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Particles are present in IV therapy in large
numbers
It is possible to protect infants against the
effects of particulate contamination
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 of
infusate have been reported, for patients
receiving intensive IV therapy1. The largest
contribution appears to come from small volume
additive drugs2.
Particles can be removed from IV infusions using
appropriate filters2. 0.2µm filters are suitable for
use with infusion fluids and drugs in solution.
Lipid emulsions can be filtered using 1.2µm
filters11,12.
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 venous access. 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.
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.
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.
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
Most of these organisms are Gram-negative
bacteria which are capable of surviving and
replicating in simple solutions23.
In parenteral nutrition, the use of lipids is an
acknowledged risk factor for infection with fungi
such as Malassezia furfur and Candida
species11,24.
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 fungal contamination from
lipid emulsions is achieved with appropriately
validated 1.2µm filters.
0.2µm filters remove bacteria and fungi from
infusion fluids and drugs in solution. Those filters
that retain endotoxin and therefore are suitable
for extended use can also reduce the number of
catheter hub manipulations, a recognised source
of catheter related sepsis24, making them a
useful addition to standard infection control
practices.
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.
Effective endotoxin retention is possible
with an appropriate filter membrane
IV filters that retain endotoxin completely can be
used for longer than 24 hours25, 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 filter26.
Several filter membranes have been tested for
endotoxin retention25,27-28.
Retention of endotoxin by IV filter
membranes
Author
Cellulose Posidyne
Horibe et al
No
Polyethersulphone
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 units29,30.
Intravenous medications for infants,
including neonates, can be effectively
filtered.
Cost effective delivery of medications at flow
rates and doses used for infants, including
neonates can be achieved with small volume
endotoxin-retentive 96 hour IV filters31-34.
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.
ELD132B
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Reference
1.
Kirkpatrick CJ, Krankenhauspharmazie
1988;9:487-490.
19. Bin Ibrahim A & Ghaznawi HI, 2nd Int Conf Hosp
Infect Soc, London, 1992.
2.
Backhouse CM et al, J Pharm Pharmacol
1987;39:241-245.
20. Lacey S & Want SV, J Hosp Infect 1991;17:45-51.
3.
Brunning EF, Arch Path Anat 1955;327:460-479.
4.
Sarrut S & Nezelof C, Presse Medicale
1960;68:375-377.
23. Holmes CJ et al, J Clin Micro 1980;12:725-731..
5.
Jacques WF & Mariscal GG, Bull Intern Assoc Med
Museums 1951;32:63-72.
24. Lee K, 25th Conf Infect Contr Nurse Assoc,
Lancaster, 1994.
6.
Puntis JWL et al, Arch Dis Child 1992;67:
1475-1477.
25. Richards C & Grassby PF, J Clin Pharm Therap
1994;19:199-202.
7.
Cant AJ et al, BMJ 1988;296:968-969.
26. van Lingen RA et al. Journal of Clinical Microbiology
and Infection 1997: 3; 122.
8.
Walpot H et al, Anaesthesist 1989;38:544-548.
9.
Falchuk KH et al, NEJM 1985;312:78-82.
21. Frean JA et al, J Hosp Infect 1994;27:263-273.
11. Lewis JS, Hosp Pharm 1993;28:656-658,697.
12. Pall Technical Bulletin 2001.
13. Willis J et al, Pediatrics 1981;67:472-473.
17. Ng PC et al, J Hosp Infect 1989;14:363-368.
18. Todd N et al, J Hosp Infect 1990;15:295-297.
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29. Bennion D & Martin K, Paediatric Nursing,
June1991.
30. Kunac DL et al. Australian J hospital Pharmacy
1999;29:321-327
14. Coppa GF et al, J Parent Ent Nut 1980:5:166-168.
16. Twum-Danso K et al, J Hosp Infect 1989;
14:271-274.
27. Horibe K et al, J Parent Ent Nut 1990:14:56-59.
28. Richards C & Thomas P, J Clin Pharm Therap
1990;15:53-58.
10. Thomas PH, Proc Guild Hosp Pharm 1989;
26:3-10.
15. Matsaniotis NS et al, Infection Control 1984;
5:471-474.
22. Garland SM et al, J Hosp Infect 1996;33:145-151.
31. Freeman A et al. NZ Hospital Pharmacists'
Association 1997.
32. Birnie L et al. NZ Hospital Pharmacists' Association
1998.
33. Birnie L et al. NZ Hospital Pharmacists' Association
1998.
34. Wilkie A et al. NZ Hospital Pharmacists'Association
1998.
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©1999, 2001 Pall Europe Limited.
Printed in England. PMED/2M/DAP/05/2001
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