Medicine and medical device supply disruptions

The fluids in the following table are the products most at risk of shortages. Allocated supply of these products will be based on historical usage.

The Clinical Advisory Group, led by Safer Care Victoria, has developed recommended conservation strategies.

Health services are to review, assess and implement the recommended conservation strategies ensuring due consideration of appropriateness and safety. Refer to the Safety Considerations for further information.

IV fluids are used for 3 main purposes:

1. IV hydration
2. flushing and management of vascular access devices (VAD) and
3. to administer medicines.

The conservation strategies described here have been grouped by area of practice and according to these main purposes.

General use

General advice

Review patients currently prescribed IV infusions and switch to alternative routes of administration as soon as clinically feasible.

Minimise fluid wastage by preparing fluids or infusions only when required, and not in advance.

Use a fluid type and volume that is most appropriate for the indication and current stock level (“most stock of at that time”). Seek advice from Pharmacy.

Ensure there are various sized pressure bags available for arterial and central line monitoring so that an alternative bag size can be used in the event of a shortage.

Do NOT use IV fluids for non-IV administration or use including off-label use (for example, wound flushing, eye irrigation or as traction devices).

IV hydration

Use oral or nasogastric routes of administration for hydration where possible.

Flushing and management of IV access

Use a volume of sodium chloride 0.9% most appropriate for current stock levels (“most stock of at that time”) for purposes of “drug and flush” or “to keep vein open” and VADs should be flushed, locked and capped where possible.

Administration of medicines

Use IV bolus injections or administration via a syringe driver.

Use alternative routes of administration such as oral, subcutaneous and intramuscular.

Use sterile Water for Injection ampoules instead of sodium chloride 0.9% for reconstituting IV medicines where compatible. Refer to the Australian Injectable Drugs Handbook for information.

Surgical patients

IV hydration

Minimise fluid fasting in surgical patients by encouraging clear fluids up until 2 hours prior to surgery. This may include instructing same day admission patients to drink water before leaving home and/or providing water on arrival if timing allows. The Sip Til Send protocol should be considered particularly for inpatients as surgery may be delayed. There are some patients to whom this guidance may not apply, such as those at increased risk of aspiration. For more information please review:

• Sip Til Send factsheet | SaferCare Victoria
• Guidance on sparing of intravenous fluid use | Australian and New Zealand College of Anaesthetists (ANZCA)

Consider the need for routine use of IV fluids. Where postoperative IV fluids are necessary, consider the rate and duration of administration with review as required.

General advice

Consider indications for arterial pressure monitoring and sampling ensuring a clinical need exists.

Continue using irrigation fluid bags and bottles for peritoneal lavage and other body cavity lavage. The manufacturers have confirmed that these irrigation fluids have been produced and packaged with the same sterility standards as IV fluids but as they are intended for irrigation, they cannot be used intravenously.

Maternity patients

General advice

Do NOT use IV fluids for non-IV administration including off-label use (for example, heat packs)

IV hydration

Encourage oral fluids while in labour, as tolerated. Only use IV fluids where there is a clinical indication.

Maintain strict fluid balance for all women during labour and birth.

Review the need for post-operative fluids in women who can tolerate oral fluid intake.

Administration of medicines

Restrict tranexamic acid prophylaxis planning for women with post-partum haemorrhage risk. Administer 1g undiluted over 10 minutes.

Use antiemetics to treat hyperemesis and test oral fluid intake. Reserve IV fluids for severe cases.

Use ferric carboxymaltose (Ferinject®) for IV iron infusions. Inject doses of up to 500 mg undiluted at a maximum rate of 100 mg/minute. Inject doses of 500–1000 mg undiluted over 15 minutes. Slow IV administration is necessary to reduce the risk of extravasation and skin staining.

General

Only use fluids labelled for intravenous use for injection or infusion. Ensure clinicians and staff involved in supply of fluids are aware that fluids marketed for irrigation are unsuitable for injection or infusion.

All fluid bags, including those that are locally manufactured, contain air in the bag. Higher volumes of air may increase the risk of air embolism. To minimise this risk:

• Administer IV fluids via a volumetric infusion pump or other device with air in- line detection where possible.
• Where a pressurised infusion is required, it is recommended to:
  • Remove the air from the bag
  • Secure the bag horizontally and inflate the cuff prior to hanging
  • Hang the cuff and bag vertically
  • Monitor the line closely for the presence of air for the duration of the infusion.

Refer to the Clinical Excellence Commission factsheets for further information:

Information for clinicians – Intravenous (IV) fluid bags – International alternatives and associated safety considerations (nsw.gov.au)

Information for NSW Health clinicians - Risk of air embolism when administering intravenous IV fluids without in line air detection

Digital configurations

Consider the need to adjust eMM/EMR settings and/or IV pumps to facilitate safe use of conservation strategies.

• Alerts to notify clinicians of supply disruption.
• Clinical decision support for medicine administration utilising smaller fluid volumes and/or alternative routes.
• Updates to the medication library on syringe pumps and large volume pumps to facilitate conservation.

Preparation of intravenous infusions of medicines

Ensure compatibility of IV medicines with the selected diluent and ensure the final concentration is within the acceptable range for administration/stability. Refer to the Australian Injectable Drugs Handbook and the Paediatric Injectable Guidelines via Clinicians Health Channel.

Features of IV fluid bags, including overfill and maximum volume that can be added as well as comparison of constituents is available in the Australian Injectable Drugs Handbook.

Some medicines such as ciclosporin, tacrolimus and diazepam are incompatible with polyvinyl chloride (PVC) and some IV fluid bags may not be appropriate for administration of these medicines.

Reporting

Report all IV fluid stock holdings to HealthShare Victoria (HSV) each week (by COB Wednesday). This includes a count of stock in Pharmacy / central store.

Escalate to HSV in circumstances where there is less than five days' supply for a product and there is not a clinically acceptable alternative available.

Collated state level data is being reported to health services on a weekly basis.

Stock management

Limit stock levels held in clinical areas and conduct regular stock counts to inform escalations.

Reserve stock of the product in limited supply for use in circumstances where other volumes or fluids are not suitable.

The Therapeutic Goods Administration (TGA) has approved overseas registered IV fluids under Section 19A. Refer to the TGA website. Consider risk minimisation strategies to ensure the safe use of these alternatives, particularly given differences in presentation and volumes of air.