implementation strategies for questioning the 30 mils per kilo for septic patients or utilizing ideal body weight instead of actual body weight for those calculations, if anyone in the panel can speak to that. It's a tough, I'll just say it's a tough decision because there's not a ton of data on it. And I think, again, initially that volume is probably very important. And when you're, you know, giving a medication, you think about how it distributes or giving a fluid and you think about how it distributes, you know, actual body weight for something like that, it's probably right, quote unquote, to ensure that there's adequate volume given. I think some of the discussions I think that we all have through the years is whether, you know, is that 30 cc is the right number. And I think it is a number and I think it gets thrown around quite a bit, but the 30 mils per kilo, or is it, you know, should we be doing things more patient specific in general and giving smaller volumes more frequently and assessing changes. And again, just instead of just thinking about filling a tank, just thinking about how are we actually getting more output from this? Are we actually getting more cardiac output and actually increasing, you know, what were the goals that we're trying to achieve? And so I don't know the magic number, and I think giving a little less is probably not that impactful as long as we're assessing and seeing how they respond to whatever we administer. And that's true with volume, that's true with medications as well. I do have a couple of questions in the chat that I wanted to make sure that we address. A question, I think, Jillian, when running antibiotics on primary lines, how are your teams ensuring that the full dose gets administered? For example, the volume that's left in that primary tubing, if you do not have any kind of flush system set up? Yes, that's a great question. And we actually had to go back to some basics from many, many years ago and implement the use of dial-a-flow or control-a-flow. So that was part of kind of a mass education push specifically for nursing, utilizing, you know, the smaller volume bags, how can we make sure the patient's getting every last drop possible? And it's we, a small group of us from each of the different divisions of the hospital got to, how can we do this? How can we ensure this? But really implementing dial-a-flow or control-a-flow, if you're not familiar with what that is, it's about a seven-inch extension tubing that we would put at the end of the primary tubing. And this was a variation for nursing practice because they're, they have to know the Alaris pump and we have pump integration here at Cedars. So they, you can program a certain volume as well, but we know it's about 50 cc's. We know in the tubing, it's about 22 cc's. So the nurse will now, at this point, with that extension tubing in place, after they've hung the original dose, they have to remove the tubing from the pump and make sure it's open. And then the dial-a-flow, which we've had actually, it's been live for about a week, realizing obviously different IV sizes in different vessels. Gravity isn't always your friend if you have a little tiny gauge IV, but the nurses had to quickly adjust and they've been so amazing and resilient throughout the whole hospital, learning to use this piece of equipment that frankly we used 20, 30, 40 years ago, but because of all the technology haven't had to. So kind of back to a, back to basics approach to make sure they're getting all that, all 50 cc's, 50 of those 50 cc's. Thank you, Julian. Alejandro, this one's really for you. The VA document that you mentioned, was that all VAs or was that a local or a regional document? We have some VA members who are asking if they had not seen anything like that yet. Oh, that's interesting. It came from the National Emergency Medicine Group. So it came from NEMO, so it came from National. I think a lot of the focus for fluid restrictions has been in the inpatient setting and this question applies to, or includes the scope of outpatients in home infusion centers, those who service patients who are on chronic TPNs as an outpatient or home inotropic therapy. Has anyone collaborated with their home infusion centers in order to address those patients, or are you seeing readmissions in order for them to maintain their needed medications? We have not, and I don't know, and we have not had any, I don't think anyone reached out to us to kind of navigate those challenges. Because I know obviously that this is impacting a lot of different places and a lot of different facilities that make medication. We don't do that a lot here, but I think we would, that would have to be a patient-specific conversation of how we're going to, would we support that or be able to move inventory around to prevent any issues from occurring if patients are running out of supply, but we have not run across that so far. Jillian, this question was for you. What did your institution decrease your NPO times to? As low as two hours, two-hour NPO guidelines, reading it from an email right on the other side of my screen. But that's appropriate, you know, you have to be mindful of the exclusion diagnosis. Some patients you simply cannot do that, but also the use of carbohydrate oral fluids. Again, the Gatorade. We get, we get a daily kind of list of where we're at across the organization, not just with the IV fluids, but now with the Gatorade and the other fluids and Tero fluids. So everyone can have awareness around the amount, you know, where we're at. Yeah. We talked a little bit about this with the passive leg raises and ultrasounding your IVC. Has anyone implementing CBPs or RAP, anything else in terms of using more objective data to determine when resuscitation can be slowed down or reduced? Yeah, I think, again, we're using a lot less, we have patients that don't have central lines like they used to. That isn't necessarily as common as it used