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Filtration in IV Therapy for Infants |
- Particles are present in IV therapy in large numbers
- Particles have pathological effects
- It is possible to protect infants against the effects of particulate contamination
- Air can be a clinical problem in IV therapy
- It is possible to protect infants against air embolism from the infusion system
- Microbial contamination can gain access to IV systems
- It is possible to protect infants against inadvertent microbial contamination from the infusion system
- Endotoxin can be released by bacteria trapped within an IV filter
- Effective endotoxin retention is possible with an appropriate filter membrane
- Intravenous medications for infants, including neonates, can be effectively filtered
- Summary
- References
Particles are present in IV therapy in large numbers
Particles of glass, rubber, metal, plastic, crystalloid material, fibres and other material are routinely present in IV infusions. These arise from the drugs and fluids, infusion equipment, manipulations and drug incompatibilities. Levels as high as half a million particles per litre infused have been reported, for patients receiving intensive IV therapy1. The largest contribution appears to come from small volume additive drugs2.
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Particles have pathological effects
Since the 1950's reports of particles in the lungs of children at post mortem examination have been published. Earliest reports were of granulomata containing cotton fibres, in 5-10% of children who had received IV therapy3,4, with a relationship between the number of granulomata and the amount of fluid infused5. More recently, glass particles have been seen in the lungs of neonates6 and a case report described fatal bowel necrosis in a neonate due to plastic material from a syringe; histological examination of the small bowel showed infarction and thrombus in the mesenteric arteries containing irregular fragments of polypropylene7.
It has been proposed, based on post mortem results and animal studies, that the presence of particles in the pulmonary circulation induces thrombosis, capillary endothelial damage, granulomata and foreign body giant cell formation. It has been suggested that these effects on the lung microvasculature, coupled with impairment of the clearance system, may accelerate the course of respiratory distress syndrome and multiple organ failure1,8.
In addition to potentially serious systemic effects, particles have been shown to have an important role in the pathogenesis of infusion-related thrombophlebitis and loss of cannula patency. In adults the incidence of phlebitis is reduced by half by the use of 0.2µm filters to remove particles from the infusion9, and a study in neonates showed a significant improvement in cannula site life in neonates in whom 0.2µm filtration was used10.
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Air can be a clinical problem in IV therapy
Air can gain access to IV systems by degassing as fluids are warmed to room temperature, by disconnection or incomplete priming, or due to a vented line running dry. There is a risk that air embolism can develop, particularly on central venous lines, with potentially serious clinical implications, especially when the foramen ovale or ductus arteriosus are still patent13.
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It is possible to protect infants against air embolism from the infusion system
Air can be effectively prevented from entering the catheter by attaching a suitable filter to the catheter hub14. Effective air eliminating filters enable venting of entrained air to the atmosphere, preventing the system from becoming air-locked.
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Microbial contamination can gain access to IV systems
Multiple manipulations increase the risk of inadvertent microbial contamination. All patients on IV therapy are at risk of this, but there have been several reports in recent years of outbreaks affecting babies and children15-22.
| Author | Patients | Organism involved |
| Matsaniotis et al | Infants & children | Enterobacter species |
| Twum-Danso et al | Neonates & a child | Klebsiella pneumoniae |
| Ng et al | Neonates | Acinetobacter calcoaceticus |
| Todd et al | I neonate | Mucor species |
| Bin Ibrahim et al | Neonates | Klebsiella pneumoniae |
| Lacey & Want | Children | Pseudomonas pickettii |
| Frean et al | Infants | Serratia odorifera |
| Garland et al | Neonates | Pseudomonas aeruginosa |
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It is possible to protect infants against inadvertent microbial contamination from the infusion system
Microbes can be removed from IV infusions using appropriate filters. In parenteral nutrition, complete retention of Candida12 and Malassezia furfur24 from lipid emulsions is achieved with 1.2µm modified nylon filters.0.2µm filters remove bacteria and fungi from infusion fluids and drugs in solution. Those filters that are suitable for extended use can also reduce the number of catheter hub manipulations, a recognised source of catheter related sepsis25, making them a useful addition to standard infection control practices.
