Baxter & The IV Fluid Shortage

One thing I haven't seen reported in the media/news related to Hurricane Helene is the critical shortage of IV fluids due to the shutdown of a Baxter plant in Marion, NC, due to the hurricane. Baxter is a principal supplier of IV fluids to medical facilities. It appears to be the only source of certain staples of medical care including 0.9% saline (normal saline), D5W, D10W, sterile water, and peritoneal dialysis fluid. The shortage has caused hospitals to take extreme measures to ration these IV fluids, including postponing elective surgeries; curtailing the use of the IV fluids by removing orders for them from standard order sets for patients, requiring doctors to add them to the orders only if there is an absolute need; administering the meds via IV push rather than hanging them in a small infusion bag; and changing patients to oral hydration as soon as possible after surgeries or for disorders requiring IV hydration.

It is not clear when the shortages will be alleviated. Such fluids are FDA-approved for use, so alternatives cannot be imported from abroad to make up the shortfall. Other plants cannot be adjusted to produce these products because they have to be cleared by the FDA to produce the IV fluids.

Why has this not made the news? Perhaps the mainstream media is not interested. But more conservative media outlets don't seem to have this story on their radar at all either. Am I just missing news reports? Has anyone else seen information on this? (My information comes from the hospital where I have recently worked specifying the rationing guidelines for these fluids.)

It seems there is a critical problem with only one source of something that is all but indispensable for acute medical care, that can be life-saving. This is a big story.

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The situation brought to mind my experience 44 years ago (1980) when I worked for a short time in Cairo, Egypt, at the Abassia Fever Hospital (attached to the Naval Medical Research Unit there). I was a young lieutenant in the Naval Reserve and had volunteered for a rotation at that facility.

In Egypt, there was no availability of IV fluids. That can make a life-and-death difference for something like cholera. But there were none, except in the Maadi Military Hospital.

At the Fever Hospital, there were critically ill patients suffering from a wide variety of mostly infectious diseases and illnesses. There was a full ward of patients with Tuberculous meningitis. In my 40-plus years of practice in the US, I have seen only one patient with a history of tuberculous meningitis that had been treated. The patient had severe residual neurologic problems despite the eradication of the tuberculosis. (Tubercular meningitis is a terrible illness.)

Besides no IVs, there were only reusable glass syringes, and reusable needles that were autoclaved after each use. There were no nurses in attendance at the bedside of these critically ill patients. The family members provided the nursing care, the meals, etc. On schedule, the charge nurse would bring a tray with the syringes filled with the antibiotics for the given dose, distribute them to the family members who would administer the intramuscular injection, and return the needle and string to the nurse. This process occurred several times a day with each dose of antibiotics. Most patients were on multiple antibiotic regimens. All had severe neurological deficits from the disease. There were dozens of patients in the ward. There weren't even screens on the windows — they were simply left open all day and closed at night.

Then there were weekly lumbar punctures to assess the cell counts in the spinal fluid. Now, in America, performing a lumbar puncture is a somewhat involved process. First, informed consent is obtained. With that, the patient is positioned in bed, lying on his or her dish, with knees drawn up and head down to separate as much as possible the vertebrae to allow insertion of the spinal needle. A procedure tray is brought in with betadine, specimen tubes, spinal needle, and local anesthesia, that is in a sterile package. The doctor performing the LP enters wearing sterile gown and gloves. The spot of the needle placement is swabbed three times with betadine in a specific fashion and then the betadine is removed with an alcohol swab. The area is anesthetized. The doctor then palpates the landmarks and inserts the spinal needle with tracer, then removes the tracer and fills the collection tube with spinal fluid. The patient is to remain in bed to avoid the onset of a spinal headache (which can occur despite many precautions). The procedure takes 15 minutes or so to complete.

In Egypt, no informed consent is required for lumbar puncture rounds. The patients were lined up in a row with backs to the doctor. With sterile gloves on, he was seated on a rolling swivel chair. A nurse brought in a tray with sterile spinal needles and collection tubes. Another nurse had a tray with betadine swabs. No anesthesia is used. The doctor starts at one end of the line on his rolling swivel chair, has the patient bend over and place his hands on his knees, swabs off the location of needle insertion, is handed a needle and a tube by the nurses, inserts the needle, collects the fluid, removes the needle, swabs off the site, and rolls to the next patient. The process is repeated a dozen or so times. A dozen or more spinal punctures are performed in the space of 30 to 40 minutes. The patients return to their beds. A tray of Turkish coffee is brought in (I became completely addicted to that coffee in Egypt), everyone relaxes for a short time, and the lumbar puncture rounds are over.

The doctors caring for that very large number of patients with that terrible disease published a paper detailing their outcomes 16 years after I worked there. The paper covered the years 1976 through 1996, so it included my time there. The number of patients admitted with tuberculous meningitis during those 20 years was an astonishing 1,430 patients. Their results, though terrible (for it really is a terrible disease), were as good as the outcomes anywhere in the world. One contribution of that paper was the finding that the use of dexamethasone in the treatment of these patients reduced the death rate, along with the rate of ocular complications of the disease. One of the authors was a mentor of mine, Dr. Zohair Fareed, a physician trained in Cairo and at the London Tropical School of Medicine and at the University of Chicago (he did an infectious disease fellowship there). He was a great infectious disease physician. He also contributed to the treatment of Schistosomiasis, a disease endemic in Egypt. He had written a textbook on infectious disease that was concise and extremely useful for a young internist like myself.

The doctors and nurses were dedicated, very hardworking, very pleasant, and low-key about their work. What stood out especially was the huge difference they made with almost no resources for such a large number of patients.

That experience helps me put the current IV shortage in better perspective. The doctors in Egypt would not be affected by a sudden supply chain shutdown for IV fluids. I suspect they would have ways of correcting supply chain problems that would affect them with more alacrity than our bureaucratic system is able to muster.