Conference: 2017 PH Professional Network Symposium
Release Date: 10.06.2017
Presentation Type: Abstracts
File Download: 2017 PHPN Abstract 1026
Download Adobe Acrobat
Abstract presented at the 2017 PH Professional Network Symposium held in Bethesda, MD on October 5-7, 2017
To describe a change in practice guidelines regarding add-on filters for inpatient intravenous (IV) epoprostenol administration for management of pulmonary arterial hypertension (PAH).
Intravenous epoprostenol is used for treatment of PAH in both ambulatory and inpatient settings. Filter and tubing types for delivery of IV epoprostenol with inpatient infusion pumps are not specified, however, manufacturers advise a 0.2 micron in-line filter for administration with ambulatory infusion systems. Based on this recommendation, University of Maryland Medical Center (UMMC) guidelines require use of a 0.2-micron add-on filter with CareFusion SmartSite tubing 2420-0007 for inpatient IV epoprostenol delivery via CareFusion Alaris 8100 infusion pumps. The filter used for this purpose at UMMC was ICU-B9061 by ICU Medical.
This case describes a 61-year-old female patient admitted to the Cardiac Care Unit (CCU) for management of severe PAH and administration of IV epoprostenol (Veletri). While in the CCU, the patient had repeated episodes of systemic hypotension, acutely altered mental status and respiratory decompensation. Clinical changes were not responsive to dose adjustments and the patient required intubation on two occasions. Nursing assessment noted blood reflux into the IV tubing through which epoprostenol was infusing. The patient care team initially attributed the back-siphoning to a defect with the patient’s central venous access, however, the problem persisted despite placement of two subsequent central venous access sites. A nurse priming a new IV set observed air to enter the tubing distal to the filter and dependent on its position relative to the medication bag. Unit nurses conducted a literature search to investigate best practices and determine if the 0.2-micron filter might be associated with back-siphoning and inconsistent delivery. A single article was found describing both back-siphoning and bolusing effects seen with 0.2 micron filters secondary to filter position. The article indicated that a 0.2-micron model with a smaller priming volume might be utilized to mitigate this effect. A Vygon AMS-427 0.2-micron add-on filter with a 0.52 ml priming volume was obtained as a substitute for the ICU-B9061 (priming volume 4.6ml) and epoprostenol therapy was continued with this product.
After the filter change, the patient experienced rapid and marked improvement in PAH symptoms with no further hemodynamic instability or alteration in mental status. She was later discharged on home prostacyclin infusion therapy. Following discussions with nursing, the medical team, product manufacturers and other institutions, UMMC revised practice guidelines to require the use of the AMS-427 0.2-micron filter for inpatient IV epoprostenol administered via the Alaris 8100. No further incidences of back-siphoning or bolusing have been observed since switching to the AMS-427.
Consideration of filter dynamics as a potential source of unexplained and inconsistent symptoms in patients with PAH receiving IV epoprostenol through hospital infusion pumps may be warranted. Filters with smaller priming volumes may deter back-siphoning and bolusing.