Reason for the Shortage

• • Baxter has lactated ringer's available.[1]
  • BBraun has lactated ringer's available for current customers.[2]
  • Hospira has lactated ringer's available.[3]

Available Products

• • Lactated Ringer's Injection Solution, BBraun, 1000 mL PVC/DEHP-free bag, 12 count, NDC 00264-7750-00
  • Lactated Ringer's Injection Solution, BBraun, 250 mL PVC/DEHP-free bag, 24 count, NDC 00264-7750-20
  • Lactated Ringer's Injection Solution, BBraun, 500 mL PVC/DEHP-free bag, 24 count, NDC 00264-7750-10
  • Lactated Ringer's Injection Solution, Baxter, 1000 mL bag, 14 count, NDC 00338-0117-04
  • Lactated Ringer's Injection Solution, Baxter, 250 mL bag, 36 count, NDC 00338-0117-02
  • Lactated Ringer's Injection Solution, Baxter, 500 mL PVC/DEHP-free bag, 24 count, NDC 00338-6307-03
  • Lactated Ringer's Injection Solution, Baxter, 500 mL bag, 24 count, NDC 00338-0117-03
  • Lactated Ringer's Injection Solution, Pfizer, 1000 mL bag, 12 count, NDC 00409-7953-09
  • Lactated Ringer's Injection Solution, Pfizer, 250 mL bag, 24 count, NDC 00409-7953-02
  • Lactated Ringer's Injection Solution, Pfizer, 500 mL bag, 24 count, NDC 00409-7953-03
  • Lactated Ringer's with 5% Dextrose Injection Solution, BBraun, 1000 mL bag, 12 count, NDC 00264-7751-00
  • Lactated Ringer's with 5% Dextrose Injection Solution, BBraun, 500 mL bag, 24 count, NDC 00264-7751-50
  • Lactated Ringer's with 5% Dextrose Injection Solution, Baxter, 1000 mL bag, 14 count, NDC 00338-0125-04
  • Lactated Ringer's with 5% Dextrose Injection Solution, Baxter, 500 mL bag, 24 count, NDC 00338-0125-03
  • Lactated Ringer's with 5% Dextrose Injection Solution, Pfizer, 1000 mL bag, 12 count, NDC 00409-7929-09
  • Lactated Ringer's with 5% Dextrose Injection Solution, Pfizer, 500 mL bag, 24 count, NDC 00409-7929-03

• • All marketed presentations are available.

• • Lactated ringer's, sodium chloride, and 5% dextrose injections are all widely used.[4] The product most affected is the 1,000 mL bags of 0.9% sodium chloride but other solutions for injection may be in short supply, including lactated ringer's and lactated ringer's with 5% dextrose injections.[1,2,3]

• • Clinicians may need to utilize different product sizes if large bags are not available. More frequent bag changes may be needed.
  • Multiple brands of products may be available in the system.

• • Consider using oral hydration whenever possible.
  • Make policies to allow substitution of products based on product availability at the site. For example, an organization could choose to allow Lactated Ringers Solution to be substituted for 0.9% sodium chloride solution or 5% dextrose with 0.45% sodium chloride to be substituted for 5% dextrose. Table 1 provides a comparison of fluid components.
  • Evaluate total fluid requirements for surgeries. The American College of Surgeons 2014 Principles and Practice notes total volume replacement needs for elective surgeries are much less (500 mL to 3000 mL total) than traditionally thought (4500 mL to 6000 mL total).[5]
  • Evaluate the clinical need for intravenous fluid replacement and "keep vein open" orders at every shift change. Consider catheter locks and flushes for eligible patients. Discontinue infusions when appropriate.
  • Use smaller bag sizes for low rate infusions when possible. See Table 2 for suggestions.
  • Consider reserving some products for specific clinical situations as outlined in Table 3.

