UC Irvine

Background: A national intravenous fluid (IV) shortage prompted our institution to implement fluid conservation measures in the perioperative setting. Results from a preliminary survey conducted during the restriction period revealed that most anesthesia providers did not adhere to the restriction guideline, with nearly half opposing its implementation. There was a noticeable increase in anecdotal reports of postoperative nausea and vomiting (PONV) and hypotension in the postoperative anesthesia care unit (PACU). A multidisciplinary anesthesia team subsequently developed and implemented an updated preoperative IV fluid guideline concurrent with the replenishment of IV fluid supplies. This is particularly relevant given persistent gaps in national and local preparedness for supply chain disruptions driven by escalating natural disaster events. Objective: This QI project sought to evaluate improvements in provider reported adherence, workflow efficiency, and perceived utilization following the implementation of an updated, evidence-based guideline, with the goal of informing future planning in the event of an IV fluid shortage without compromising postoperative outcomes. Methods: This QI initiative was conducted within an urban anesthesia department at an academic Level I trauma center. A survey was distributed to 209 anesthesia providers within the department to evaluate an updated guideline, assess adherence, and examine provider perceptions. The Logic Model framework was employed to systematically identify and assess short and long term outcomes related to the guideline implementation. Results: A follow-up survey showed that while most providers reported low to moderate adherence, nearly twice as many providers chose to follow the updated guideline compared to the original (55% vs. 26%). Provider perceptions were more positive overall, with fewer expressing opposition. More providers felt that fluid waste was no longer a concern and believed the guideline did not cause delays or alterations in treatments or surgical start times. Although self reported on-time case rates did not improve, many providers reported increased satisfaction with having fluids prepared preoperatively. Sixty percent of respondents felt that 500 mL was sufficient for cases under two hours. The survey results identified certain procedural and surgical locations where reducing volumes to 250 mL was considered safe, as well as there was strong provider opposition to such reductions. The site of anesthesia delivery, patient acuity, and duration were identified as significant factors influencing providers’ perceptions of a safe initial IV fluid volume. Conclusion: When facing externally imposed fluid restrictions, a clear gap in practice was identified, in which no guidelines existed to drive clinical decision making. While provider acceptance improved, an adherence paradox emerged - support for the guideline increased, yet the proportion of providers who reported not following it rose, suggesting acceptance does not guarantee compliance. Additionally, under-resuscitation carries meaningful patient safety risks including PONV, hypotension, acute kidney injury, and myocardial infarction, reinforcing that fluid volumes must be tailored to patient acuity, surgical location, and case duration. There is a gap in the literature regarding fluid shortages and patient outcomes. Future studies should expand data collection to include patient outcomes, develop guidelines through expert feedback, and establish organizational policies to address IV supply chain disruptions, so that facilities have a clear basis for decision making.