IV Fluid Shortage Linked to Jump in Postoperative Kidney Injury

SAN ANTONIO—New research has concluded that institutional fluid conservation practices born of supply chain disruptions were associated with significant reductions in intraoperative crystalloid administration, increased colloid usage, and higher rates of postoperative acute kidney injury (AKI). The investigators said the results demonstrate the negative effects that medication-related shortages can have on patient outcomes.

“Inappropriate fluid management contributes to complications and increased healthcare costs and is a major driver of postoperative AKI, which occurs in 7% to 18% of major surgeries,” said Rachel Rigsby, BS, a medical student at the University of Pennsylvania’s Perelman School of Medicine, in Philadelphia. “Yet despite the importance of fluid management practices, their relationship to postoperative AKI remains unclear.

“We sought to use the natural experiment created by Hurricane Helene, which made landfall in late September 2024,” she continued. “The hurricane damaged a Baxter facility that creates 60% of the IV fluids used by U.S. hospitals, equating to 1.5 million IV bags. This extreme supply chain disruption affected healthcare systems across the country.” The researchers sought to characterize the changes in intraoperative fluid management practices resulting from this shortage, and to assess the impact of such changes on patient outcomes.

They performed a descriptive analysis of perioperative care and surgical outcome data from the electronic medical records of adult patients undergoing procedures in four health-system hospitals between October 2023 and January 2025. Patients were excluded if they underwent cardiac, obstetric, or nonsurgical procedures; patients without documented baseline creatinine values, those with stage 4 or 5 chronic kidney disease, and those who were ASA physical status V or VI were also excluded.

© Nishat

“Our exclusion criteria were designed to either exclude cases where we’d be unable to detect AKI, as well as those with either very high or very low risk of AKI, in which we believed perioperative practices would be less affected by the fluid shortage,” Rigsby said at the 2025 annual meeting of the ASA (abstract A3198).

Practices and outcomes were compared during the year before the shortage period with those during the October 2024 to January 2025 shortage period. The study’s primary end point was total intraoperative crystalloid volume; secondary outcomes included the prevalence of postoperative AKI (per KDIGO [Kidney Disease: Improving Global Outcomes] criteria using peak seven-day postoperative creatinine) and colloid utilization. The primary comparator was the pre-shortage period, defined as the year preceding the shortage. A smaller group of time-matched controls (comprising a three-month interval within the larger pre-shortage period) was also compared to account for seasonal variation in case mix.

In total, 46,345 cases (38,068 patients) were included in the study (mean age, 60.6 years; 53% female); the majority were classified as ASA III in both time periods (57.4% pre-shortage; 57.1% during). Among these, the median volume of intraoperative crystalloid administration decreased significantly, from 1,735 mL (IQR, 938-3,156 mL) prior to the shortage to 1,036 mL (IQR, 500-2,063 mL) during the shortage (mean difference, –700 mL; P<0.001). This difference was found to persist when compared against time-matched controls (–684 mL; P<0.001).

“Interestingly, the proportion of cases utilizing zero crystalloid increased from 0.4% to 11.3%,” Rigsby said.

The study also found that AKI occurred in 10.4% of patients before the shortage, a figure that rose to 12.1% during the shortage period (P<0.001). The incidence of postoperative AKI also increased during the shortage period in time-matched control comparisons (11.1%; P=0.02). However, the distribution by KDIGO stages showed no significant difference in distribution of AKI severity: stage 1 (pre-shortage 7.6% vs. shortage 9.0%), stage 2 (1.7% vs. 1.7%), and stage 3 (1.2% vs. 1.4%).

“Next we looked at albumin practices to see if we were increasing colloid administration by decreasing crystalloids,” Rigsby continued. “We found that the proportion of cases utilizing albumin increased from 2.6% before the shortage to 4.1% during the shortage. When we looked at the actual volume being used among recipients, it increased from 402 to 420 mL, which, although statistically significant, is not really clinically significant.”

As Rigsby explained, the study was limited by its single-institution nature and use of descriptive analyses.

“Every hospital is going to respond differently to the shortage,” she said. “It’s also possible that all four hospitals within our system acted differently despite receiving the same fluid practice guidelines. At this point, we have an observational study with unadjusted analyses, so we can’t draw any causal inference at this point. That is something we’re working on.

“It’s also important to note that our data relies on clinician reporting of fluids, which might not be as reliable during the shortage period because practices changed so significantly,” she added. The investigators are currently developing adjusted analyses and causal inference methods.

Session co-moderator Andrew Davidson, MBBS, MD, the medical director of the Melbourne Children’s Trials Centre, in Australia, found the study particularly interesting. “Did you look at whether the AKI was occurring in patients who are less sick as opposed to those who are more sick? Because it could be interesting to see which patients are getting AKI.”

“We actually looked at AKI by ASA class and found a statistically significant increase in postoperative AKI for patients in ASA class III, where the incidence increased from 11.8% to 14.6%,” Rigsby responded. “That said, it’s also important to remember that most of our study cohort was ASA class III.

“At this point, we haven’t looked at fluid volume administration by ASA class, but we were interested by the increase in AKI.”

By Michael Vlessides

Davidson and Rigsby reported no relevant financial disclosures. The abstract was selected as one of the meeting’s best.