- February 26, 2018 at 2:20 pm #14077
I was at a policy dinner last week and several infusion providers asked me about the current saline shortage, wondering how others were handling the shortage to avoid treatment disruptions. It got me wondering, what are the best practices in preparing for and handling a saline shortage?
How does your practice prepare for and handle saline shortage? What resources do you use to find saline?
Here is the FDA’s drug shortage page for saline bags: https://www.accessdata.fda.gov/scripts/drugshortages/dsp_ActiveIngredientDetails.cfm?AI=Sodium%20Chloride%200.9per%20Injection%20Bags&st=c&tab=tabs-1. Is this site helpful?
Lead Goon, Team NICAFebruary 26, 2018 at 6:37 pm #14082
Thank you for posting the FDA NS shortage list.
It has affected the workforce drastically in delays, time, and costs. I work in 3 different environments, mainly managing an infusion center for an orthopedic practice infusing biologics, an Urgent Care Center environment and a home environment. With biologics, all need to be mixed into NS, mainly NS 100ml, Remicade into 250ml, and Rituxan into 500ml. I can no longer get the NS 100mls. We now have to mix in NS 250mls. The cost is doubled. Now we are told that we can only get NS 500ml – another hike in cost.
Delays are incurred from late deliveries, and having to infuse a larger amount of NS over more time rather than the less time with the smaller bags, mainly on elderly patients. Conversely, time is required to withdraw 150mls from the bag. This requires more sticks into the bag than required increasing the likelihood of contamination.
Money is lost by the increased cost of larger bags.
Our next step: We have purchased empty 150ml bags and will be transferring NS from the 250 and 500ml bags to these for mixing medications. In addition, several boxes of NS 10ml saline flushes have been purchased as a back up system for creating infusion bags.
Additionally, we have signed up and become registered with several more supply companies in the hopes of being able to acquire smaller bags of saline or just plain saline period!
The main priority is to keep in touch with whomever your sales rep is for the company you normally order from. They are your best bet for acquiring saline in a timely manner.
Back up plan: After much discussion with team members, it was decided that if we became drastically low on NS, then patients who are on Actemra, Orencia, and Simponi Aria would be switched over to weekly SubQ injections. Remicade and Rituxan patients would get the infusions.
The urgent care centers are without any impact at this time as it is considered a high priority facility.
The home environment is impacted. In one visit I had to mix 25 10ml-saline flushes. That took quite a bit of time. It worked; however, having to add 25 flushes via an adapter increases the risk of contamination in an unsterile environment 20 fold or more times over.
In conclusion, we have been fortunate to have not run out … however we were dangerously close with the orthopedic practice. Adversely, not only NS is affected, but other supplies such as 10ml vials of sterile water are out of stock and we now have to purchase 30ml vials and sometimes waste 1/3 or 2/3rds of a vial, depending on the need.
DonnaMay 3, 2018 at 7:30 am #14341
Hi all, as an update to the NS shortage, I recently stated that all that I could purchase for our unit were the NS 250ml bags. This has changed. Now, all I can purchase are NS 500ml bags. The problems are: Do you use an entire 500ml bag for every medication that needs to be infused on patient? Do you attempt to pump in 500mls into an elderly person possibly throwing them into CHF? Or do you drain out each bag to the proportions that you need, i.e. 250ml for your Remicades, and 100mls for your other biologics? Each is time consuming, each is expensive.
We’ve decided to purchase “Elastomeric pumps” otherwise known as Eclipses. We’ve used these in home care for a multitude of antibiotics. They would be prepared in advance and sent to the homes. However; because they were prepared in a sterile environment under a hood and in a clean room, they could be stored for a week in the refrigerators. But in the case of preparing these elastomeric pumps in a physician’s office or any other facilities not using a hood or glove boxes, these devices must be used within 2 hours after preparation.
Using a 500ml bag, we withdraw about 70-90 mls of NS and instill into the eclipse, then inject the medication. Depending on the medication, will determine how much saline you will need. The eclipses can hold up to 120mls of fluid. The eclipses come with a filter and rate regulator attached to a very thin tubing. On the filter it will state a number such as: 100ml or 200ml. This indicates the flow rate per hour. As an example, we infuse Orencia throughout the day. Most often the dose is 750mg which would require a mix of 30mls total with sterile water. We withdraw 70mls of NS from the 500ml bag, instill this into the an eclipse having a rate regulator of 200ml — then add the 30 mls of prepared med solution to the eclipse, totaling 100mls. Infusing at 200ml/hr, the eclipse, once the clamp is released, will flow in over 30 minutes.
Although it takes time to mix these eclipses, it provides a solution to cost, prevents fluid overload, and at the end of the infusion does not require flushing of the line. The tubing is so thin that priming is only 1-2mls. I can mix up 5-6 eclipeses with 1 500ml bag. Patients love these devices — they are easy to carry to the examine room should the patient be scheduled for an office visit during their infusion rather than lugging a pole and pump down the hallways. They have become quite the conversational piece in the infusion room and practice throughout!
We now have plenty of NS to last until the shortage is resolved. Last I heard, it was to improve by July of 2018. I will be looking forward to using the 100ml bags again.
DonnaMay 19, 2018 at 8:03 pm #14409
This has been quite the stuggle at my institution, and one that pharmacy is consistently evaluating. We were able to purchase bags to make our own. Pharmacy has also put into place many conservation efforts to make what we have last. We are a pediatric facility so luckily on some we can use admin in syringes, but that doesn’t work for everyone. Our new issue has been the prefilled syringes, but hopefully that will be resolved soon.May 20, 2018 at 9:14 am #14411
Our pharmacy has focused on decreasing the volume distributed for infusion to a 96 hour volume. For pediatric patients there is a lot of waste when a liter bag is used so this has helped us make the bag last longer. Information related to the shortage has been widely distributed which helped but it is still a struggle.May 20, 2018 at 2:42 pm #14414
In the acute care facility I work at, we have eliminated kvo infusions
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