Two interesting commentaries on the saline shortages:

• M Mazer-Amirshahi, ER Fox. NEJM 2018; 378: 1472-4.
• AM Patino et al.  NEJM 2018; 378: 1475-7.

The first explains that large quantities of saline bags are needed each month –more than 40 million bags per month!  While saline is inexpensive, the production requires meticulous care to avoid contamination and there have been supply issues since 2014, prior to Hurricane Maria.  However, the problem has been much worse since Hurricane Maria which damaged Puerto Rico.  Puerto Rico supplies 44% of the IV bags in the U.S.  These fluids are given to virtually all hospitalized patients, either for IV fluids or as a component with medications/flushes.

Other points:

• “Drug manufacturers are not required to have redundancy in their facilities or even a business contingency plan in case of a disaster.”
• The  FDA has “recently approved saline products from two additional manufacturers”
• “To conserve large-volume saline bags, oral hydration is recommended.”

The article by Patino et al provides Brigham and Women’s Hospital Oral Rehydration protocol. Key points:

• Using their protocol, the volume of IV fluid use decreased over 30% in the first week of implementation
• The fraction of ED patients using IV fluids dropped by 15% in the first 3 weeks of implementation.
• Oral hydration protocols are a “rational practice change…even after the current IV-fluid shortage crisis ends.”