Association of a bundle intervention to address fluid shortages with intraoperative fluid use, total fluid balance, and postoperative outcomes

A recent study examined how implementing a bundle intervention impacts intraoperative fluid use, total fluid balance, and postoperative outcomes during fluid shortages.

The Takeaway

When Hurricane Helene ravaged North Carolina in 2024, it also took out Baxter’s ability to provide 60% of the United States’ intravenous fluid supplies. Despite significant changes in fluid management strategies, there were no changes in patient outcomes.

Study Overview

Objective: To assess the effectiveness of a bundle intervention designed to manage fluid shortages in surgical settings.

Method: Retrospective cohort study, analyzing data from surgeries performed during periods of fluid shortages.

Excerpts

According to the US Department for Health and Human Services, a preexisting shortage in intravenous (IV) fluid supplies³ recently blossomed into an immediate crisis in the USA with nationwide impact,⁴ when Baxter International Inc's facility in North Cove, NC, which is responsible for about 60% of US hospital infusion solution supplies, was severely damaged by flooding from Hurricane Helene.⁵ Subsequently, the US Food and Drug Administration, together with other federal institutions, recommended restricting the use of crystalloid infusions.⁶ Impairments in fluid distribution are projected to persist into early 2025.

This intervention included: (1) a request to use the smallest available IV fluid bag; (2) prioritising the use of normal saline over balanced electrolyte solutions unless needed for fluid resuscitation; (3) a change in the availability of IV fluids (1 L and 0.5 L bags were removed from anaesthesia carts and only made available to anaesthesia providers upon request); (4) a directive to reserve the use of Plasmalyte® solution (an isotonic and balanced solution) for cardiothoracic surgical procedures preferentially; (5) a revision of the network's preoperative fasting guideline, supported by the American Society of Anesthesiologists,⁷ to encourage patients to continue oral intake of clear fluids up to 2 h before surgery (including water, fruit juice without pulp, carbonated beverages, carbohydrate-rich nutritional drinks, clear tea, and black coffee with no milk; no alcoholic beverages), and where, before the intervention, patients were told to cease fluid intake after midnight before surgery; (6) the implementation of a new protocol for oral rehydration in inpatients; and (7) biweekly conference calls to distribute updated information on the availability of specific IV fluid formulations

Data from patients undergoing procedures with anaesthesia care between January 1, 2016, and October 27, 2024 

We included 670 665 patients, of which 97 587 were patients from 2024. Among these, 89 817 (92%) procedures were conducted before the notice of a fluid shortage (T1, before October 4, 2024), 1415 (1.5%) between the first notice and implementation of the bundle intervention (T2, October 4–8, 2024), and 6325 (6.5%) after the intervention (T3, from October 9, 2024).

Although crystalloid use, urine output, and total fluid balance went down, albumin and ephedrine use increased, and there was no change in phenylephrine administration. There were no observed effects on patient outcomes. 

Citation

Borngaesser F, Bald A, Zhang L, Ramishvili T, Lorenzen SJ, Rinke ML, Schaefer ST, Freda J, Fassbender P, Thota R, Kiyatkin ME, Racine AD, Eikermann M. Association of a bundle intervention to address fluid shortages with intraoperative fluid use, total fluid balance, and postoperative outcomes. Br J Anaesth. 2025 Jan 20:S0007-0912(24)00764-5. doi: 10.1016/j.bja.2024.12.014. Epub ahead of print. PMID: 39837699.

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