By Derrek Blake RN, IgCN - Co Author: Amy Ehlers BS, PharmD, BCPS.

Who knew that Hurricane Maria could lead to such a dramatic shortage of medical products in the United States that all hospitals and pharmacies rely on? Puerto Rico was one of the hardest hit areas by Maria and damaged American manufacturing hubs for medical products. Roughly 43% of the United States IV fluids, IV bags and minibags are manufactured and produced in Puerto Rico. Add that to the devastating flu season and we are seeing mass shortages of IV fluids and supplies in hospitals and pharmacies nationwide. This shortage has mostly been attributed to hurricane-damaged manufacturing facilities in the Caribbean. However, manufacturing or quality problems at other facilities not affected by weather events, as well as mergers, acquisitions, and plant closures, have also contributed to the current shortage of these products.

There is also the concern on the importation of drugs and fluids into the United States, as well as the stability and extent of the international supply. While importation has reduced shortages in the United States, it is possible that these shortages could eventually become worldwide.

Amy Ehlers, the Director of NuFACTOR's Temecula California Pharmacy and her team spend hours on the phone daily, checking with suppliers, as well as looking for any alternative solution/supplier in an attempt to help reduce the current shortages. In the meantime, we at NuFACTOR, have been diligent using other resources while focusing on the quality and professional care. At this time manufacturing plants are back up and running, but the dates of product availability are still unknown.

Below is a list of items NuFACTOR and other hospitals and pharmacies are having difficulty still obtaining.

• Pooling bags
  • Uses: HyQvia administration and in IVIG to combine multiple vials into one bag for administration.
  • This is an on-going issue supply and is critical. NuFACTOR is not routinely sending them for IVIG pooling and continues to prioritize what is in stock for HyQvia patients.
• Sterile Water 10 ml and 20 ml vials
  • Uses: Reconstitution of lyophilized medications such as REMICADE^® (infliximab).
  • Alternatives are being utilized. The estimated resolution date is the end of April or early May.
• IV Fluids
  • Uses: IV hydration, administration of medications such as REMICADE and high doses of Solu-Medrol.
  • This shortage remains critical and full conservation efforts are in effect.
  • Patients are encouraged to orally hydrate starting 2 days before each dose of IG, every day a dose is received, and for 2 days after the IG course is completed. Unless fluid restricted or in the presence of diseases such as congestive heart failure or renal insufficiency, the recommend fluid intake is:
    • Adults: 64 ounces of water (#8 - 8 oz glasses)
    • Children 9-17 years: 48 ounces of water (#6 - 8 oz glasses)
    • Children 1-8 years: 32 ounces of water (#8 - 4 oz glasses)
  • There is no resolution date at this time.

In the meantime, to accommodate for the shortages, NuFACTOR has reworked what we are sending to our current patients.

• Supply workarounds
  • NuFACTOR is no longer sending the 250 ml Saline bags in the anaphylaxis kit to preserve our supply for our Remicade patients.
  • NuFACTOR is only sending pooling bags to HyQvia patients, IVIG patients will be infused directly out of the vial.
  • As stated above, we are currently not sending IV hydration to patients. Unless the patient is fluid restricted, we highly encourage all patients to oral hydrate over the use IV fluids.
  • If a physician wants the patient to have IV fluids along with IVIG, NuFACTOR could suggest the use of a 5% IG solution. However, the use of more 5% products resulted in shortages, hence the importance of oral hydration.
  • With the shortages of 10 ml and 20 ml vials of sterile water, alternatives are being used. Currently NuFACTOR has been approved to use 10 ml pre filled syringes of Normal Saline 0.9% for the dilution of all lyophilized products including Remicade.

While we understand the frustration of nurses in the field wanting specific items for infusions, we ask that you be patient and please know when certain supplies are available, we will ship them. We as care providers are all striving for the same goal: providing exceptional patient care with the resources we have today.