to be, but I think when those things are available, we're taking that data and we're trying to, again, trying to use it dynamically as opposed to just what the measurement is. I think we know the flaws of some of that, the way we used to interpret that information, but certainly trying to use those markers as opposed to just raw numbers, giving smaller boluses as opposed to, I think our default ends up always being give a liter, maybe give half a liter, but starting even smaller when possible and reassessing and seeing if there's a change, not just in pressure, but in some of the things we know are actual markers of and surrogates of something meaningful happening. None of them are perfect, of course, but. I think it's interesting, we talk about shared decision-making when it comes to patient-provider, patient-physician communications. I think probably this is where we need to deploy shared decision-making as a team so that, for example, if somebody is pushing you for that 30 cc per kilo bolus, but you know that there is a way around it if you document properly the reasons why, and you know through the dynamic markers that Jeremy's talking about, you know the effectiveness of your interventions, then probably this is the best time to come up with shared decision-making strategies at the clinical team level. A few questions in here around, excuse me, oral hydration. What products are people utilizing for oral hydration? I know Gatorade's been mentioned, Gator Light, there's Pedialyte, are there other powdered products? Is that something that food services are preparing or dispensing with pharmacy, and how is that operationally being rolled out to different folks? Yeah, at my institution, it's not pharmacy, it's supplied by nutrition and dietary, and we have a guide of what we have in terms of Pedialyte, I think, and Gatorade, and Body Armor Zero, and some other things that are potentially helpful for patients that can't tolerate some of the ingredients in some of these solutions, and so again, something we're trying to do is get something in place to support that, and not only have a selection of what, or a document that states what you can use, but have something, one, that's dynamic, because things get consumed, and we don't always have the same products that we did a week ago, and again, things get shared across the different institutions within our system, but also it gives some clinical guidance as to what to use and when, but others may have different solutions. No, and if we want to go further on conservation strategies, probably half-cut Gatorade works well, so you can even half-cut that, comes from like old DCCC military, you know, two decades ago, so that's another point, I think the big argument is that regular Gatorade and the sugar load, versus if you cut it in half, you can still get that sugar and electrolyte component, but maybe our pharmacy friends can help me verify that. I like the idea of extending the supply further, it's a great idea. As long as we're able to dilute it with tap water and not sterile water. For those who are trying to limit fluids with primary tubing and switching to IV push, like, for example, antimicrobials, are you still using fluids to flush or limiting bag sizes for flushes? I know, Jillian, you said that you're really primarily focused on setting those up as primary, but for other institutions, anyone utilizing smaller bag sizes for KVOs or flushes? We will manually flush just with a 10cc syringe after the IV push meds are given, but we do your TKO bags, or if there is a primary bag, or giving blood volume, we're actually priming the tubing, blood tubing with the blood, and then just utilizing the 50cc bag to make sure that all of the blood goes in, as one example, but yeah, smaller volume bags if there are any flushes needed. Yeah, our experience is similar. I don't think we've seen a massive issue with the flush syringes at this point, and so those have been something we've continued to use for the push, and as we contemplate expanding our push portfolio, obviously there's a lot of literature, there's a lot of guidelines from various societies on what you can push, and there's literature that expands that and extends that list even further, depending on how far folks want to go with it, but I think there's always some things to think about, and I think what we at least here try to do is push as much as possible at baseline, and a lot of that has to do with thinking about the kinetics of the drug and making sure that it's safe, and when we start to get to these antibiotics, I think there's real conversations to be had, just pharmacokinetically, dynamically, are you optimizing therapy, and of course you have to deal with the fluid shortage, and it's better to get some antibiotic than none, of course, but while we're in conservation mode or various stages of the shortage, when do you pull the trigger on things like cefepime or Ceftaz that you have critically ill patients with infections that are maybe at sources difficult to treat, and so just discussions that need to be had as to whether there are exclusion criteria, whether you are changing your doses and intervals to try to maximize the effect and minimize any negative impact of switching to a rapid push as opposed to a prolonged infusion. There's some question, and as we talk about volume of fluid that patients are getting, sometimes there's maybe not as much transparency about the amount of fluid that patients receive from other infusions, whether it's their antibiotics or continuous infusion sedatives or analgesics. Is there been any strategies to ensure that if there's a fluid prescription that a patient needs or a fluid volume that's needed, that those are incorporated into that volume? I don't know of any. I think that's a big thing for us generally, is a focus. I agree that getting all that stuff documented is tough because in the EHR, it takes a lot to do that, and whether that's from a