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Lactated Ringer’s Injection Bags

[12 November 2014]

Products Affected - Description

Lactated Ringer’s, Baxter
250 mL bag (NDC 00338-0117-02)
500 mL bag (NDC 00338-0117-03)
1000 mL bag (NDC 00338-0117-04)
500 mL bag, PVC/DEHP-free (NDC 00338-6307-03)

Lactated Ringer’s with 5% Dextrose, Baxter
500 mL bag (NDC 00338-0125-03)
1000 mL bag (NDC 00338-0125-04)
 
Lactated Ringer’s, BBraun
250 mL bag, PVC/DEHP-free (NDC 00264-7750-20)
500 mL bag, PVC/DEHP-free (NDC 00264-7750-10)
1000 mL bag, PVC/DEHP-free (NDC 00264-7750-00)

Lactated Ringer’s with 5% Dextrose, BBraun
500 mL bag, PVC/DEHP-free (NDC 00264-7751-10)
1000 mL bag, PVC/DEHP-free (NDC 00264-7751-50)

Lactated Ringer’s, Hospira
250 mL bag (NDC 00409-7953-02)
500 mL bag (NDC 00409-7953-03)
1000 mL bag (NDC 00409-7953-09)
 
Lactated Ringer’s with 5% Dextrose, Hospira
500 mL bag (NDC 00409-7929-03)
1000 mL bag (NDC 00409-7929-09)

Reason for the Shortage

  • Baxter has lactated ringer’s on shortage due to increased demand.1
  • BBraun has lactated ringer’s on allocation due to increased demand.2
  • Hospira cites increased demand as the reason for the shortage.3

Available Products

Insufficient supplies are available for usual ordering.

Estimated Resupply Dates

  • Baxter has all lactated ringer’s injection on allocation. Lactated ringer’s with 5% dextrose injection in 500 mL and 1000 mL bags are also on allocation. Baxter has additional information regarding their allocation process in a Dear Customer letter.1
  • BBraun has all lactated ringer’s injection and lactated ringer’s with 5% dextrose injection on allocation and the company is releasing product as it becomes available.2
  • Hospira has all lactated ringer’s injection and lactated ringer’s with 5% dextrose injection on allocation to current customers. Lactated ringers 500 mL bags and 1000 mL bags are on back order and the company estimates release dates in mid-November 2014. Lactated ringer’s with 5% dextrose 1000 mL bags are on back order and the company estimates a release date in late-November 2014.3

Implications for Patient Care

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.1-3

Safety

  • 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.

Alternative Agents & Management

  • 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. Use smaller bags and low flow rates as sodium chloride 0.9% is often used to keep an intravenous line open.
  • Consider reserving some products for specific clinical situations as outlined in Table 3.
  • Consider using commercial dialysis solutions whenever possible instead of compounding with normal saline.
Table 1. Comparison of Selected Intravenous Fluids6-9
 

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 Situations10-12
 

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.

Related Shortages

References

  1. Baxter (personal communications). February 11 and 20, March 24, May 27, July 10, August 20, October 9, and November 5, 2014.
  2. BBraun (personal communications). January 16, February 12, April 7, May 27, August 21, October 20, and November 5, 2014.
  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, and November 12, 2014. 
  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.
  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.

Updated

Updated November 12, 2014 by Leslie Jensen, PharmD, Drug Information Specialist. Created February 11, 2014 by Jane Chandramouli, PharmD, Drug Information Specialist and Michelle M Wheeler, PharmD, Drug Information Specialist, University of Utah, Drug Information Service. Copyright 2014, Drug Information Service, University of Utah, Salt Lake City, UT.

Disclaimer

This information is provided through the support of Novation to ASHP solely as a service to its members, which shall not use this information for their further commercial use. The content was prepared by the Drug Information Center of University of Utah. Novation, ASHP, and the University of Utah make no representations or warranties, express or implied, including, but not limited to, any implied warranty of merchantability and/or fitness for a particular purpose, which respect to such information, and specifically disclaim all such warranties. Users of this information are advised that decisions regarding the use of drugs and drug therapies are complex medical decisions and that in using this information, each user must exercise his or her own independent professional judgment. Neither Novation, ASHP nor the University of Utah assumes any liability for persons administering or receiving drugs or other medical care in reliance upon this information, or otherwise in connection with this bulletin. Neither Novation, ASHP nor University of Utah endorses or recommends the use of any drug.

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