  Table 1. Comparison of Selected Intravenous Fluids6,7,8,9

  Product	mOsm/L	Na (mEq/L)	Cl (mEq/L)	Dextrose (g/L)	K (mEq/L)	Ca (mEq/L)	Lactate (mEq/L)
  0.9% Sodium Chloride	308	154	154
  0.45% Sodium Chloride	154	77	77
  5% Dextrose plus 0.225% Sodium Chloride	329	38.5	38.5	50
  5% Dextrose plus 0.45% Sodium Chloride	406	77	77	50
  5% Dextrose plus 0.9% Sodium Chloride	560	154	154	50
  5% Dextrose	252			50
  Lactated Ringers Solution	273	130	109		4	2.7	28
  Lactated Ringers and 5% Dextrose Solution	525	130	109	50	4	2.7	28

  
  

  Table 2. Suggested Bag Sizes for Specific Rates of Infusion

  Infusion Rate	Bag Size
  20 mL / hour or less	250 mL
  21 mL/hour to 40 mL/hour	500 mL

  
  

  Table 3. Considerations for Reserving Products for Selected Clinical Situations10,11,12

  Clinical Situation	Product	Comments
  Large volume replacement (surgery)	Lactated Ringers Solution	Large volumes of 0.9% sodium chloride may contribute to hyperchloremic acidosis.
  Patients requiring sodium restriction	5% Dextrose Solution and Low Sodium Containing Solutions	Consider reserving a supply of solutions that are low in sodium.
  Patients susceptible to hypoglycemia	Products containing 5% Dextrose Solution	Women and children may be more susceptible to hypoglycemia following fasts > 24 hours.

  
  

• 1. Baxter (personal communications). February 11 and 20, March 24, May 27, July 10, August 20, October 9, November 5, 2014; January 28, March 9, April 15, May 4, July 6, September 17, October 29, 2015; January 26 and 27, April 14 and 29, May 31, and July 21, 2016.
  2. BBraun (personal communications). January 16, February 12, April 7, May 27, August 21, October 20, November 5, 2014; January 28, July 6, September 17, 2015; January 26, April 13 and 29, and July 18, 2016.
  3. Hospira (personal communications and website). February 10 and 21, March 4 and 25, April 9, May 8 and 23, June 11, July 2 and 14, August 29, October 20, November 12 and 24, December 1 and 17, 2014; January 28, February 16, March 13 and 23, May 4, July 6, September 17, October 30, 2015; January 26, April 14, May 4, 12, and 31, and July 26, 2016.
  4. McEvoy GK, Snow EK, Kester L, Litvak K, Miller J, Welsh OH, eds. AHFS DI (Lexi-Comp Online). Bethesda, MD: American Society of Health-System Pharmacists; 2014.
  5. Evolution of Intraoperative Fluid Therapy for Elective Surgeries: Historical and Current Fluid Requirements. In: Souba WW, Fink MP, Jurkovich GJ, Kaiser LR, Pearce WH, Pemberton JH, Soper NJ. ACS Surgery: Principles and Practice 2014. Accessed March 1, 2014 via STAT!Ref Online Electronic Medical Library. http://online.statref.com/Document.aspx?fxId=61&docId=158.
  6. Hospira. Lactated Ringer's Injection USP, Lactated Ringer's and 5% Dextrose Injection, USP [product information]. Lake Forest, IL: Hospira; 2009.
  7. Hospira. Dextrose and Sodium Chloride Injection, USP [product information]. Lake Forest, IL: Hospira; 2009.
  8. Hospira. Sodium Chloride Injection, USP [product information]. Lake Forest, IL: Hospira; 2010.
  9. Hospira. Dextrose Injection, USP [product information]. Lake Forest, IL: Hospira; 2010.
  10. Intravenous Fluids. In: Morgan GE, Michail MS, Jurray MJ, eds. Clinical Anesthesiology. 4th ed. New York, NY: Lange Medical Books / McGraw-Hill Medical; 2005: 692-696.
  11. Peng ZY, Kellum JA. Perioperative fluids: a clear road ahead? Curr Opin Crit Care. 2013 Aug;19(4):353-8.
  12. Raghunathan K, Shaw AD, Bagshaw SM. Fluids are drugs: type, dose and toxicity. Curr Opin Crit Care. 2013 Aug;19(4):290-8.