Fluid Stewardship in Crisis: Impacts of an IV Fluid Shortage on Hospital-Onset Acute Kidney Injury

Introduction: In September 2024, Hurricane Helene disrupted U.S. pharmaceutical manufacturing, causing an intravenous (IV) fluid shortage. Hospitals responded by limiting IV use to essential cases, avoiding maintenance fluids, and substituting types based on availability. At Emory Healthcare, this shortage occurred from Oct-Dec 2024. This analysis examined the impact of compelled changes in IV fluid use on patient outcomes, specifically hospital-onset acute kidney injury (HA-AKI).


Methods: A retrospective cohort study was conducted among adults admitted from the emergency department during the same seasonal period in different years: pre-shortage (Oct–Dec 2023; n = 12,657) and shortage (Oct–Dec 2024; n = 13,658). Fluid usage was compared using t-tests. Multivariable models assessed differences in HA-AKI, vasopressor use, and 30-day mortality, adjusting for demographics, comorbidities, and IV fluids given in the first 24 hours. HA-AKI, selected to reflect the potential impact of fluid management on kidney function, was defined as creatinine ≥1.5× baseline between 48 hours and 7 days post-admission.


Results: Demographics and comorbidities were similar across cohorts (53% female, 56–57% Black, mean age 61, 33% heart failure, 74% hypertension, 26% liver disease). The shortage cohort received 28% less IV fluid in the first 24 hours and 26% less overall. During the shortage, unadjusted rates of HA-AKI were higher (5.4% vs. 4.8%), 30-day mortality lower (4.7% vs. 5.6%), and vasopressor use stable. After adjustment, odds of HA-AKI increased by 20% (p=0.002) vasopressor use increased by 10% (p=0.024), and 30-day mortality decreased by 10% (p=0.045).


Conclusions: Reduced IV fluid use during the shortage was associated with modest but clinically meaningful outcome changes. Despite adjusting for fluid volume, the shortage period was linked to higher HA-AKI and vasopressor use, but lower mortality. The mortality effect may be attributed to limited power, unmeasured cohort heterogeneity, differences in fluid type or timing, decreased total fluid volume, or other shifts in clinical practice. These results underscore the complexity of clinical care during supply shortages and highlight the need for further data-driven research to guide fluid stewardship in both crisis and routine settings.