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Failure of an iv fluid warming device

Dalhousie University, Halifax, Canada, E-mail: swilsonmedic{at}hotmailcom

To the Editor:

We recently experienced a failure of a fluid warmer (Level 1- H1000, Fast Flow Fluid Warmer, Smiths Medical, Rockland, MA, USA) which could have resulted in significant harm to a patient. Although we could find no other reports of this particular failure, it has been documented in other types of counter-current fluid warmers.¹ The incident occurred during the elective repair of an abdominal aortic aneurysm, under general anesthesia, with the placement of a thoracic epidural for postoperative analgesia. There were no problems during the case from either a surgical or anesthetic point-of-view. The patient was transfused with blood from the cell saver during the case. This blood was transfused through the Level 1, under pressure.

At the end of the operation, a small pool of blood was observed near the base of the Level 1 fluid warmer. Further investigation revealed that fluid in the reservoir of the Level 1 was mixed with blood. We assumed that a communication must have existed between the infused fluid, and the warming fluid within the counter-current aluminum heat exchanger of the warmer. We could not establish if the exchange of fluid occurred unidirectionally (from the iv infusate into the warming fluid), or if the patient had been transfused with fluid from the warming reservoir.

We were concerned about the potential for infection because the fluid reservoir is not sterile. Electrolyte disturbances and hemolysis were also potential problems, because of the hypotonicity of the warmer fluid. The patient was continued on prophylactic antibiotics, and cultures of the patient’s blood, and the reservoir fluid were obtained. The patient experienced a transient bacteremia, however, the isolates from her blood did not match the isolates from the reservoir fluid. Fortunately, the patient did not suffer any ill effects from this mishap.

We reported the problem to our quality assurance officer, and to the manager of the anesthesia technicians. They involved the Biomedical Engineering Department of the hospital, whose investigators discovered a small hole in the aluminum tube of the counter-current heat exchanger (Figure). It did not appear that this hole was the result of mishandling or faulty installation of the heat exchanger and tubing assembly prior to use. The source of the defect remains unresolved, and the Level 1 manufacturer has been advised of the issues.

View larger version (62K): [in this window] [in a new window]   FIGURE The pinhole which allowed communication between the infused fluid and the warming fluid. The fault was found in the aluminum tube inside the heat exchanger disposable unit, as shown.

A larger issue that this incident raises relates to the safety of counter-current heat exchangers which use fluids as the heat transfer medium. While failures like the one reported are rare, the potential complications from an infection control perspective could be serious. Preoperative inspection and ongoing vigilance when using these devices are warranted. Further, as new technologies emerge which appear to be safer, and equally effective,^2–4 perhaps we could eliminate one more risk from the operating room environment by adopting alternative fluid-warming methods.

Footnotes

Accepted for publication December 21, 2006.

^A Personal communication with Daniel Cashen, Manager, Department of Anesthesia, Queen Elizabeth II Health Sciences Center, Halifax, NS, Canada.

References

1 Anonymous. Hazard Report. Greater vigilance urged in use of SIMS Level 1 Hotline fluid warmers to detect leaks in warming set. Health Devices 2000; 29: 478– 80.[Medline]

2 Satoh J, Yamakage M, Wasaki SI, Namiki A. Performance of three systems for warming intravenous fluids at different flow rates. Anaesth Intensive Care 2006; 34: 46–50.[Medline]

3 Horowitz PE, Delagarza MA, Pulaski JJ, Smith RA. Flow rates and warming efficacy with Hotline and Ranger blood/fluid warmers. Anesth Analg 2004; 99: 788–92.[Abstract/Free Full Text]

4 Dubick MA, Brooks DE, Macaitis JM, Bice TG, Moreau AR, Holcomb JB. Evaluation of commercially available fluid-warming devices for use in forward surgical and combat areas. Mil Med 2005; 170: 76–82.[Medline]

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