From shortage to success: How MUSC anesthesia team navigated IV fluid crisis

As we approach the first anniversary of flooding from Hurricane Helene that devastated parts of North Carolina, the anesthesia department from the Medical University of South Carolina is sharing how it responded to one effect of that flooding: the disruption of the IV fluid supply chain.

“The culture in anesthesia is to be prepared for everything,” said Carlee A. Clark, M.D., lead author of the MUSC study published in A&A Practice. The journal is for doctors working in anesthesia and pain medicine, focusing on short, peer-reviewed articles on innovative treatments and solutions. 

The anesthesia team was prepared for an IV fluid supply shortage. Previous publications have produced basic recommendations on how to conserve fluid. But implementing them at a large academic medical center came with different challenges than smaller sites faced. The MUSC Health-Charleston Division has nearly 80 locations across seven hospitals where patients receive anesthesia services. 

And that wasn’t the only concern. While some other health care facilities delayed elective surgeries to make scarce IV fluids available for essential operations, MUSC Health didn’t want to delay any operations unless it had to.

So when flooding damaged the Baxter manufacturing plant, which supplies more than half the IV fluids in the U.S., Clark and her colleagues wanted to keep patients safe, keep operations on track if possible and document their findings to share with colleagues who might find themselves in similar situations.

They set a goal last year of quickly reducing IV fluid use before and after surgery by 60%, starting Oct. 1. “We responded immediately by referring to our NPO guidelines and asked our patients to continue oral hydration with clear liquids until two hours before their procedures,” Clark said. NPO is an abbreviation for a Latin term that means nothing by mouth.

“Patients presented for their procedures better hydrated” than if they’d stopped drinking liquids the night before, like they’d normally do.

“We created an algorithm for inpatient and outpatient procedures and surgeries to assist our teams when making resuscitation decisions. Our study focused on our ambulatory [outpatient] centers where we probably had the largest reduction in fluid administration,” Clark said.

The research focused on five MUSC Health sites: 

A children’s surgery center. An adult surgery center that does eye procedures, such as cataract removal. An adult surgery center that does orthopedic procedures. A hospital-based surgery center that does a range of procedures. An endoscopy center, where tubes with cameras let doctors see inside the body, often the digestive tract. 

They found they didn’t need IV fluids automatically prepared for certain patients and procedures. That was one opportunity for conservation. 

Some patients got what Clark called a “flush” instead of a full bag of IV fluids. A flush is typically a smaller syringe of an IV fluid solution  that is used after medications are given in the IV.  Using small flush syringes instead of full IV fluid bags was an additional way to conserve fluids during the shortage.

“We thought about: ‘What's the case they're having? Where are they having surgery? What are their comorbidities? How are we going to change this?’ We responded quickly and did not cancel any procedures.”

After a month, MUSC Health reviewed the data to see if the strategy was having any negative effects. It looked at several markers, including whether patients needed medication to treat hypotension during surgery, suffered from nausea and vomiting after surgery and how long they stayed in the recovery room after the procedures.

The conclusion, as stated in the published study: reducing the use of IV fluids “was not associated with significantly increased rates” of related problems.

Now that the IV fluid shortage is over, Clark said her team is applying some of the lessons learned to its regular procedures. “In the past, we approached each patient with the same fluid resuscitation plan, typically starting with a one-liter bag of IV fluid in the holding room. Now, we use different-sized bags in different areas. We changed our practice after learning during the fluid crisis. The change was not driven by cost but, rather, by making appropriate choices for patient care while conserving fluids and decreasing waste.”

Doctors also encourage patients, when appropriate, to hydrate at home before surgery. Clark said it works – and it makes patients feel better when they arrive for procedures. “Patients are happier.”

She hopes that publishing her team’s research can help others who work in anesthesia and pain management. Her colleagues involved with the publication include Nicole C. McCoy, M.D.; Carey L. Brewbaker, M.D.; Bethany J. Wolf, Ph.D.; Jennifer V. Smith, M.D.; Travis J. Pecha, M.D.; Robert A. Mester, M.D.; and Sylvia H. Wilson, M.D.

Their research is also helping at MUSC Health, where people getting outpatient procedures aren’t the only ones who can drink liquids the morning of. So can some patients who are hospitalized, thanks to the IV fluid shortage study.

Now that the research is complete, Clark said credit is due to everyone working in the perioperative areas. “The teamwork and collaboration between the perioperative nursing teams, our pre-op clinic, the surgeons and our anesthesia team members was impressive. I’m proud of how quickly everyone got into the mindset of ‘Let's figure this out together.’” 

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