procedural area or just all the infusions that are being administered to make sure all that is collected and accurately displayed is tough at baseline, but probably now is when you really want to know that so that you know how much patients are getting and you're not overdoing it with extra fluid. I think that also goes back to that burn rate monitoring. It's a different practice style, but we are in a kind of contingency-type mode, so maybe at the unit level, the same way we have antibiotic stewardship and the same way we deploy certain patient safety efforts, maybe at the unit level there should be an added responsibility in terms of checking all those things that normally we ignore. We're just kind of having a more detailed, more precise approach. I think that deployment needs to happen at the unit level and not at the big institution level. The operationalizing of any strategy needs to happen at the boots-on-the-ground level. There's a few questions about strategies to reduce fluid use in the ORs. Has anyone collaborated with partners in the OR in fluid restriction or fluid management? Let's say that that's interesting, knowing that the OR is just frankly one of the highest users of fluids, also in the ICU, of course, but the OR is the one place at CEDARS that is still, especially with L&D and all of the things happening in the operating room, they're the ones that have the least restrictions. Let me say it that way to the point Alejandro was just making. We have reduced PAR levels, what is in the supply rooms on the units, but the charge nurses only are reaching out directly to central supply. I don't want to get away from the OR question because I apologize for not having a great answer, knowing that's probably one of the bigger challenges for the bigger medical centers, but really that mitigation and reduced PAR, but every step of this has its rhyme and reason on distributing what we have left, right? But someone else might have something more insightful to say about the OR reduction. I'm sorry, I don't. Yeah, and I can contribute from this document that we got from the VA. It's interesting because it also does this specific strategy addressing peritoneal dialysis and surgical and anesthesia conservation. So there's a surgical anesthesia conservation and a couple of things I'm seeing are actually interesting. It says use pre-operative oral hydration using clear liquids until two hours before procedures. Reserve balanced salt solutions such as LR for selected operations with higher anticipated blood loss. Consider colloid solutions for selected patients. Use small volume ampoules instead of small volume IV fluid bags. There's an interesting list and then I think it kind of goes back to that shared decision-making and that collaborative process. I think there needs to be, you know, an all-hands-on-deck approach and the consensus in terms of this needs to have specificity in the unit. For example, the challenges in the emergency department are different than the challenges in the ICU and are different than the challenges in the OR. So I like that approach of being unit-specific and developing consensus based on the specificity of each unit. And I think, you know, remembering that these are, it's a, you know, fluid shortage issue and so there's things that we compound especially for that space that become challenging but there may be commercially available alternatives that can be pivoted to. So, of course, there's a resuscitation piece that obviously, you know, others can have spoken to but, you know, whether that's, you know, changing, you know, your mannitol solution or to, you know, from 20% to 25% vials or, you know, using a different heparin concentration for, you know, that may be commercially available as opposed to what's manufactured. I think that's where, you know, the creative thinking comes in to see what else, what other products can be obtained that don't rely on, you know, these large volume mixtures. Several people have commented about, you know, the switching of antibiotics, for example, from IV piggyback to IV push and we touched on this a little bit but are there restrictions or are there any concerns about certain populations or areas that we may want to continue to utilize prolonged infusion or situations where the IV push antibiotics, while okay to administer, is maybe not clinically the best? Yeah, and for those reasons, we haven't made a massive shift. Again, I think if your drug supports the kinetically, the switched IV push subtraxone, for example, you know, I think it's a good example. I think that's a great thing to do. In certain drugs, you know, you're going to give up some of that benefit that you get from a prolonged infusion, so a time-dependent antibiotic. So, I think in patients with specific disease states, you know, meningitis, various CNS infections, I think that's an exclusion criteria that we've discussed if we do move to IV push for some of these time-dependent antibiotics that we would call out as something that, as someone that would not get IV push. Now, I think you could always argue to, you could probably achieve that same kinetics. You just have to give lower doses more frequently and I think just a little bit unknown how to do that and so we probably would just prioritize keeping those patients on, you know, extended infusions, prolonged infusions, continuous infusions, whatever it may be to achieve those dynamics to make sure we're not compromising clinically. But I think making sure that we do as, convert as many meds to IV push as possible that don't, you know, that we don't sacrifice on the PKPD, I think is crucial. But we definitely, I definitely think there should be some exceptions or at least some considerations in certain patient populations and, you know, specific infections. Excuse me, is any, have any of your institutions started canceling surgeries or limiting the type of surgeries? For example, if there's a shortage or hospitals