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Endotoxin can be released by bacteria trapped within an IV filter
Endotoxin is a component of the outer layers of Gram-negative bacteria. It is released in large amounts during cell lysis and has potentially lethal clinical effects. Bacteria trapped within an IV filter can release clinically significant amounts of endotoxin after 24 hours, so conventional filters require daily change23.
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Effective endotoxin retention is possible with an appropriate filter membrane
IV filters that retain endotoxin completely can be used for longer than 24 hours26, reducing the number of filter and IV set changes and the number of catheter hub manipulations. A recent study has shown a significant reduction in septic and thrombotic complications in neonates with the use of an endotoxin retentive IV filter27.
Several filter membranes have been tested for endotoxin retention26,28-30.
| Author | Cellulose | Posidyne | Polysulphone | Charged polysulphone |
| Horibe et al | No | Yes | ||
| Richards & Thomas | Yes | No | ||
| Richards & Grassby | Yes | No | ||
| Barnett & Cosslett | Yes | No |
The safe extended use of filters and sets has enabled cost savings to be made in neonatal care units31.
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Summary
- Particles are present in IV therapy in large numbers. Particles have pathological effects. It is possible to protect infants against the effects of particulate contamination.
- Air can be a clinical problem in IV therapy. It is possible to protect infants against air embolism from the infusion system.
- Microbial contamination can gain access to IV systems. It is possible to protect infants against inadvertent microbial contamination from the infusion system.
- Endotoxin can be released by bacteria trapped within an IV filter. Effective endotoxin retention is possible with an appropriate filter membrane.
- Intravenous medications for infants, including neonates, can be effectively filtered.
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References
- Kirkpatrick CJ, Krankenhauspharmazie 1988;9:487-490.
- Backhouse CM et al, J Pharm Pharmacol 1987;39:241-245.
- Brunning EF, Arch Path Anat 1955;327:460-479.
- Sarrut S & Nezelof C, Presse Medicale 1960;68:375-377.
- Jacques WF & Mariscal GG, Bull Intern Assoc Med Museums 1951;32:63-72.
- Puntis JWL et al, Arch Dis Child 1992;67:1475-1477.
- Cant AJ et al, BMJ 1988;296:968-969.
- Walpot H et al, Anaesthesist 1989;38:544-548.
- Falchuk KH et al, NEJM 1985;312:78-82.
- Thomas PH, Proc Guild Hosp Pharm 1989; 26:3-10.
- Lewis JS, Hosp Pharm 1993;28:656-658,697.
- Barnett MI et al, Clin Nutr 1995;14:49.
- Willis J et al, Pediatrics 1981;67:472-473.
- Coppa GF et al, J Parent Ent Nut 1980:5:166-168.
- Matsaniotis NS et al, Infection Control 1984; 5:471-474.
- Twum-Danso K et al, J Hosp Infect 1989; 14:271-274.
- Ng PC et al, J Hosp Infect 1989;14:363-368.
- Todd N et al, J Hosp Infect 1990;15:295-297.
- Bin Ibrahim A & Ghaznawi HI, 2nd Int Conf Hosp Infect Soc, London, 1992.
- Lacey S & Want SV, J Hosp Infect 1991;17:45-51.
- Frean JA et al, J Hosp Infect 1994;27:263-273.
- Garland SM et al, J Hosp Infect 1996;33:145-151.
- Holmes CJ et al, J Clin Micro 1980;12:725-731.
- Robinson R & Ball P, New Zealand Hospital Pharmacists' Association meeting, Auckland, New Zealand, October 1996.
- Lee K, 25th Conf Infect Contr Nurse Assoc, Lancaster, 1994.
- Richards C & Grassby PF, J Clin Pharm Therap 1994;19:199-202.
- van Lingen RA et al. Journal of Clinical Microbiology and Infection 1997: 3; 122.
- Horibe K et al, J Parent Ent Nut 1990:14:56-59.
- Richards C & Thomas P, J Clin Pharm Therap 1990;15:53-58.
- Barnett MI & Cosslett AC, Pharmaceutical Sciences 1996;2.
- Bennion D & Martin K, Paediatric Nursing, June1991.
- Pall Technical Bulletin 1997
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