The instructions have recently changed. Now the package insert for all I.V. fat emulsion (e.g., Intralipid, Nutrilipid) states to use a 1.2-micron filter for all infusion. Previous instructions were not as specific, stating that filters were not recommended or that a filter of less than 1.2-micron pore size was not to be used. This brings up several questions about the most appropriate filtration for infusing all parenteral nutrition solutions. When all components are admixed together in one solution container (ie, 3-in-1 or Total Nutrient Admixture), the recommendation has always been to use an in-line 1.2-micron filter for infusion. IVFE will not pass through filters with a smaller pore size. The concern was and still is cracking the fat emulsion, possibly resulting in a fat embolism. What about filtration for a 2-in-1 solution containing protein, carbohydrates, and other additives? The practice has been to use a 0.2-micron filter on this solution to ensure removal of all particulate matter and microorganisms. IVFE was piggybacked below the filter or given through a separate catheter with no filtration. Now the IVFE requires a 1.2-micron filter regardless of where it is infused. There are several options for configuring the filters. According to 2016 INS Standards of Practice and a 2014 ASPEN guidelines document, a 0.22-micron filter is needed for the 2-in-1 PN solution due to particulates from the compounding process and microorganisms that could enter the system. To follow these new IVFE manufacturer instructions, 2 filters of 2 different sizes must be used - a 1.2-micron filter on the IVFE and a 0.22 micron filter on the 2-in-1 PN. The other option would be to use a 1.2-micron filter in the system and infuse both 2-in-1 PN and IVFE thru the same filter. This could be considered the same as infusing a 3-in-1 PN solution thru a 1.2-micron filter. To make the clinical decision about filters, I would want to know what filtration, if any, was done by the pharmacy during the compounding process. If pharmacy is filtering, what pore size filter is being used? To reduce microbial contamination, I would strictly enforce the policy of NOTHING being injected or piggybacked into this system and the system would ONLY be taken apart when it is time to change the entire administration system once every 24 hours.
Mary Lynn Rae
4/20/2016 09:58:49 am
We have trialed several different 1.2 micron filters for IL. They all have not been great. They beep occlusion several times during the infusion. Obviously the filter is doing its job but when you have to change the filter 4-5 times thus breaking into the system and increasing the risk of infection and causing a lot of frustration with the nursing staff. Our IL often also run overnight and really hard to do all of this in decreased lighting conditions. We've trialed 4 now.
Lynn Hadaway
4/26/2016 05:04:51 am
Mary Lynn, Obviously there is something wrong. a couple of issues come to mind. First are you infusing a 3-in-1 parental nutrition solution? This complex admixture can result in cracking the fat emulsion. In this case, that filter is saving the patient from a fat embolus. Second, are these filters being primed correctly by following the manufacturers instructions for the correct position. They may be having air trapped inside the filter and causing this occlusion. This is not a common problem across the country so there is something going on that is causing this problem. Comments are closed.
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Author: Lynn HadawayLynn Hadaway is an international thought leader in infusion therapy and vascular access, having been in this practice for more than 40 years. Her experience comes from hospital-based infusion teams, device manufacturers, and continuing education services. Her journal and textbook publications are extensive. She also maintains board certification in infusion nursing (CRNI) and nursing professional development (RN-BC). Categories
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