New recommendations on in-line filtration
“When my information changes, I change my mind. What do you do?” This quote attributed to renowned economist John Maynard Keynes also seems to apply to medical associations across the globe. In light of study results demonstrating the benefits of in-line filtration for intravenous infusions on intensive care units1,2,3, a number of global and national associations – including the Infusion Nurses Society (INS) and the German Commission for Hospital Hygiene and Infection Prevention (KRINKO) – have recently updated their guidelines accordingly, now recommending in-line filtration to reduce patient harm and improve patient outcomes.4,5,6,7,8
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Posidyne® ELD Filter
Air-eliminating filter designed for 96-hour particle, bacteria, and endotoxin retention
Supor® AEF Intravenous Filter
The Supor AEF Intravenous Filter Set is an air-eliminating filter indicated for use with any IV administration set for the removal of inadvertent particulate debris and microbial contamination.
TNA Intravenous Filters for Parenteral Nutrition
Air-eliminating filter set for lipid-containing nutritional IV administration.
Recommendations on in-line filtration: Focussing on particles and air prevention
The routine use of intravenous in-line filters has always been controversial with guideline makers making strong statements against the use of filters due to the lack of scientific evidence on the prevention of microbiological issues. The focus has however shifted from the prevention of microbiological issues towards the prevention of particulate contamination. In 2001, the British Pharmaceutical Nutrition Group (BPNG) summarized in a Position Paper “Patients who require intensive or prolonged parenteral therapy, the immunocompromised, and neonates and infants might have increased susceptibility to the detrimental effects of particulate contamination. Filters can be used during the administration of intravenous drugs, fluids, and Parenteral Nutrition (PN) to reduce the particle load administered”.4
The INS Infusion Therapy Standards of Practice (2016) states “Consider fluid and medication filtration in critically ill patients; filter use was associated with a significant reduction in overall complications for patients in pediatric intensive care units, including a significant reduction in systemic inflammatory response syndrome (SIRS); a 0.2-micron filter was used for crystalline solutions and a 1.2-micron filter was used for lipid-containing admixtures”5 and the German Commission for Hospital Hygiene and Infection Prevention recommends in 2017 “particle filters should be used in the infusion systems of ICU patients (air separation, lower systemic inflammatory response reaction)”.6
Several guidelines mention particles as a rationale to implement filters.
- American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Parenteral Nutrition Safety Consensus (2014)7
“In-line filters are required for PN administration to reduce the potential for patient harm due to particulates, microprecipitates, microorganisms, and air emboli”.
- Infusion Nurses Society (INS) Infusion Therapy Standards of Practice (2016)5
“Recognize that there is evolving evidence documenting the effect of particulate matter (e.g. rubber, glass, latex) on capillary endothelium and the effect of microbubbles of air that may cause cerebral and pulmonary ischemia; use of particulate-retentive and air-eliminating filters can prevent potential damage from air/particulates (e.g. cardiac anomalies with right-to-left shunting)”
- The European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN), European Society for Parenteral and Enteral Nutrition (ESPEN), European Society for Paediatric Research (ESPR)
Guidelines on pediatric parenteral nutrition: Organisational aspects (2018)8
“PN solutions contain particulate matter and biochemical interactions can lead to chemical precipitates and emulsion instability; they also act as a media for microbiologic growth should contamination occur”.
“In critically ill children therefore, it appears that infused particles may impair the microcirculation, induce systemic hypercoagulability and inflammation”.
Placing the filter: What do the guidelines recommend?
- BPNG: “In-line filters should be placed as close to the patient as possible”.4
- INS: “Locate add-on bacteria- and particulate-retentive and air-eliminating membrane filters as close to the vascular access device (VAD) hub as possible”.5
- ASPEN: “Filters should be placed as close to the patient as possible on the administration system”.7
Filtering parenteral nutrition solutions and change of filters: What do the guidelines recommend?
“Filter parenteral nutrition solutions without lipids using a 0.2-micron filter and lipid-containing emulsions (3-in-1) using a 1.2-micron filter, and change filters every 24 hours.
1. When lipids are infused separately from dextrose/ amino acids, use a 0.2-micron filter for the dextrose/ amino acid solution and infuse the lipid emulsion below the 0.2 filter (eg, during “piggyback”).
2. Separate lipid emulsions may not require filtration; consult manufacturers’ directions for use. If required, a 1.2-micron filter is used on the separate lipid emulsion (refer to Standard 61, Parenteral Nutrition)”.
- “0.22-micron filter is recommended for a dextrose/amino acids formulation; a 1.2-micron filter is used for a TNA formulation”.
- “PN infusions shall be infused through a filter appropriate for the type of formulation”.
- “Administration tubing and filters shall be changed with each new PN container (every 24 hours for TNAs and dextrose/amino acid formulations; 12 hours for IVFE infused separately)”.
- “The 1.2 µm filters should be used for the administration of lipid-containing solutions including AIO admixtures and changed every 24 h. The 0.2 µm endotoxin-retaining filters should be used for the administration of non–lipid containing solutions and can be changed every 96 h”.
Filters may block: What do the guidelines recommend?
ASPEN7: “Because nurses must deal with the problem of pump alarms at the point of care, nursing competencies for PN administration shall include appropriate actions and troubleshooting in response to high-pressure alarms or an occluded filter. This education shall emphasize that a filter that becomes occluded during PN administration should raise suspicions that the incorrect filter size has been used or that a precipitate or particulate is present in the formulation. When an occluded filter triggers pump alarms, the PN infusion shall be stopped. Before resuming PN, a pharmacist should review the PN formulation to determine if incompatibility issues are the cause of the problem and to identify actions to prevent further occurrences”.
ESPGHAN / ESPEN / ESPR8: “Filter blockage is more likely to indicate a problem with the solution than the filter, and must be thoroughly investigated”.
In-line filtration is no longer simply considered as “nice to have”, but as a crucial factor to improving patient outcomes. The consensus from the guidelines is that filters are being recommended to deal with particles and air. As a beneficial side effect, they can also trap any microbial contamination that is present within the line.
- Boehne, M. et al (2013). In-line filtration minimizes organ dysfunction: New aspects from a prospective, randomized, controlled trial. BMC Pediatrics, 13 (21), 1-8
- Jack, T. et al (2012). In-line filtration reduces severe complications and length of stay on pediatric intensive care unit: a prospective, randomized, controlled trial. Intensive Care Med, 38, 1008-1016
- Schmitt, E. et al (2019). In-line filtration of intravenous infusion may reduce organ dysfunction of adult critical patients. Critical Care, 23 (373), 1-11
- Bethune, K. et al (2001) Use of Filters During the Preparation and Administration of Parenteral Nutrition: Position Paper and Guidelines Prepared by a British Pharmaceutical Nutrition Group Working Party. Nutrition, 17, 403– 408
- Gorski, L. et al (2016). Infusion Therapy Standards of Practice. Journal of Infusion Nursing, 39 (1S), 1-1969
- KRINKO (2017). Prävention von Infektionen, die von Gefäßkathetern ausgehen Bundesgesundheitsblatt, 60, 171–206
- Ayers, P. et al (2014) A.S.P.E.N. Parenteral Nutrition Safety Consensus Recommendations. Journal of Parenteral and Enteral Nutrition, 38 (3), 296–333
- Puntis, JWL. et al (2018) ESPGHAN/ESPEN/ESPR guidelines on pediatric parenteral nutrition: Organisational aspects. Clinical Nutrition, 37 (6), 2392–240