Per nursing reports and Alaris alert data from the last 3 months, we have seen a significant increase (about 5-10x) in occlusion alarms occurring during 20% mannitol infusions. We use BD IV tubing, and BD 0.2 micron low protein binding filter extension sets, and currently have ICU medical 20% mannitol 500 mL bags.

I've contacted BD and ICU Medical and am awaiting follow-up. Does anyone else have this problem too or have any experience troubleshooting this or similar issues?

Thanks,

Will Vincent
Boston Medical Center

We recently switched back to using mannitol bags in the ED as opposed to the vials.  One issue that has come up is that with the mannitol bags looking very similar to regular IV fluids, we have had some nurses continue the infusions after completed through the pump (example – bags are 100 g total, a patient receiving 80 g would have some remaining in the bag at the end of the infusion that is then continued by the RN as they mistook it for IVF).  We are working on continuous education with the nursing staff but were trying to brainstorm some other ideas to make it stand out a little better