Filtration in Vascular Access Device Management Policy

1. Policy Statement

All clinicians responsible for the preparation and administration of parenteral solutions, blood products, and intraspinal therapies shall apply evidence-based in-line filtration practices that match filter characteristics to clinical indication, patient population, and infusate properties. Filter selection shall be guided by a formal risk-benefit evaluation, in compliance with manufacturer instructions for use and applicable professional standards, to protect patients from particulate contamination, microbial exposure, and air embolism while avoiding filter-related risks including sorption, pressure elevation, and inappropriate use as a substitute for medication compatibility.

2. Purpose

• To establish mandatory filtration requirements for high-risk infusate categories including parenteral nutrition, blood products, and intraspinal solutions
• To define evidence-based criteria for filter selection, including pore size, membrane composition, electrical charge, and compatibility with specific medications and solutions
• To specify technically correct filter positioning, priming, and change intervals to maintain filtration efficacy and patient safety
• To provide population-specific guidance for neonates, pediatric critical care, adult critical care, and patients with cardiac or pulmonary shunting
• To identify prohibited filtration practices that create patient safety risk
• To standardize filter change intervals and documentation requirements across all clinical areas

3. Scope

• All licensed clinicians, including registered nurses, pharmacists, and advanced practice providers, who prepare or administer parenteral infusions
• All clinical settings in which parenteral nutrition, lipid injectable emulsions, blood products, intraspinal solutions, or intravenous medications are administered
• All peripheral and central vascular access devices through which filtration-indicated infusions are delivered
• All add-on in-line filters, integrated administration set filters, and filter needles used in the preparation or administration of parenteral medications

4. Policy Requirements

4.1 Mandatory Filtration by Infusate Category

4.1.1 Parenteral Nutrition and Lipid Injectable Emulsions

4.1.1.1 All parenteral nutrition (PN) solutions, whether formulated with or without lipid injectable emulsions (ILEs), shall be administered through a 1.2-micron filter.

4.1.1.2 Lipid injectable emulsions infused as a separate infusion from PN shall also be administered through a 1.2-micron filter.

4.1.1.3 Administration of PN or ILE without an appropriate in-line filter is prohibited. Unfiltered PN or ILE administration carries risk of fatal pulmonary embolism.

4.1.1.4 The 1.2-micron filter for PN (with or without ILE) shall be changed every 24 hours.

4.1.1.5 The 1.2-micron filter for ILE infused separately from PN shall be changed every 12 hours.

4.1.2 Blood and Blood Components

4.1.2.1 All blood and blood components shall be administered through a filter appropriate for the specific component being transfused.

4.1.2.2 Standard blood administration sets incorporate a 170–260 micron filter and shall be used for red blood cell transfusions.

4.1.2.3 Specialized administration sets for platelets and other components shall incorporate equivalent pore sizes with reduced priming volumes per manufacturer specifications.

4.1.2.4 Blood product filter changes shall conform to administration set change protocols and manufacturer instructions for use.

4.1.3 Intraspinal Solutions

4.1.3.1 All intraspinal solutions shall be filtered through a surfactant-free, particulate-retentive, air-eliminating filter.

4.1.3.2 Filter type and change interval shall comply with manufacturer guidance for the specific intraspinal delivery system in use.

4.1.4 Medications Drawn from Glass Ampoules

4.1.4.1 When withdrawing medication from a glass ampoule, a 5-micron filter needle or filter straw shall be used to prevent aspiration of glass particles.

4.1.4.2 The filter needle used for withdrawal shall never be used for patient administration. The filter needle shall be replaced with a standard needle or needleless connector immediately before administration.

4.2 Evidence-Based Filter Selection

4.2.1 Risk-Benefit Evaluation

4.2.1.1 Filtration decisions shall require evaluation of the benefits and risks for each clinical situation. The evaluation shall consider: medication and solution characteristics, patient clinical status, and manufacturer specifications.

4.2.1.2 Documented filter risks include: sorption of active pharmaceutical ingredients, leaching or extraction of filter components, shedding of particulate matter, elevated line pressures capable of masking infiltration or extravasation, shearing of liposomal structures, and hypersensitivity reactions.

4.2.1.3 Filter selection shall match filter characteristics to the medication or solution being administered, including: pore size, membrane composition, electrical charge, and published manufacturer compatibility data.

4.2.1.4 When manufacturer compatibility data for a specific medication and filter combination is unavailable, pharmacist consultation is required before administration through an in-line filter.

4.2.2 Biologic and Protein-Based Medications

4.2.2.1 Biologic and protein-based medications shall be filtered strictly in accordance with manufacturer filtration guidance.

4.2.2.2 Inappropriate filtration of biologic or protein-based medications can trigger immune reactions or result in dose loss through protein binding. Deviations from manufacturer guidance are prohibited.

