Update on the Use of Filters for Parenteral Nutrition: An ASPEN Position Paper

Abstract

Intravenous in‐line filters play a critical role in promoting patient safety during parenteral nutrition (PN) administration. Guidelines for using filters for PN have been issued by a number of professional organizations and manufacturers of PN components. Yet despite this guidance, filter use remains controversial. Recent changes in recommendations for filtering lipid injectable emulsions have added to confusion and created considerable variation in practice. This Position Paper aims to review past guidance regarding the filtration of PN, examine the clinical consequences of infusing particulate matter, discuss the challenges and issues related to filtration, and clarify the American Society for Parenteral and Enteral Nutrition (ASPEN) recommendations for the use of filters for PN administration. This paper was approved by the ASPEN Board of Directors.

High particle counts in neonatal parenteral nutrition solutions with added cysteine: Relationship to crystal formation and effect of filtration on cysteine content

“…19 The American Society for Parenteral and Enteral Nutrition (ASPEN) recently updated its position statement on the use of filters for PN. 20 Although the solutions that contained CaGlu, cysteine, and MgSO4 had very high particles counts in the current study the availability of cysteine from neonatal PN solutions when cysteine is added at the time of compounding does not appear to be significantly decreased due to filtration. A previous study in which cysteine was added at the time of compounding measured prefilter and postfilter concentrations of cysteine/cystine after 24 h at room temperature and did not find a significant decrease in concentrations postfiltration which were 85%-91.5% of the initial concentration.…”

Filtering Out the Facts: Recommendations to Optimize Performance of In-Line Filters for Parenteral Nutrition and Injectable Lipid Emulsion Infusions

“…When ILEs are infused via a Y-site configuration with the PN formulation (2-in-1), the recommendation is to use a 1.2-μm in-line filter that is positioned distal to the Y-site. 12,13 A 2019 Georgia Society for Parenteral and Enteral Nutrition newsletter on the "Considerations for Injectable Lipid Emulsion Administration: In-Line Filters and DEHP-Free Tubing," 15 explained that, because lipid emulsions contain particles that can range from approximately 0.1 μm to 1.0 μm , they are able to pass through 1.2-μm filters without concern for shearing of the lipid particles. 15 All ILEs currently approved in the United States conform to USP Chapter <729>, indicating that the mean droplet size does not exceed 500 nm (0.5 μm) and that no more than 0.05% of droplets are >5 μm.…”

“…In 2016, the Institute for Safe Medication Practices11 published a safety alert highlighting this prescribing information change and reminding clinicians that 1.2-μm filters are recommended for both TNA and ILE when infused separately 11. In recent years, consensus promoting the use of a 1.2-μm filter for ILE is growing from organizations such as American Society for Parenteral and Enteral Nutrition (ASPEN)12,13 and Infusion Nurses Society (INS)7 to reduce the potential for patient harm that may occur due to IV infusion of particulate, precipitates, and air emboli. In 2021, ASPEN published a position paper on the use of filters for PN 13.…”

“…In recent years, consensus promoting the use of a 1.2-μm filter for ILE is growing from organizations such as American Society for Parenteral and Enteral Nutrition (ASPEN)12,13 and Infusion Nurses Society (INS)7 to reduce the potential for patient harm that may occur due to IV infusion of particulate, precipitates, and air emboli. In 2021, ASPEN published a position paper on the use of filters for PN 13. While 1.2-μm filters are not recommended as a routine infection control measure to prevent bloodstream infections,13,14 they can trap Candida albicans and therefore may be effective in mitigating the risk of this pathogen from reaching the patient.…”

ASPEN lipid injectable emulsion safety recommendations part 2: Neonate and pediatric considerations

“…ILE infusion is usually via a Y‐site into the same catheter as the PN. ILE is infused using a 1.2‐µm in‐line filter located below the bifurcation of the tubing, closest to the catheter hub 76 . When ILE is infused separate from PN, utilizing a different intravenous vascular access device (VAD), each infusion line (PN and ILE) should include a 1.2‐µm filter between the infusion container and the intravenous catheter.…”