IV in-line filters are vital: Case report of a 13-year-old

In February 2022, Shinya Shimoyama and colleagues from the Department of Pediatric Cardiology and the Department of Pharmacy of the Gunma Children’s Medical Center at Shibukawa, Japan published a case report emphasizing the importance of proper infusion management, including the presence of an Intravenous (IV) in-line filter in the infusion set-up (1).

Who was the patient?

13-year-old girl with severe cardiomyopathy requiring IV treatment on the ICU, including catecholamine, olprinone, diuretics, vasodilators, and heparin.

What was the issue?

Repeated interruption of the drug infusion line due to route obstruction, resulting in fluctuating condition of the girl. The drug infusion line, including our NEO96 IV in-line filter, was only infused with dobutamine, olprinone and heparin diluted with 5% glucose solution. No apparent abnormalities were observed in the CVC, infusion route, in-line filter or infusion pump.

What was the cause of the frequent obstruction in the infusion line?

Experiments, including scanning electron microscopy (SEM) and energy dispersive X-ray (EDX) methods, revealed:

• microscopic particles (not visible to the naked eye) were formed in the infusion circuit during drug infusion therapy.
• a large amount of these particles was trapped on the IV in-line filter surface on the upstream side and solid material was observed on the IV in-line filter surface on the downstream side.
• trapped materials derived from interaction of the infused drugs.

Why are particles of concern for the ICU patient?

Intensive care patients usually receive a multitude of IV infusions with studies showing up to one million inadvertent particles per day (2-5). Without IV in-line filters, microscopic particles are inevitably infused into the body and studies have shown that this may lead to a disturbance in the microcirculation, and a compromised microvascular flow in vital organs may result in organ dysfunction of ICU patients (6-12.)

What were the lessons learned by Shimoyama et al.?

• Clinicians should be aware of the risk of precipitate formation and reconsider prescription when starting drug infusion therapy.
• Drug-drug interactions may not be readily apparent in clinical practice.
• IV in-line filters retain particles and provide a practical option to reduce potential risks due to particulate matter (13).

How can we help when IV in-line filters block?

IV in-line filters block (cause pressure alarms), because they are just doing their job and removing particles. To avoid blockages, we would recommend using the expertise of our clinical specialists who have years of experience in infusion and IV in-line filter management. Our clinical specialists will work together with clinicians, nurses, and the pharmacy to optimize the infusion regime to the benefit of the ward and patients.

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References

1. Shimoyama S, Takahashi D, Arai S, Asami Y, Nakajima K, Ikeda K, et al. A large amount of microscopic precipitates are inevitably injected during infusion therapy without an in-line filter. Oxf Med Case Reports. 2022;2022(2):omab134. doi:10.1093/omcr/omab134.
2. Perez M, Maiguy-Foinard A, Barthélémy C, Décaudin B, Odou P. Particulate Matter in Injectable Drugs: Evaluation of Risks to Patients. Pharm Technol Hosp Pharm. 2016;1(2):91-103. doi.0rg/10.1515/pthp-2016-0004.
3. Langille SE. Particulate Matter in Injectable Drug Products. PDA J Pharm Sci and Tech. 2013;67:186-200. doi.org/10.5731/pdajpst.2013.00922.
4. Perez M, Décaudin B, Abou Chala W, Nelken B, Barthélémy C, Lebuffe G, Odou P. In vitro analysis of overall particulate contamination exposure during multidrug IV therapy: impact of infusion sets. Pediatr Blood Cancer. 2015;62(6):1042-1-47. doi:10.1002/pbc.25442.
5. Benlabed M, Perez M, Gaudy R, Genay S, Lannoy D, Barthélémy C, et al. Clinical implications of intravenous drug incompatibilities in critically ill patients. Anaesth Crit Care Pain Med. 2019;38(2):173-180. doi:10.1016/j.accpm.2018.04.003.
6. Lehr HA, Brunner J, Rangoonwala R, James C. Particulate Matter Contamination of Intravenous Antibiotics Aggravates Loss of Functional Capillary Density in Postischemic Striated Muscle. Am J Respir Crit Care Med. 2002;165:514-520. doi.org/10.1164/ajrccm.165.4.2108033.
7. Kirkpatrick CJ, Rangoonwala R, Reshetnykov M, Barbeck M, Ghanaati S. Non-Equivalence of Antibiotic Generic Drugs and Risk for Intensive Care Patients. Pharmaceut Reg Affairs. 2013;2(1):1-7. doi:10.4172/2167-7689.1000109.
8. Schaefer SC, Bison PA, Randoonwala R, Kirkpatrick CJ, Lehr HA. 0.2 µm in-line filters prevent capillary obstruction by particulate contaminants of generic antibiotic preparations in postischemic muscle. Chemother J. 2008;17:172-178.
9. Jack T, Boehne M, Brent BE, Hoy L, Kӧditz H, Wessel A, et al. In-line filtration reduces severe complications and length of stay on pediatric intensive care unit: a prospective, randomized, controlled trial. Intensive Care Med. 2012;38:1008-1016. doi:10.1002/14651858.CD005248.pub2.
10. Boehne M, Jack T, Kӧditz H, Sidemann K, Schmidt F, Abura M, et al. In-line filtration minimizes organ dysfunction: New aspects from a prospective, randomized, controlled trial. BMC Pediatrics. 2013;13(21):1-8. doi.org/10.1186.1471-2431-13-21.
11. Sasse M, Dziuba F, Jack T, Kӧditz H, Kaussen T, Bertram H, et al. In-line Filtration Decreases Systemic Inflammatory Response Syndrome, Renal and Hematologic Dysfunction in Pediatric Cardiac Intensive Care Patients. Pediatr Cardiol. 2015;36(6):1270-127. doi:10.1007/s00246-015-1157-x.
12. Schmitt E, Meybohm P, Herrmann E, Ammersbach K, Endres R, Lindau S, et al. In-line filtration of intravenous infusion may reduce organ dysfunction of adult critical patients. Critical Care. 2019;23(1):373. Published 2019 Nov 22. doi:10.1186/s13054-019-2618-z.
13. Perez M, Décaudin B, Abou Chahla W, Nelken B, Storms L, et al. Effectiveness of in-Line Filters to Completely Remove Particulate Contamination During a Pediatric Multidrug Infusion Protocol. Sci Rep. 2018;8(1):7714. Published 2018 May 16. doi:10.1038/s41598-018-25602-6.

Author bio

Dr. Volker Luibl, MBA

Dr. Luibl is a Demand Generation Marketing Manager in medical device and clinical science.