4.2.3 Prohibited Filter Practices

4.2.3.1 Filters shall never be used to compensate for medication incompatibilities. Incompatible medications shall not be co-administered regardless of the presence of an in-line filter.

4.2.3.2 Routine use of in-line filters solely for the prevention of thrombophlebitis is not recommended and shall not be used as the sole clinical indication for filtration.

4.2.3.3 Patients with a documented allergy to a filter component shall have an appropriate alternative filter type identified and documented in the medical record prior to administration.

4.3 Technical Requirements for Filter Use

4.3.1 Priming and Positioning

4.3.1.1 All filters shall be primed and positioned in accordance with manufacturer directions for use prior to initiating infusion.

4.3.1.2 In-line filters shall be positioned as close to the vascular access device (VAD) hub as clinically feasible to capture particulate matter shed from add-on components proximal to the filter.

4.3.1.3 Air-eliminating filters shall be secured at the level of the VAD insertion site to prevent inadvertent pauses or fluid boluses resulting from positional changes.

4.3.1.4 When the position of an air-eliminating filter changes relative to the VAD insertion site during patient movement or care activities, a clamp shall be placed on the tubing between the filter and the VAD hub until the filter is resecured at the correct position.

4.3.2 Filter Change Intervals

4.3.2.1 Add-on filters shall be changed coinciding with scheduled administration set changes and shall not exceed the manufacturer-approved duration of use.

4.3.2.2 Integrated in-line filters (incorporated into primary administration sets) are preferred over separate add-on filters to minimize system manipulation and contamination risk.

4.3.2.3 Filter change intervals by infusate category are summarized in Section 4.4.

4.4 Filtration Quick Reference

The following table summarizes mandatory filter requirements and change intervals:

4.5 Population-Specific Filtration Guidance

4.5.1 Patients with Right-to-Left Cardiac or Pulmonary Shunting

4.5.1.1 Patients with documented right-to-left cardiac or pulmonary shunting shall have air-eliminating filters applied to ALL infusions unless specifically contraindicated.

4.5.1.2 A relative contraindication exists for small-dose or narrow therapeutic index medications for which filter compatibility data is absent. In such cases, pharmacist consultation shall be obtained and the clinical decision documented.

4.5.2 Neonates

4.5.2.1 Routine indiscriminate filtration of all infusions in neonates is not recommended. (Evidence I)

4.5.2.2 Filter use in neonates shall be guided by specific infusate requirements (e.g., PN, ILE) or patient-specific risk factors such as right-to-left shunting.

4.5.3 Pediatric Critical Care

4.5.3.1 Routine in-line filter use should be considered for pediatric critical care patients based on the potential protective effect against pulmonary, renal, and hematologic dysfunction and systemic inflammatory response syndrome (SIRS). (Evidence III)

4.5.4 Adult Critical Care

4.5.4.1 Routine indiscriminate in-line filtration of all infusions in adult critical care patients is not supported by evidence and shall be avoided. (Evidence III)

4.5.4.2 Filtration in adult critical care shall be applied based on specific clinical indications per this policy.

5. Compliance

5.1 Key Performance Indicators

• Percentage of parenteral nutrition and ILE administrations with appropriate 1.2-micron filter in place and correctly changed at required intervals
• Percentage of intraspinal infusions with required surfactant-free, air-eliminating filter in place
• Rate of clinician compliance with filter needle protocols for glass ampoule withdrawals
• Rate of documented pharmacist consultations when filter compatibility data is unavailable for a biologic or protein-based medication
• Absence of reported filter misuse incidents (e.g., filter used to compensate for incompatibilities; filter needle used for administration)
• Audit findings from periodic observation or chart review of filter change documentation

5.2 Enforcement

Non-compliance with mandatory filtration requirements shall be addressed through the institution’s established performance management and patient safety reporting processes. Repeated or serious violations involving high-risk infusate categories (PN, ILE, intraspinal solutions) shall be escalated to department leadership and the Vascular Access Governance Committee. All adverse events potentially related to filtration practice shall be entered into the institution’s event reporting system.

6. Exceptions

Exceptions to mandatory filtration requirements (excluding PN and ILE, for which no exceptions are permitted without explicit pharmacy and physician authorization) may be granted when manufacturer labeling explicitly contraindicates filtration for a specific medication, or when validated patient-specific allergy to all available filter materials is documented. All exceptions require prescriber authorization, pharmacist review, and documentation in the medical record. Exceptions shall be reviewed at the time of each infusion order.

7. Related Documents

• Parenteral Nutrition Preparation and Administration Policy
• Blood and Blood Component Administration Policy
• Intraspinal Analgesia and Medication Delivery Policy
• Needleless Connectors for Vascular Access Devices Policy
• Add-On Devices for Vascular Access Systems Policy
• Vascular Access Device Insertion Policy
• Pharmacy Sterile Compounding and Admixture Standards
• ASPEN Parenteral Nutrition Safety Consensus Recommendations

8. Revision History