Hospitals across the United States have been feeling the impact of the shortage of IV-fluid minibags, which has hindered normal patient care and disrupted pharmacy and nursing practice. Due to unforeseen manufacturing circumstances and natural disasters, minibag manufacturers have struggled to keep up with the demand for many of their products. Several products are currently on back order or provided only on an allocation basis. This has left healthcare facilities scrambling for alternatives to minimize the impact on patient care. While manufacturers are actively ramping up production, sufficient levels have reportedly yet to be reached.
Minibags are 50-250 mL solution bags that are used for diluting or reconstituting antibiotics and other medications to be infused intravenously. Large-volume infusion pumps are the devices most commonly used to deliver these medications to patients. Minibags are often used in large quantities, which has further exacerbated the problem.
Healthcare facilities are seeking out alternatives to combat the solution shortages. Beyond the minibag crisis, ECRI Institute has received several reports of overall fluid shortages leading to nonstandard infusion delivery practices—for example, advising clinicians against flushing of medication lines to conserve fluids. These issues can pose a risk for patient care and could even lead to patient harm in a worst-case scenario.
ECRI Institute has compiled a functional equivalence chart for IV solution bags to help healthcare facilities find suitable alternatives for products in case of vendor shortages. This Excel file provides a snapshot of the data as of January 16, 2018. A dynamic, up-to-date version of this information is available to members of ECRI Institute's PriceGuide CrossCHEQ™ service.
However, as most vendors of IV solution minibags are experiencing issues, finding an alternative product may be hard or nearly impossible; further complicating the situation are hospitals' contractual obligations with solution vendors. Some alternative approaches and clinical recommendations are outlined by the Institute for Safe Medication Practices (ISMP) and the American Society of Health-System Pharmacists (ASHP):
1. ISMP safety alerts:
a) January 2018: Drug Shortages Continue To Compromise Patient Care
b) January 2014: Regarding the Current IV Solution Shortage Affecting US Hospitals
2. ASHP free resource: Small-Volume Parenteral Solutions Shortages
In addition, some alternative technological approaches exist that may aid facilities in dealing with the shortage. For example:
1. Using syringe pumps instead of large-volume pumps to deliver some medications
a) In some cases it may be possible to use syringes instead of minibags if considered clinically acceptable. Syringes of up to 60 mL are available at relatively low cost.
b) Such use, however, presents some challenges—for example:
(1) The clinician may be required to change syringes more often than minibags if splitting doses, due to the smaller fluid capacity of syringes; this can result in an increased infusion management burden as well as increased infection risk due to more frequent disconnection of the IV line.
(2) Most facilities have significantly fewer syringe pumps than large-volume pumps. Syringe pumps are generally not used in the adult care environment, but rather in neonatal ICUs. Syringe pump loaners could be considered as an option if readily available.
(3) Syringe pump user interfaces may differ from those of large-volume pumps. Clinicians may have limited familiarity with syringe pump programming.
(4) Changes to the configuration of the drug library, computerized provider order-entry (CPOE) system, and electronic medical record (EMR) may be needed to accommodate medication delivery with a syringe pump and ensure appropriate documentation.
2. Using large-volume pumps to deliver from a syringe instead of a syringe pump
a) Some large-volume infusion pumps can deliver from syringes—specifically:
(1) ICU Medical Plum A+ and Plum 360
(a) The PlumSet cassette-based administration set accommodates infusion from syringes up to 60 mL without the need for additional accessory sets. The rigid Clave or capped PlumSet should be used when infusing from a syringe.
(b) A syringe adapter should be used for syringes 10 mL or less to ensure delivery accuracy, according to the Plum 360 user manual.
(2) BD Alaris Pump Module: BD sells a special accessory set, known as the Syringe Adapter Set, that can be used to connect a syringe to the pump module.
(a) BD states that accuracy specifications are the same as for other BD Alaris administration sets.
(b) According to BD, the syringe adapter sets are currently on manual allocation and are prioritized for current customers who have been using them.
b) When using large-volume pumps to deliver from syringes, make sure that:
(1) Staff are trained
(2) Required consumables are stocked
c) We are not aware of other large-volume pumps that can deliver from a syringe.
More information on the current status of IV fluid shortages can be found from the FDA website.