Reduce Lipid Related Embolisms in Preemies


A recent issue has arisen regarding filtering of intralipids.  The following is a quote from the Institute of Safe Medication Practices (ISMP).

A change in the package insert for nutritional fat emulsions indicates that a 1.2 micron filter should be used during administration, which could stop fat emboli, air emboli, microorganisms, and particulate matter from reaching the circulation. Keep in mind, some drug information resources or products with older labels may still state that filters are not needed, or that a filter of less than 1.2 micron pore size must be used. ISMP Quarterly Action Agenda, Jan/Feb 2016

This practice of using a filter when infusing intralipids alone may be a new one to your organization, particularly in the Neonatal Intensive Care Unit.  Filtering three-in-one solutions (dextrose, protein and intralipids) has long been a recommendation from the Infusion Nurses’ Society (INS) (J Infusion Nursing; 34 (1S) and the American Society of Parenteral and Enteral Nutrition (ASPEN) (J Parenter Enteral Nutr. 2014;38(3):296-333).  The INS has just issued new standards of practice and state the following:

Filter PN solutions without lipids using a 0.2 micron-filter and lipid containing emulsions (3-in-1) using a 1.2-micron filter to reduce the risk of microbial, precipitate, or particulate contamination.  When lipids are infused separately from dextrose/amino acids, a 0.2 micron filter is used for the dextrose/amino acid solution and the lipid emulsion must be infused below the 0.2 micron filter (eg during “piggyback”).  Separate lipid emulsions may not require filtration; consult manufacturers’ direction for use.  If required, a 1.2 micron filter is used on the separate lipid emulsion. (J Infusion Nursing;39(1S):S1-

One of the major manufacturers of 20{28f25cd67d050831d96b595822aa7832ec2efa90ff8f96cc7373c1377a36f705} intralipids is Fresenius Kabi in Uppsala, Sweden.  This company manufactures intralipids distributed in the United States by Baxter Healthcare Corporation.  This package insert, revised in May 2015 states the following:

Use a 1.2 micron filter with INTRALIPID 20{28f25cd67d050831d96b595822aa7832ec2efa90ff8f96cc7373c1377a36f705}.  Filters of less than 1.2 micron pore size must not be used.

According to the ISMP, this is a change in instructions for administration.  As a nurse hanging the intralipids, we do not typically have access to the package insert.  While there may be other manufacturers that do not recommend this filtration, it is paramount that the most recent version of the package insert be checked to validate whether a filter is indeed recommended.  Reportedly, Baxter issued a Safety Alert in mid-2015 but this is not available on their website where other safety alerts are archived.  Therefore, communication from the ISMP, INS and ASPEN serve to alert end users of this.

In the NICU, where the parenteral nutrition and intralipids are administered separately, the configuration that is recommended is use of a 0.2 micron filter for the parenteral nutrition above a bi-fuse or tri-fuse with the intralipids on the secondary port of the bi-fuse.  After the bi-fuse tubing, the 1.2 micron filter, as recommended by the manufacturer should be placed.  One should avoid having the intralipids infuse through a 0.2 micron filter as the fat will occlude the filter.  Conversely, parenteral nutrition (dextrose and amino acids) should be filtered with a smaller micron filter, a 0.2 micron filter to clear any possible precipitation that would not otherwise be filtered out with a larger micron filter.


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