Thursday, February 27, 2014

Clinicians Look for Ways To Ease Effects of Saline Shortage

A shortage of IV sodium chloride solution has struck hospitals across the United States, forcing some clinicians to adopt conservative saline measures or to turn to alternative products.

To ascertain the effect of the shortage, the American Society of Heath-System Pharmacists (ASHP) surveyed U.S. pharmacy directors earlier this month. Of the pharmacists who responded, 76% reported that the shortage has affected their institutions. Among the pharmacists affected by the shortage, slightly more than half said conservation efforts have been sufficient to preserve supplies. Pharmacists who indicated their supply of saline was inadequate to fulfill patient needs, on the other hand, represented 29% of respondents.

“While the survey does not point to patients being harmed as a result of the shortage, such a severe shortage of this widely used intravenous solution is extremely concerning,” said Paul W. Abramowitz, PharmD, ScD (Hon.), the chief executive officer of ASHP, in a Feb. 11 statement.

The ASHP survey revealed that the shortage has had a wider influence among certain areas of care than others. An impact on surgery and perioperative care was reported by 64% of pharmacists, whereas 10% of respondents cited an impact on pediatric care.

At St. Jude Children’s Research Hospital, in Memphis, Tenn., clinicians are “weathering the storm,” said William L. Greene, PharmD, St. Jude’s chief pharmaceutical officer. “Conservation efforts have focused on minimizing waste, especially at the bedside, where allowing longer hang times [up to 48 hours] of simple solutions reduces the need for replacement,” Dr. Greene said. Although changing IV bags at 24 hours is a common infection control method due to the perceived increase in risk of contamination over time, a 2009 study found no relationship between length of infusate use and bacterial colonization (J Clin Nurs 2009;18:3022-3028).

Lactated Ringer’s solution, dextrose and other fluids may provide health care systems with alternatives to saline, which 64% of the ASHP survey population report using. But these are not always good substitutions for sodium chloride solution, Dr. Greene noted; certain medications compatible with saline are incompatible with dextrose, for example, including the antifungal agent caspofungin, as well as the antibiotics daptomycin and meropenem. 

The lack of saline has also started to put pressure supply of substitute options. “We’re beginning to see that it’s more difficult to obtain some of the alternative fluids,” Dr. Green said, “but it’s not elevated to the point where anyone would call it a shortage.”

The FDA, meanwhile, is pursuing the importation of sodium chloride, and other forms of saline may be available. Compounded saline or 0.45% sodium chloride solution, for example, could be used as alternatives to 0.9% saline, said Bona E. Benjamin, BS Pharm, the director of Medication-Use Quality Improvement at ASHP. For health care systems that choose to use compounded sodium chloride, purchasers should “make sure [saline] is compounded by an ethical, licensed pharmacy that observes sterile standards,” she said.

There are few details regarding why saline is in short supply. “Apparently, one manufacturer had some production problems, and that shifted demand to other providers,” Dr. Greene said. “This strain on supplies was accentuated when another manufacturer had a scheduled shutdown … for maintenance purposes.  Production levels simply have not returned to levels which meet demand.”

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