Specific lots of baxter exacta-mix empty eva bags used for custom 2-in-1 and 3-in-1 parenteral nutrition compounds have been experiencing a loss of integrity when filled with solution.The affected lots at our institution do not include those already recalled under recall event 81240 on 11/2 for product code h938741.Our additional lots include multiple example with loss of integrity at seams, ports, or from spontaneous rips in bags from lot 60141892.Despite, multiple reports of these cases to the manufacturer, there has not been further guidance or follow up to our healthcare sites.Several losses of integrity have occurred while product was actively infusing to patients, leading to additional monitoring of electrolytes, additional therapy in the form of supplemental nutrition preparations and intravenous fluids, and additional resources from pharmacy to prepare replacements.We have been sequestering affected lots when an issue is discovered, but the problems have persisted with new lots obtained as replacements.
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