don't have cardioplegia solution or is pharmacy mixing those or canceling those surgeries? We've been lucky enough at CEDARS that there hasn't been any canceling yet. I do know from colleagues in some East Coast facilities that they have had to cancel certain elective surgeries, but I would never speak to an organization that I don't work at. I can just make that, I just, just knowing from a personal connection to a colleague. So, but luckily we've been very, we've been lucky here at CEDARS so far, but that's always looming over, over us. Yeah, we similarly had a short term, you know, pause, you know, pause and delay of some procedures that, that were elective. And I think it's now, you know, the attempt to kind of get those back on the schedule. And I think that's where the daily, you know, the multiple times a day meetings come into play where we're figuring out kind of what status that you're in and are you in conservation mode or are you in something more, more, more severe and what, what the specific action items for each department are for, for, for that. And you know, trying to project it out is really tough because things can change so quickly, but obviously these aren't things that you can necessarily decide the day before or day of. So here it's become really difficult decisions. Jillian, it looks like there's a couple of questions that folks have about the KVO fluids. And are there certain patients that must have the KVO fluids? Their facility is considering stopping all given limited evidence for benefit or any, any, you know, advice on the KVO topic? I, I think that that will, we've been very lucky in the ICU here at Cedars to reduce to one KVO per patient, but I wouldn't be surprised if in the future we have to move all everything being a primary into the ICU as well, depending on how the situation pans out. I don't really have major words of wisdom. I apologize for whoever asked that question. I just, that was the start of the small work group again, about 10, 12 days ago, get rid of all primaries when we can make secondaries, primaries. In the ICU, it gets difficult with our transducer tubing again with TKO and transducer lines. We're going to just use a little bit more. But I can see that happening in the future where we'll have to, even in the ICU, have no KVO and everyone will be using the dial-up hose. We only have a few minutes left. You know, come January or February 2025, when hopefully this is behind us. Moving forward, what things can we take from this experience and how can we develop framework to better prepare for when a few years down the road, or hopefully longer, we may have another tragedy similar? So I think this conversation is super healthy, not just for the now, but to come up with a framework for how to deal with in the future. This is, you know, the typical after-action hot wash that needs to happen. A lot of the conversations, for example, on international, you know, near-shoring, French-shoring for supply chain disruptions started during the pandemic. And it's interesting that four years out, we're still having the same conversations. There's a lot of conversations happening at the regional cooperative networks with global health diplomacy efforts. And the point is, we need to move from understanding that there is an issue and actually addressing those issues, right? Because right now we're saying that maybe there's some hesitancy to deploy international solutions because of the quality of the products, or maybe the logistics are not super clear. But the way to deal with any kind of major emergency from a supply standpoint is to have redundancies, right? So I think it's important to look at what do those redundancies look like. Baxter, for example, has a huge factory in the Dominican Republic and in other countries. And the question is, can some of these arrangements at the specific institution or health system level be deployed so that you have solutions from a contingency standpoint and from a mitigation and resiliency standpoint? And so a lot of it starts with these conversations and then turning these conversations into some sort of policy document recommendation, and then just making sure that it doesn't stay as letters and words, but actually the operationalizing of any kind of policy document is the biggest challenge. I think it helps that we know that this is a big concern, that institutions are scared because of what's happening, and the idea of figuring out how to turn these lessons learned into avoidable future scenarios is super important. Yeah, I think there are just so many lessons to learn from things like this. As Alejandro mentioned, I think just from a pharmacy perspective, I think, again, thinking about where we obtain medications from and fluids from, that's not the main impact here. I think it's something to consider as a lot of our meds have been impacted and how much we keep and pushing ourselves to think about how we can optimize the way we give medications at baseline, let alone when there's an emergency and how we should set ourselves up to have our guidelines in place to be able to pivot to so that these things aren't created on the fly when this stuff happens. I think this will conclude our Q&A session. I'd like to thank Jeremy, Jillian, and Alejandro for participating in this panel discussion. Thank you to the audience for attending. We appreciate your questions and your thoughtful questions and answers, panelists. Again, this webcast is being recorded, and the recording will be available to registered attendees within five to seven business days. Log into mysccm.org, navigate to My Learning tab, and click on IV fluid management during shortages. Click on the Access button to access the recording. This will conclude our presentation today.

IV fluid shortages

healthcare settings

mitigation strategies

procurement challenges

alternative fluids

oral rehydration solutions

hospital units

dynamic markers

future preparedness