SleepTalker November 2024

Kudos

Dr. Srinivas Pentyala, Professor, has been granted tenure in the School of Medicine. Congratulations!	Dr. Eman Nada was appointed the Chair of the ASA Subcommittee on Regional Anesthesia and Acute Pain. Congratulations!
Dr. Vincent Bargnes ASA Reference Committee for Finance and has transitioned from Junior to Senior Residents' Review Co-Editor for the ASA Monitor. Congratulations!	Dr. Seth Greenspan served on the ASA Reference Committee for Scientific Affairs. Congratulations!

On IV Fluid Shortages and Conservation

Tazeen Beg, MD

   I'm sure many of you have taken home plenty of knowledge about the latest developments in our field from the recently concluded ASA meeting and so have I. I attended a panel discussion on "An urgent Situation: The impact of Baxter IV solution shortages on patient care and safety" highlighting the intravenous fluid shortages in the country because of the flooding of the Baxter facility during Hurricane Helene’s onslaught in North Carolina. Why we have one single company keeping 60-65% of the Intravenous Fluid industry hostage is a discussion topic for another day. The panel consisted of Drs Beverly Philip, Patricia Mack and Scott Lindberg.

   Apart from obvious monitoring of the situation and frequent collaborative meetings with the stakeholders (administration, hospital supply chain teams, pharmacy and physicians), postpone or delay elective cases espy those requiring larger fluid utilization for now. Many hospitals around the country have done so. Prioritize the urgent cases. However, the main objective should be to prevent harm, mitigate health inequities and to show equal concern for all recipients of care. Here is what I learned about the various conservative strategies that can be implemented even if we do not have a shortage:

Pre-procedural aspects:

• Maintain euvolemia preoperatively and recommend oral hydration for patients. This may include the glucose drinks for ERAS protocols; clear liquid diet up to 2 hours prior to surgery or 3 hours for colonoscopy prep drinks (higher volume).
• Special consideration for geriatric and pediatric patients to avoid over hydration and electrolyte imbalances.
• Heplock IVs after placement in presurgical holding areas, which is what we do here
• IVF orders can be tagged and reminders/alerts placed in the EMR when being ordered on admitted patients pre or postoperatively
• You may keep the IV fluids that arrive with the patient from the floors.

Intraoperative considerations:

• Goal-directed Fluid Therapy and Restrictive Fluid management strategies have been recommended for certain procedures and being used in anesthesia.
• Avoid spiking bags unless needed espy for Arterial lines
• Avoid dilution bags-use prefilled saline flushes and vials whenever possible
• Use saline flushes with or without extension tubing or smaller IV bags (100 cc, 250 cc) for surgeries less than an hour
• Have one running IV instead of several unless access needed for positioning issues for example in robotics where an extension tubing can be used
• Utilize syringe pumps for medications instead of fluid bags
• Use Colloids (Albumin, Hespan, etc.) when fluid boluses are needed.
• Consider using D5NS, D51/2 NS or other such fluids if appropriate (non-diabetic)
• Use Plasmalyte (Baxter) for cardiac and liver transplants (we don't do them here) surgeries
• Outpatient cases like ECT, TEE, Cardioversions, IR biopsies, cataracts, EGD, colonoscopy, minor surgical procedures, etc. can be taken care of with medication pushes flushed with saline syringes
• Optimizing use (hanging and spiking) of suction and irrigation systems for robotic and laparoscopic (urologic, gyn, general)-use only when needed

Postoperative considerations:

• Surgical debrief to include fluid management with the team
• Bring the IV fluid bag from the OR to PACU, no need for a new IV bag setup
• Transition patients to oral, nasogastric or orogastric hydration as soon as safely possible
• IVF orders can be tagged and reminders/alerts placed in the EMR when being ordered on admitted patients pre or postoperatively

On the Floors and ICU:

• Assess the need for carrier infusions-medication drips without a carrier fluid (Propofol, Dexmedetomidine)
• Use of concentrated solutions with proper safety precautions and preparation by pharmacy

Other considerations:

• Surgeons should be discouraged from using IV bags as axillary rolls!
• There should be an engagement with the hospital admin
• It’s a system resource so plan a framework for the response to possible shortage-weekly inventory, conservation, rationing, and even severe rationing if needed for all perioperative areas.

To our patients: Inform the patients (especially when cancelling or postponing their procedures) through media, communications, signage and posters that we are responding to the shortage but without any compromise on their safety.

   As per the latest updates on the Baxter website and reporting from major newspapers, ‘IV fluid supplies across the US will likely remain unstable until early December, forcing more hospitals to adopt conservation measures to combat shortages as the federal government tries to police cases of price gouging’. We are fortunate that we have another vendor for our hospital and have not been affected by the shortage, but this may be an eye-opener. It may help us evaluate our resources, and to conserve and search for alternatives.

Meetings

   A colleague of Dr. Jonathon Schwartz, presented their research abstract at ESICM LIVES 2024, in Barcelona, Spain. October 5-9

Modem V, El Mir A, Kapoor S, Schwartz J, Matos J, Wong AI, Anthony Celi L. Development and validation of a multivariable logistic regression model showing the association between right shift in oxyhemoglobin dissociation curve and mortality in a large multi‑center cohort of critically ill patients.

   MS4 James Espeleta presented two posters at the 2024 American Society of Enhanced Recovery and Perioperative Medicine Meeting (ASERPM 2024) in Houston, Texas from September 19-21

Espeleta J, Bruzzese A, Singh N, Tsivitis A, Moore R, Hsieh H, Singh S. Developing an enhanced recovery program for pediatric trauma surgery

Espeleta J, Nada E, Parikh S, Shmelev A, Singh SM. Developing a stratified enhanced recovery after surgery pathway for robotic and open hernia repairs

  Dr. Robert Moore presented a lecture at the NYSSA District 8 Meeting "Pediatric Anesthesia for the General Anesthesiologist".

    

  Stony Brook Anesthesiology was represented at the New York and New Jersey Pain Medicine Congress. Dr. Rahman Sadiq presented a poster "Effectiveness of Neuromodulation on Pain & Mood: A Case Series on Spinal Cord Stimulation" Dr. William Caldwell lectured on "Advancing Interventional Pain Management: Expanding Access To Patients With More Treatment Options"

    

Alumni Corner

We received an email from former attending Chris Gallagher

   So sorry to hear about Eldhose. He was a gem.

   Hello to all and sundry. Update from my end:
   - Still on wait list for Nobel Prize.
   - Still on wait list for People Magazine's "Sexiest Man Alive"
   - Still on wait list for picking winning lottery ticket.
   - Still on wa...

There is a lot of waiting when you're retired, in case anyone is wondering.

Yours in decrepit senescence!

Photography Corner

James P. Dilger, PhD

October was a delight for astronomy buffs!